Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure at L5-S1. This patient presents with a history of chronic low back pain that has failed to improve despite treatment with physical therapy, epidural injections, sacroiliac joint injection, and facet injections. The patients provider has recommended treatment with the Intracept procedure. Highlighted in the current peer-reviewed medical literature are studies demonstrating superior health outcomes with use of the Intracept procedure as compared to standard available therapies in the treatment of patients with chronic low back pain. Researchers assessed the efficacy of intraosseous radiofrequency ablation of the basivertebral nerve in the management of patients with chronic low back pain. The authors concluded that minimally invasive radiofrequency ablation of the basivertebral nerve demonstrated a significant improvement in pain and function in patients with chronic vertebrogenic-related low back pain. Similarly, researchers reported that patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain showed sustained clinical benefits and maintained high responder rates at two years following treatment. Given this support, the requested Intracept procedure at L5-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested Intracept procedure at L5-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for shoulder surgery (CPT 29807  arthroscopy, repair of SLAP [superior labrum anterior and posterior] lesion; CPT 29826  arthroscopy, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release). Findings:  The physician reviewer found that Erickson and colleagues noted that, Over the past 10 years, the total number of biceps tenodeses has increased, whereas the number and relative percentage of SLAP repairs within our practice have decreased. The average age of patients undergoing SLAP repair is decreasing, and most SLAP repairs are performed for type II SLAP tears. The records provided for review document that this patients MRI findings were equivocal for a labral tear. The patient has reported multiple subluxation episodes since a prior dislocation. However, on physical examination, the patients range of motion and strength are normal. In addition, there is a lack of documentation that the patient has been treated with nonsurgical modalities to support an indication for surgical intervention. Therefore, the requested shoulder surgery (CPT 29807  arthroscopy, repair of SLAP lesion; CPT 29826  arthroscopy, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for allergy testing (CPT 86001, CPT 86003, CPT 86008, CPT 82785) provided by Foundation Labs. Findings:  The physician reviewer found that the standard approach to the diagnosis of food allergies includes immunoglobulin (Ig) E measurements to specific foods in question as part of a food allergy evaluation, there is a lack of evidence in current medical literature supporting the use of an extensive array of blood tests that examine aeroallergen component IgE along with food IgG4 testing in the evaluation of food allergies. Therefore, allergy testing (CPT 86001, CPT 86003, CPT 86008, CPT 82785) provided by Foundation Labs was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the allergy testing (CPT 86001, CPT 86003, CPT 86008, CPT 82785) provided by Foundation Labs at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade induction and maintenance infusions. In a systemic review on medical therapies for inflammatory bowel disease, Talley and colleagues found that tumor necrosis factor (TNF) inhibitors, such as infliximab (brand name Remicade), are strongly recommended based on their efficacy at inducing remission in patients with moderate to severely active symptoms. The American Gastroenterological Associations guidelines for initial treatment of Crohns disease recommend using anti-TNF- drugs, such as infliximab, to induce remission in patients with moderately severe Crohns disease that is refractory to other therapies. The guidelines further recommended anti-TNF monotherapy over no therapy or thiopurine monotherapy, and the continued use of anti-TNF  drugs to maintain remission. Alternatives to anti-TNF therapy, such as immunosuppressants, aminosalicylates, corticosteroids, and antibiotics, were not recommended. In this case, the patient has moderate Crohns disease. He is dependent on corticosteroids. The records noted negative laboratory test results for tuberculosis and hepatitis B. Without treatment, the patient is at risk for complications from Crohns disease, such as fistula, stricture, hospitalization, and need for surgery. Given the current medical literature, the requested medication regimen is medically indicated in this setting. Therefore, Remicade induction and maintenance infusions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for second lumbar/sacral facet joint block  at bilateral L4-5 (subsequent to the first authorized block). In this case, the patient has chronic axial back pain without radiation into the lower extremities. The patient reportedly underwent a positive diagnostic lumbar facet joint injection providing 80% relief. Based on the current guidelines, a repeat injection is indicated to confirm the diagnosis and to test for future radiofrequency ablation procedure, which is supported if the second injection is also diagnostic with at least 80% pain relief. Researchers evaluated the effectiveness of lumbar medial branch blocks and facet joint injections. The authors concluded that, facet blocks might provide prognostic value before radiofrequency ablation. Similarly, a review by Manchikanti and colleagues reported that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The current medical literature supports the use of medial branch blocks to determine whether this patients pain is facet joint mediated and to determine whether the patient is a candidate for a radiofrequency ablation procedure. Based on these findings, the requested second lumbar/sacral facet joint block  at bilateral L4-5 (subsequent to the first authorized block) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve stimulation (PNS) trial and implantation with Stimwave (CPT 64555). In this case, the patient has chronic occipital migraines, which have been diagnosed as occipital neuralgia. The records document that the patients symptoms have been refractory to medication management, physical therapy, Botox injections, and occipital nerve blocks. The provider has recommended treatment with peripheral nerve stimulation (PNS). However, there are insufficient data in the current peer-reviewed medical literature to support use of PNS in lieu of standard of care modalities. Cadalso and colleagues assessed the safety and efficacy of occipital nerve stimulation in the treatment of patients with refractory headaches. The authors noted that this therapy may be effective when compared to placebo, but additional prospective randomized controlled clinical trials are needed to determine whether PNS yields improved patient health outcomes when compared to current treatment options. A systematic review published by Yang and colleagues reported that, the evidence of occipital nerve stimulation efficacy established by randomized controlled trials was limited. All told, the requested PNS trial and implantation with Stimwave (CPT 64555) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested PNS trial and implantation with Stimwave (CPT 64555) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a GenVisc 850 injection series in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited.  In this case, the patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a GenVisc 850 injection series in both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) referral to a licensed midwife (not a certified nurse-midwife) for prenatal and postnatal care and (2) referral to an International Board Certified Lactation Consultant (IBCLC) for prenatal and postnatal care. There is a lack of clinical documentation in the submitted records supporting referral to a licensed midwife, given that certified nurse-midwives are licensed by the California Board of Registered Nursing as an advanced practice provider and have been made available to the patient. Therefore, (1) referral to a licensed midwife (not a certified nurse-midwife) for prenatal and postnatal care is not medically necessary for the treatment of this patient. Researchers notes that for patients who choose to breastfeed with risk factors for breastfeeding problems or low milk supply, prenatal consultation with a lactation consultant, and special education and attention during initiation of breastfeeding may be beneficial. Therefore, (2) referral to an IBCLC for prenatal and postnatal care is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg twice daily. The current treatment options for alopecia areata are limited, especially for multifocal involvement where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy, and conventional immunosuppressants are oftentimes inadequate to control symptoms and are associated with side effects. Although trials remain underway, there is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors such as Xeljanz for alopecia areata. In one open label pilot study 8 of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring. Another study included patients with at least 40% scalp hair loss due to alopecia areata treated with Xeljanz (Liu, et al.). The authors found that 77% of the patient treated achieved a clinical response with minimal adverse effects. Moreover, these results are superior to data on treatment with contact immunotherapy and systemic steroids. In conclusion, the requested Xeljanz 5 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Xeljanz 5 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the abdomen. This patients records document current complaints of epigastric and right upper quadrant pain without findings to explain symptoms on ultrasound. The patient previously underwent cholecystectomy in 2004. The patients provider has recommended further evaluation with MRI of the abdomen. Researchers supports the use of MRI with magnetic resonance cholangiopancreatography for the evaluation of patients with right upper quadrant pain, lack of fever and leukocytosis, possible biliary disease, and negative or equivocal ultrasound. Right upper quadrant abdominal pain can be indicative of choledocholithiasis or other biliary disease such as choledochal cyst, or uncommon complications such as cholecystitis of the remnant gallbladder after cholecystectomy. In this clinical setting, the requested MRI of the abdomen is consistent with the ACR recommendations. For these reasons, the MRI of the abdomen is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Euflexxa injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. Corticosteroid injections and physical therapy have not been successful. The patient is not an ideal candidate for bilateral total knee replacements as the osteoarthritis is most severe in the patellofemoral compartment and relatively mild in the medial and lateral compartments. For these reasons, the requested bilateral Euflexxa injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.