Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vraylar. A study reports cariprazine (brand name Vraylar) was significantly better than placebo at response in treating bipolar 1 disorder. Another study notes while cariprazine was generally well tolerated, there was a lack of significant improvement in depressive symptoms with adjunctive cariprazine and antidepressant treatment for patients with major depressive disorder. In this case, the patients diagnoses include both major depressive disorder and bipolar disorder. Given the provider recommended a medication regimen augmenting antidepressants with cariprazine and the patient has stabilized on this regimen, the requested medication is medically indicated. In this patients case, the medication Vraylar is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Vraylar is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 psychiatry 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: An enrollee has requested authorization and coverage for itraconazole.Itraconazole has been approved by the U.S. Food and Drug Administration for the treatment of onychomycosis. According to Westerberg and Voyack, the success rates in treating chronic onychomycosis is 63% for pulse dosing with itraconazole. Alternaria is a recognized cause of these infections and may be treated with itraconazole. In this case, the patient has failed terbinafine because of nausea symptoms. Additionally, notes show that topical treatments have not eliminated the infection. Dermatophyte culture taken on 2/03 reported growth of Alternaria species. The medical evidence supports the requested medication in this clinical setting. Thus, itraconazole is medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in infectious disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a computed tomography (CT) colonography. Robertson and colleagues note, Given the high positive predictive value of fecal immunochemical test (FIT) for cancer detection, colonoscopy is recommended when the test is positive, not repeat FIT. The authors further note, Colonoscopy is the one structural examination that both directly evaluates the entire colorectal mucosa and affords the opportunity to simultaneously remove significant neoplasia. Given these characteristics, it is the optimal test to follow up on a positive screen. In this case, the records show that difficulty with bowel preparation for both colonoscopy and CT colonography has been the obstacle to screening, rather than a direct contraindication to the colonoscopy procedure itself. Gu and colleagues note that there are currently multiple low-volume bowel preparations available. Given that the records do not document a contraindication to the colonoscopy procedure itself, and as current medical literature supports the use of a colonoscopy rather than CT colonography in patients with a positive FIT, the requested service is not medically indicated. Therefore, CT colonography is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam therapy, hypofractionation 28 fractions, 80 Gy (CPT 77520, 77522, 77523, and 77525).Currently, there is insufficient clinical data to discern whether treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by The American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. In conclusion, proton beam therapy, hypofractionation 28 fractions, 80 Gy (CPT 77520, 77522, 77523, and 77525) is not medically necessary to treat the patients medical condition.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 radiation oncology 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 Taltz. The U.S. Food and Drug Administration (FDA) approves the use of Taltz (ixekizumab), a humanized interleukin-17A antagonist, for the treatment of adults with moderate to severe plaque psoriasis. Menter and colleagues noted that the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines on the management and treatment of psoriasis with biologics recommend ixekizumab as a monotherapy treatment option in adult patients with moderate to severe plaque psoriasis, without recommendations on step therapy. In this case, the patient has a diagnosis of chronic plaque psoriasis. Given that current medical literature supports the use of the Taltz in this clinical setting, the requested medication is medically indicated. Therefore, Taltz is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 dermatology 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 Intraoperative Radiotherapy (IORT).Findings: Two out of three physician reviewers found that the requested Intraoperative Radiotherapy (IORT) is likely to be more beneficial than any other available standard treatments for the patients medical condition.Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. APBI use is supported by the National Comprehensive Cancer Network (NCCN), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO). In this case, the patient meets ABPI criteria set by the American Society of Breast Surgeons, with an age greater than or equal to 45 years, and a tumor size less than or equal to 3cm. Negative surgical margins and negative lymph nodes are also criteria and are confirmed at the time of surgery. APBI may be delivered using external beam radiotherapy, brachytherapy, or IORT. For APBI delivered using IORT specifically, the TARGIT-A trial, a phase III randomized trial, showed equivalent 4-year local control rates between IORT and external beam whole breast radiotherapy. Toxicity and quality of life may also be slightly improved with IORT. The peak of local recurrence in the TARGIT-A trial occurred at 3 years, which is on par with other early breast cancer trials. Accordingly, the requested Intraoperative Radiotherapy (IORT) is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 patients parent has requested authorization and coverage for local anesthesia (as opposed to general anesthesia). In a study of 114 patients to evaluate the surgical and anesthetic aspects of histrelin implantation for the treatment of precocious puberty, Davis and colleagues report that while histrelin implantation is straightforward, removal presents technical challenges, and that local anesthesia, with possible nitrous oxide supplementation, is well tolerated. Eugster reports, Placing and removing the [histrelin implant] is a minor outpatient procedure easily accomplished by a pediatric surgeon using local anesthesia. In this case, the patient received an implant with local anesthesia due to her anxiety, and the provider has recommended removal of the implant as it is over a year old. Given that current medical literature supports local anesthesia in this clinical setting as safe and effective, the requested service is medically indicated. Therefore, local anesthesia (as opposed to general anesthesia) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 anesthesiology with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting reimbursement and prospective authorization and coverage for (1) Xtampza ER capsules and (2) Xtampza ER capsules. Findings: On determining when to initiate or continue opioids for chronic pain, a study finds, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic pain due to spondylosis of the spine. They have been managed on a medication regimen, including Xtampza and oxycodone, along with interventional procedures. The records note that the patient is at low risk for medication misuse and has not shown aberrant or drug seeking behavior. Given that the patient is stable on his current medications for pain management, the medication at issue was and is medically indicated. Therefore, (1) Xtampza ER capsules and (2) Xtampza ER capsules were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for any or all of the intensive outpatient program (IOP) services (including cognitive services such as individual therapy, family therapy and group therapy) provided by La Europa Academy.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm due to a history of regular cannabis use but denied suicidal ideation of self-harm and expressed hope for the future, attachment to life, and a willingness to follow a crisis plan. In terms of functional status, the records support a score of 3. The documentation noted functional impairment prior to admission to the IOP due to struggles with school avoidance and significant conflict with family members. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to a history of significant cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due the divorce of her parents, her mothers mental illness, and a peer group that used substances. With regard to level of support of the recovery environment, the records support a score of 3. The records noted limited support due to the patients tense relationship with her mother and her mother not participating in family therapy.In terms of resiliency and treatment history, the records support a score of 3. The patient did not consistently attend outpatient therapy prior to admission to residential treatment and IOP, although the records suggested her recovery was maintained with strong professional support in a structured setting. With regard to treatment acceptance and engagement, the records support a score of 2. The patient engaged in treatment. Thus, the patient has a total score of 19. In this case, the recommended level of care was high intensity community-based services. This is consistent with the level of care that the patient received in the IOP. Therefore, IOP services (including cognitive services such as individual therapy, family therapy and group therapy) provided by La Europa Academy were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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: An enrollee has requested authorization and coverage for Monovisc injection in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate 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 options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Monovisc injection 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 parent of an enrollee has requested authorization and coverage for a procedure to remove a mole from the back.At issue is whether the requested procedure to remove a mole from the back is medically necessary to treat the patients medical condition. In addition, does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, disease. If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Nevi (moles) are common congenital and/or acquired lesions that are seen on the skin. They can vary in size and number. Indications for removal are the presence of clinical atypia or  lesions that have become inflamed/traumatized and cause significant discomfort or pose a threat (i.e. infection or bleeding). In this case, there appears to be evidence that the lesion is at least inflamed. The lesion is erythematous and covered with a band-aid in the submitted photograph. The patients parent reported that the patient experiences distress and discomfort from the lesion. Therefore, the requested procedure to remove a mole from the back is medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the mole on the patients back is an abnormal structure of the body. Further, the abnormal structure is caused by a benign tumor. The requested service will improve function and prevent further inflammation and pain. Accordingly, the requested procedure to remove a mole from the back is reconstructive in natureFinal 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 dermatology 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.