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

An enrollee has requested authorization and coverage for HP Acthar Gel, 80 Units daily for 10 days. Acthar Gel is indicated for the treatment of acute exacerbations of multiple sclerosis in adults. In this case, the patient has been diagnosed with relapsing-remitting multiple sclerosis. The patient has advanced disease and has been previously treated with different medication. The patient has not responded well to disease modifying therapy, and records indicate that the patient is not able to tolerate IV steroids. The use of Acthar Gel is indicated in just such circumstances, when a patient is experiencing an acute exacerbation of multiple sclerosis and is not able to tolerate traditional IV steroids. Accordingly, the requested medication, HP Acthar Gel, 80 Units daily for 10 days, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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

An enrollee has requested authorization and coverage for the requested treatment plan, as recommended by the provider and as listed in the patients complaint. The patient presents with a disabling left knee issue pertaining to painful dislocations of the patellofemoral joint and full thickness chondral loss of the patella, as well as the trochlear groove of the femur. She has tried and failed conservative treatment. Her provider has recommended surgical intervention. Based on current medical literature, the recommended matrix-induced autologous chondrocyte implantation (MACI) procedure is appropriate to regenerate articular cartilage and stabilize the patellofemoral joint. Recent data show that MACI has evolved since its inception and long-term follow-up support its use in this patient population. Given this support, the requested treatment plan, as recommended by the provider and as listed in the patients complaint, 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery and are 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

The patient has requested authorization and coverage for Xifaxan 550 mg tablet three (3) times daily for 10 days. The patient has been diagnosed with irritable bowel syndrome with diarrhea (IBS-D). Researchers reported that in a phase three study of patients with relapsing symptoms of IBS-D, repeat rifaximin treatment was efficacious and well tolerated. Authors also states that rifaximin appears to be safe and well tolerated in the treatment of non-constipation irritable bowel syndrome with no increased risk of infections, including clostridium difficile infection and no substantial differences in any adverse events versus placebo. In this case, the patient had diagnoses including IBS-D and SIBO with symptoms including diarrhea, pain, bloating, and discomfort. The patient had tried and failed over-the-counter medications. The medical evidence supports the requested medication in this clinical setting. Therefore, Xifaxan 550 mg tablet three (3) times daily for 10 days 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 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

The patient has requested authorization and coverage for a Synvisc-One injection to the left knee. The patient has been diagnosed with left knee osteoarthritis. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent benefit from a prior viscosupplementation injection. Furthermore, the patients options are limited, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection to the left knee is medically necessary for the treatment of this patientFinal 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 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 enrollee is requesting authorization and coverage for the medication, Mavenclad (cladribine Tab Therapy Pack 10 MG 10 tabs). The enrollee has a history of multiple sclerosis. The enrollee had used Rebif in the past, but a progress note reports the enrollee described pain throughout her whole body and supersensitivity to her skin after the injection, and she wanted a different medication. The enrollees mother indicates the enrollee is worsening, noting the enrollee awakens weak, demonstrates slurred speech, confuses her words, and continues to experience pain intermittently throughout the day. Records show the enrollees mother reports the enrollee now needs assistance to get around and to go to the bathroom. The physician prescribed a treatment course of Mavenclad oral tablets. Cladribine was approved in the United States by the Food and Drug Administration for the treatment of adults with relapsing forms of multiple sclerosis, including relapsing-remitting multiple sclerosis and active secondary-progressive multiple sclerosis. Because of its adverse effect profile, cladribine is generally reserved for those who do not tolerate or have shown an inadequate response to other drugs for multiple sclerosis. The enrollee has demonstrated an inadequate response and tolerance to other multiple sclerosis therapies. The enrollee has relapsing-remitting multiple sclerosis. Cladribine is beneficial for those with relapsing forms of multiple sclerosis.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with testicular hypofunction. Laboratory results dated 11/7/19 revealed a testosterone level of 251 ng/dL. The provider noted the patient has been treated with testosterone, and testosterone had helped his libido. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request form, the provider noted that the patient has failed AndroGel and Androderm. The patient has requested authorization and coverage for testosterone cypionate 300 mg injected every two (2) weeks. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether testosterone cypionate 300 mg injected every two (2) weeks is medically necessary for the treatment of the patients medical condition. Researchers reported, We recommend testosterone (T) therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. Authors reported, Evidence shows that men with age-related low testosterone (testosterone threshold, less than or equal to 10.4 nmol/L [300 ng/dL]) may show small improvements in sexual functioning. In this case, the patient was diagnosed with testicular hypofunction and has been treated with testosterone for a low testosterone level of 251 ng/dL. The medical evidence supports the requested medication in this clinical setting. Therefore, testosterone cypionate 300 mg injected every two (2) weeks 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 urology 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 was born at 38 weeks gestation via emergency cesarean section due to fetal distress. The patients birth weight was seven pounds one ounce. Her weight was seven pounds nine ounces, which placed her in the 53rd percentile. The patients weight was seven pounds 15 ounces. She was breastfeeding and taking supplemental formula. The records noted that the patient did poorly on Enfamil. Therefore, Similac was started, and the patient did well. Her weight was nine pounds five ounces, which placed her in the 56th percentile. The patients weight was 13 pounds four ounces, which placed her in the 48th percentile. The patients parent has requested authorization and coverage for Similac Pro-Advance, non-GMO powder 2.07 g-5.6 g, 4 oz given every 6 hours up to 32 oz per day. The Health Plan denied the request and reported the requested formula is not medically necessary for the treatment of this patient. At issue in this case is whether Similac Pro-Advance, non-GMO powder 2.07 g-5.6 g, 4 oz given every 6 hours up to 32 oz per day is medically necessary for the treatment of this patient. Martin and colleagues reported, Infant formula is intended as an effective substitute to breast milk and is formulated to mimic the nutritional composition of breast milk. Similac Pro-Advance non-GMO formula is a standard infant formula with added prebiotic. In this case, the patient has been maintaining adequate weight gain from birth. She regained her birth weight in less than one week and has consistently been around the 50th percentile for weight. There was only one reference in the medical records to the patients difficulty feeding. In the absence of specific details of feeding intolerance, such as vomiting, arching, fussing around feedings, weight loss, or diarrhea, there is no medical necessity for a specialty formula or one standard formula over another. The medical evidence does not support the requested formula in this clinical setting. Therefore, Similac Pro-Advance, non-GMO powder 2.07 g-5.6 g, 4 oz given every 6 hours up to 32 oz per day is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested formula 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 pediatrics with sub-specialty certification in pediatric critical care 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 enrollees parent is requesting authorization and coverage for the medication, Dupixent. This enrollee has moderate-to-severe atopic dermatitis. He was partially controlled on methotrexate with persistent, chronic dermatitis and severe impairment of quality of life. The physician reports methotrexate has impaired his sleep, social activities, and normal school activity. The physician recommends switching to Dupilimab. This enrollee has failed standard topical and systemic therapy, according professional society guidelines for atopic dermatitis. Atopic dermatitis is known to cause considerable psychosocial dysfunction in both children and adults. Control of atopic dermatitis is important to prevent complications of disease, including lichenification, scarring, and cutaneous infection. When considering the severity of this enrollee's disease, lack of response to topical corticosteroids, oral methotrexate, expected lack of response to topical calcineurin inhibitors, need to prevent worsening severity, and to improve quality of life, Dupixent for this enrollee's atopic dermatitis is an appropriate choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 bilateral breast reduction mammoplasty (CPT 19318).In this case, the patient complains of back, shoulder and neck pain. While there is mention of shoulder grooving as a complaint, it is not documented on physical exam or confirmed in the submitted photographs. The patient also complains of occasional rashes beneath both breasts that have been treated with over the counter medications, but there is no report of intertrigo that is unresponsive to medical management. There is also no report of chronic breast pain due to weight of the breasts, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Because there less than two confirmed quality of life signs, the requested service would not be considered medically necessary according to ASPS criteria. In addition, the patients proposed resection of 200 and 250 grams per breast is below the 22nd percentile of 607 grams per breast at a body surface area (BSA) of 1.78 and below the 5th percentile of 272 grams per breast at the 5th percentile. This would qualify the procedure as cosmetic according to weight. Combining this lack of determination of medical necessity based on weight with the lack of determination of medical necessity based on ASPS criteria, the requested bilateral breast reduction mammoplasty (CPT 19318) is not medically necessary to treat the patients medical condition.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; or (2) to create a normal appearance, to the extent possible. In this case, the patient has breast ptosis, which is a normal structural change associated with aging. The patients appearance is normal, and the patients subjective complaints of functional disability from the weight of her breasts is not confirmed by any objective findings of significant breast weight for resection or photographic documentation of breast hypertrophy or shoulder grooving. Accordingly, the requested bilateral breast reduction mammoplasty (CPT 19318) is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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 was noted to have atrophic gastritis with intestinal metaplasia but no dysplasia, and a history of adenomatous colon polyps. She was being treated with pantoprazole. The patient underwent an esophagogastroduodenoscopy (EGD) for atrophic gastritis. This revealed an irregular Z-line, mild atrophic gastritis in the gastric body and fundus, and a normal duodenum. Biopsies showed intestinal metaplasia in the antrum but not the fundus. Per the grievance and appeals review form, the patient was concerned about her risk for cancer due to her brothers history of esophageal cancer. The patient has requested reimbursement for the esophagogastroduodenoscopy (EGD) procedure (CPT 43239). The Health Plan denied the request and reported that the service at issue was not medically necessary for the evaluation of this patient. At issue in this case is whether the esophagogastroduodenoscopy (EGD) procedure (CPT 43239) that was performed was medically necessary for the evaluation of this patient. The ASGE Standards of Practice Committee reported, Patients with gastric intestinal metaplasia (GIM) may have a greater than 10-fold increased risk of gastric cancer than the general population. Authors reported, Increased risk for incident gastric cancer among patients with GIM.  The authors noted, Patients and providers may reasonably elect to undergo short-interval upper endoscopy to characterize presence/absence of these features or commit to longitudinal surveillance if these features are known to be present. Similarly, because we found evidence supporting increased risk for gastric cancer among patients with GIM and a first-degree relative with gastric cancer, patients with GIM and a family history could reasonably elect for longitudinal endoscopic surveillance. In this case, the patient was noted to have atrophic gastritis with intestinal metaplasia, and she reported concern for gastric cancer due to her family history. The medical evidence supports the service at issue in this clinical setting. Therefore, the esophagogastroduodenoscopy (EGD) procedure (CPT 43239) that was performed was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service was 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Gammaplex 140 grams infused over four (4) days every month. Autoimmune encephalitis is a rapidly progressive inflammatory neurological disease with subacute onset. Guidelines for the clinical diagnosis of autoimmune encephalitis include subacute onset of working memory deficits, altered mental status, or psychiatric symptoms. In addition, there should be evidence of new focal central nervous system (CNS) findings, seizures not explained by a previously known seizure disorder, cerebrospinal fluid (CSF) pleocytosis, or magnetic resonance imaging (MRI) features suggestive of encephalitis. Patients should undergo a thorough work-up to rule out other diseases that can mimic autoimmune encephalitis and cause rapidly progressive encephalopathy. Common first-line immunotherapeutic agents for treatment of autoimmune encephalitis include corticosteroids, IVIG, and plasmapheresis. For patients with medical conditions that discourage the use of corticosteroids, IVIG is often the initial treatment. In this case, the patient has a subacute progressive presentation of multiple neurological symptoms and focal findings that may suggest a possible autoimmune encephalitis. IVIG is a common first-line agent for autoimmune encephalitis. However, the records provided for review do not include adequate documentation of previous work-up including brain MRI, CSF studies, and autoantibody studies excluding other causes and establish a definitive diagnosis of autoimmune encephalitis. Therefore, the requested Gammaplex 140 grams infused over four (4) days every month is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 neurology 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.