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

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage for Repatha pen injectors. She has been diagnosed with type 2 diabetes mellitus and hyperlipidemia. The patient reported chest pain. The patients medical record states she failed multiple statins. Per the provider, treatment with ezetimibe was suboptimal. The patient had reportedly declined to restart statin therapy due to intolerance. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. The American College of Cardiology reports that proprotein convertase subtilisin-kexin type 9 inhibitors should be used for patients with a very high risk of atherosclerotic cardiovascular disease (ASCVD) or established ASCVD. Medical literature states, Clinical ASCVD includes acute coronary syndrome, those with a history of myocardial infarction, stable or unstable angina or coronary arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease, including aortic aneurysm, all of atherosclerotic origin. Very high-risk individuals include patients with a history of multiple major ASCVD events or one major ASCVD event and multiple high-risk conditions. The guidelines indicate that patients that do not meet the criteria for very high risk and have intolerance to high dose statin medication should be tried on a lower dose statin medication with ezetimibe. The guidelines recommend treatment with PKSK9 inhibitors for patients with familial hypercholesterolemia and in patients at very high risk for ASCVD. This patient has diabetes, which places her at risk for ASCVD, but there is no documentation of the patient having experienced a major ASCVD event or that she has familial hypercholesterolemia. There is a mention of chest pain, but no indication that the chest pain is cardiovascular in origin. There is no documentation of a cardiovascular evaluation that indicates that this patient has ASCVD. The medical evidence does not support the requested medication in this clinical setting. Therefore, Repatha pen injectors are not medically necessary for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 enrollee has requested reimbursement for the nasal and sinus debridement services post-endoscopic sinus surgery. He had a severe septal deviation causing 80-90% nasal airway obstruction, and turbinate hypertrophy that caused him to suffer persistent sinusitis. When his chronic condition failed aggressive medical therapy that included multiple trials of antibiotics and oral/nasal steroid, he underwent nasoseptal reconstruction, endoscopic bilateral anterior ethmoidectomy, endoscopic bilateral maxillary antrostomy, endoscopic left sphenoidotomy, and submucous resection of the inferior turbinates bilaterally as well as repairs of nasal vestibular stenosis. On the enrollees subsequent visits with his surgeon, he underwent nasal endoscopy. However, the medical records were handwritten and illegible and do not support the medical necessity for the nasal and sinus debridement services on those visits. The American Academy of Otolaryngology and medical literature support the nasal and sinus debridement for patients who undergo debridement during the postoperative period for patients whose physical exam shows possible crusting, or devitalized bone or mucosa to enhance healing. However, there is insufficient evidence in the record to support the medical necessity of the procedures on the dates in question. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified otolaryngologist, 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata including eyebrows, eyelashes and facial hair. Treatment focuses on the regrowth of hair. Alopecia areata can negatively affect patients self-esteem, body image, and self-confidence. Xeljanz is an oral Janus kinase (JAK) inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe rheumatoid arthritis. Xeljanz has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of Xeljanz in the treatment of alopecia areata. Given the support in the peer-reviewed medical literature, Xeljanz twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in dermatology and is actively practicing. One reviewer is board certified in dermatology and is actively practicing.  One reviewer is board certified in dermatology and is actively practicing.  All three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that the patient has requested reimbursement for bone density testing services. According to the National Osteoporosis Foundation guidelines, serial central DEXA testing is an important component of osteoporosis management (Cosman, et al.). More frequent testing may be warranted in certain clinical situations. The International Society of Clinical Densitometry (ISCD) guidelines indicate that intervals between bone mineral density testing should be determined according to each patients clinical status. Repeat testing is indicated one year after initiation or change of therapy, with longer intervals once therapeutic effect is established. In this case, the patient has history of osteopenia since age 24 and her vitamin D is low. There is no documentation of new or changed osteoporosis therapy to support annual bone mineral density scans. All told, the bone density testing services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  All three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cystic fibrosis gene analysis. The American College of Obstetricians and Gynecologists (ACOG) states that, complete analysis of the CFTR gene by DNA sequencing is not appropriate for routine carrier screening. The ACOG noted that, this type of testing generally is reserved for patients with cystic fibrosis, patients with negative carrier screening result but a family history of cystic fibrosis. In this case, with an affected mother, gene sequencing is also appropriate. Other forms of single gene mutation or panel testing would have likely missed the important mutation in this patient. Therefore, the cystic fibrosis gene analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the cystic fibrosis gene analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the cystic fibrosis gene analysis was likely to be more beneficial for evaluation 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 obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injections of the left knee every six months. 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, 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 patient has evidence of grade IV changes in the lateral tibial plateau noted at the time of arthroscopy in 2018. He has tried and failed various conservative therapies including NSAIDs, activity modification, and icing. The patient also underwent arthroscopic debridement without relief. He then underwent viscosupplementation, which gave him months of relief. In addition, the patients remaining treatment options are quite limited. The patient has tried and failed other conservative treatments as well as arthroscopy. The alternative is another arthroscopy with temporary relief or a unicompartmental knee arthroplasty at a young age. As such, requested Monovisc injections of the left knee every six months are medically necessary for treatment of this patients osteoarthritis of the knee.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for UCSF500 Cancer Gene Panel genomic testing.Findings:  Two out of three physician reviewers found that new biologic and molecular therapies for the treatment of recurrent or metastatic endometrial carcinoma are being assessed in clinical trials. The National Comprehensive Cancer Network guidelines recommend the use of next generation sequencing or molecular profiling for patients with endometrial cancer. Molecular analysis can help classify difficult cases and provide future therapeutic targets. This patient has stage IVB disease which may progress following partial response to first-line therapy. The medical evidence supports the requested services in this clinical setting. Therefore, UCSF500 Cancer Gene Panel genomic testing is likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation 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 internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery with a Cartiva implant synthetic of the right first metatarsophalangeal (MTP) joint. While the medical literature does show some early promising results with the use of the Cartiva implant for the treatment of hallux rigidus, there is a lack of high-quality studies demonstrating long-term safety and efficacy. The gold standard for treatment of hallux rigidus remains arthrodesis. This patients records do not include radiology studies that grade the severity of the patients degenerative changes of the great toe MTP joint. Therefore, the requested surgery with a Cartiva implant synthetic of the right first MTP joint is not likely to be more beneficial for the treatment of the patients medical condition and any available standard therapy.Final Result: Two of the three 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:  Reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. All three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a Registered Nurse (RN). This patients clinical studies and physical examination findings support a diagnosis of trifecta syndrome as noted by her provider. As described in the literature, this is an autoimmune disease with multiple components including chronic mast cell activation with dysregulated chronic inflammation. Postural orthostatic tachycardia syndrome (POTS) is related to autoimmunity and is considered an autoimmune disease due to dysregulated antibody production. This patients clinical evaluation and diagnostic studies support an underlying pathologic process of autoimmunity, dysregulated inflammation, and immune deficiency with high risk for recurrent infections. The use of IVIG has been demonstrated to be safe and effective for a variety of autoimmune and inflammatory diseases. Based on the patients diagnosis and clinical presentation, Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a RN is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a RN is likely to be more beneficial for treatment of the patients medical condition.Final Result: The reviewers determined that the Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a RN is likely to be more beneficial for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in oncology with expertise in hematologic malignancies and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in pediatric oncology and hematology 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 presented to his provider with rectal spotting and bleeding. Physical examination findings included rectal lesions. The patient was noted to be negative for human immunodeficiency virus (HIV). Biopsies were performed, and the pathology results were consistent with low-grade squamous intraepithelial lesion. The patient has requested authorization and coverage for a Gardasil 9 vaccination series. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient.  At issue in this patients case is whether a Gardasil 9 vaccination series is medically necessary for the treatment of the patients medical condition. Medical literature recommends a human papillomavirus (HPV) vaccine for the prevention of HPV infection beginning at age 11 or 12 years, although the vaccination can be administered starting at age nine. It also recommends vaccination for males through age 21 who were not adequately vaccinated previously. The HPV vaccination is recommended for males in certain populations, specifically men who have sex with men, transgender patients, or anyone with primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity, such as B lymphocyte antibody deficiencies, T lymphocyte complete or partial defects, HIV infection, malignant neoplasms, transplantation, autoimmune diseases, or immunosuppressive therapy. Researchers reported that the HPV vaccination is not indicated or recommended for the treatment of HPV infections or associated lesions. Medical evidence does not support the requested services in this clinical setting. Therefore, a Gardasil 9 vaccination series is not medically necessary for the treatment 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 family practice 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 been diagnosed with atopic dermatitis (AD). Findings:  The physician reviewer found that the patient had tried and failed treatment with clobetasol, triamcinolone, and mupirocin. The patient had also been treated with topical steroids, oral antihistamines, and oral prednisone. The patient has requested authorization and coverage for Dupixent. At issue in this patients case is whether Dupixent is medically necessary for the treatment of the patients medical condition. The Health Plan recommended formulary medications prior to beginning treatment with Dupixent. This patient is of childbearing age and most of the suggested on formulary treatments are contraindicated, as they are teratogenic. Current studies show that Dupixent is considered a first line treatment for severe disease and is safe and effective long-term, with minimal side effects. Dupilumab treatment, as monotherapy or as part of combination therapy, was associated not only with improvements in skin lesions but also with rapid and substantial reductions in pruritus. Patients treated with dupilumab had marked and rapid improvement in all the evaluated measures of atopic dermatitis disease activity. Medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent 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.