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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis but it is has not been shown to be disease modifying. The American College of Rheumatology (ACR) recently released guidelines on the treatment of psoriatic arthritis in the setting of COVID-19. The ACR clinical guidance states that for patients with moderate to high disease activity despite optimal conventional synthetic [disease modifying anti-rheumatic drugs] DMARDs, biologics may be started. The ACR does not support treatment with Otezla due to the current COVID-19 pandemic. In this case, the patient does not have a history of failure or contraindication to biological DMARDs for treatment of her psoriatic arthritis. All told, the requested Otezla 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 internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 HP Acthar Gel (CPT J0800) 80 units subcutaneously twice weekly for six months. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of refractory nephrotic syndrome. While HP Acthar Gel is not recommended as a first-line therapy, data support its use in the therapy for patients who have failed to respond to or tolerate standard therapy. This patients records document that she has failed prior treatment with high-dose prednisone, mycophenolate, Lisinopril, losartan and labetalol for her diagnosis of primary focal segmental glomerulosclerosis. Therefore, the requested HP Acthar Gel (CPT J0800) 80 units subcutaneously twice weekly for six months is medically necessary for 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 subspecialty certification in nephrology 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 proton beam therapy. Proton beam therapy for treatment of early stages of prostate cancer was introduced as a possible means to reduce side effects and increase the effectiveness of radiation treatment in patients with cancer. However, there is a paucity of controlled randomized studies demonstrating clinical improvement with proton beam therapy over patients treated with routine intensity modulated radiation therapy (IMRT) in this clinical setting. Researchers reported that their findings on early proton beam therapy have shown mixed results when compared with routine intensity-modulated radiation therapy. This patient presented with an elevated prostate specific antigen (PSA) of 5.2. He underwent biopsy, which revealed Gleason score 3+3=6 and Gleason score 3+4=7 adenocarcinoma of the prostate from both sides of the prostate gland. Based on the available documentation, there is a lack of comparative superiority with proton beam therapy in lieu of IMRT for treatment of this patients prostate cancer. Therefore, the requested proton beam therapy 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) level of care services. Applying the CALOCUS framework, this patient meets the criteria for admission to RTC level of care. The patient has been at significant risk of harm (score 3), due to history of multiple suicide attempts and recent self-harm. The patient has demonstrated serious functional impairment (score 4) given her consistent conflict with her parents and her peers at the RTC. The provider noted that the patient has a disheveled appearance. The patient failed treatment at the PHP level of care, which required transition to RTC. The patient has significant co-morbidities (score 3) due to autism spectrum disorder, substance use, and PTSD. The patients recovery environment is moderately stressful (score 3) considering her history of sexual assault and family conflict. The patients recovery environment is supportive (score 2) due to her parents engagement in therapy and treatment planning. The patient has exhibited poor response to treatment (score 4) with a lack of progress despite previous PHP treatment. The patient has been incompletely engaged with treatment (score 3). The providers report that the patient has shown difficulty with inappropriate behaviors while at the RTC. This gives the patient a composite score of 20, which is consistent with medically monitored community based services. However, due to score of 4 on functional impairment and a score of 3 on environmental stressors, the recommended level of care in this case is Level 5, medically monitored residence based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence based services due to her history of suicidality, interpersonal conflicts, co-occurring mental health and substance abuse issues, and previous failure of treatment at PHP level of care. Per CALOCUS guidelines, the length of stay at this level of care usually does not exceed 60 days. This patient received 18 days of care at this level, and was still exhibiting significant symptoms at the time of discharge. Therefore, the requested RTC level of care services 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 * 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 Anesthetic Injection (CPT64483), Epidural Injection (CPT 64484), and Dexamethasone Sodium Phosphate Injection (HCPCS J1100).In this case, the patient has a history of low back and left hip pain with radiculopathy to the left leg. Records show that the patients pain interferes with activities of daily living. She has reported significant relief of pain and improved activities of daily living with the pain medication Norco. She has been diagnosed with lumbago with left sciatica. She has undergone multiple transforaminal epidural steroid injections on the left at L4, L5, and S1 with reported improvement in pain and function. The patients pain management physician has requested authorization for a left sided transforaminal epidural steroid injection. While current evidence based medical literature supports the use of these injections as an effective treatment for radicular pain due to disc herniation, there is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis. There is no supporting medical evidence found in literature to support the safety and effectiveness of on-going routine epidural steroid injections for the treatment of radicular low back pain. There is also no evidence in this case of a lumbar spinal pathology, e.g. disc herniation, for which epidural steroid injections are clinically indicated. Accordingly, the requested treatment consisting of Anesthetic Injection (CPT64483), Epidural Injection (CPT 64484), and Dexamethasone Sodium Phosphate Injection (HCPCS J1100) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat 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: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for the medication Praluent Pen 150 mg/ml.The submitted documentation does not support that the requested medication is medically necessary. The clinical indication for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as Praluent includes those patients with clinical atherosclerotic cardiovascular disease and those with familial hypercholesterolemia who are on maximally tolerated statin therapy and require greater reduction in LDL cholesterol levels to reach their goal. The indication has also been extended to such patients with statin intolerance, generally due to myalgias and/or myopathy secondary to statin drugs with significant LDL cholesterol elevations. In this case, there is no documentation of the patients LDL cholesterol levels on no lipid lowering therapy. In addition, while the submitted records reflect that the patient has been tried on Lipitor, which had to be stopped due to myalgias, there is no documentation that the patient experienced intolerable side effects on other lipid lowering therapy (other statin or ezetimibe), nor is there documentation of inadequate LDL lowering on such drugs. Under these circumstances, the requested medication Praluent Pen 150 mg/ml is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in cardiovascular 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

The patient has requested authorization and coverage for brand name Butrans patch (buprenorphine transdermal) 20 mcg/hour. This patient has severe neuropathic pain related to a complication from a lumbar sympathetic neurolysis procedure. He has been treated with numerous medications as well as interventional procedures to manage this pain. He has found that the Butrans patch has been the most beneficial pain relief modalities. Per the records, the patient was started on the brand name Butrans patch and subsequently switched to a generic formulation. He later reported to his provider that the generic patch was not as effective as the brand name Butrans patch. The U.S. Food and Drug Administration (FDA) reports that brand name and generic formulations are similar in every parameter. The FDA noted that a generic medicine modeled after a brand-name medicine must perform the same in the body as the brand-name medicine. This standard applies to all generic medicines. A generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and the way it should be used. This patients records do not document that he experienced an allergic reaction or is intolerant to the formulary alternative to the brand name Butrans patch. Given these findings, the requested brand name Butrans patch (buprenorphine transdermal) 20 mcg/hour 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 anesthesiology with subspecialty certification in pain management 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: Urgent Care
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for air ambulance transportation services. In this case, liver transplantation would prolong the patients life, and timely travel to the location where transplant surgery was to take place was required, otherwise the patient risked missing the time window and therefore opportunity for transplant. On the date of service, it was not certain that the patient would receive another opportunity to receive a donor liver, and the patient could very well die on the waitlist as hundreds do every year. Ground travel was not an option, given that travel of more than 1,300 miles was necessary. In addition, the time that would have been involved to arrange commercial air travel and navigate check-in and security screening, even if flight timing was optimal, would have been prohibitive, not to mention the likelihood of the frequent delays commonplace in commercial air travel. On the date of service, the only reliable, timely way to get the patient to his ultimately life-extending emergency transplant surgery was via air ambulance with coordination with ground services on the receiving end of the flight. Failure to provide liver transplantation during the narrow time window it was available for the patient would be reasonably likely to result in placing his health in serious jeopardy and would certainly directly impact his life-expectancy. Therefore, air ambulance services received on the date of service were provided for an emergency medical condition as defined in Health and Safety Code section 1317.1, subdivision (b).Final Result: The reviewer determined that the services at issue were provided for an emergency medical condition as defined in Health and Safety Code section 1317.1, subdivision (b). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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

The patient has requested reimbursement for modafinil 200 mg (90 tablets/30 day supply). There are several studies demonstrating the benefit of modafinil for patients with ADHD. The researchers reported that modafinil was associated with improved short-term memory, visual memory, spatial planning, and stop-signal motor inhibition in adult patients with ADHD. This patient has a diagnosis of ADHD, but his symptoms have been stable with modafinil. Without modafinil, the patient poses a risk of decompensation. Moreover, the patient previously failed treatment with traditional stimulant medications for ADHD. The records documented that the medication dosage at issue is safe and effective in this patients case, as this dosage has been well tolerated for several years by this patient. Given patients stability, failure of previous treatment options, and clinical evidence that ADHD demonstrates benefit, the modafinil 200 mg (90 tablets/30 day supply) was medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue 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 psychiatry with subspecialty certification in geriatric 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: The patient has requested authorization and coverage for myofascial release treatment. A randomized controlled clinical trial published by Ceca and colleagues evaluated the benefits of myofascial release techniques on patients with fibromyalgia. The authors found statistically significant improvements in pain intensity, fatigue, stiffness, depression, and range of motion. Researchers assessed the effectiveness of different styles of massage therapy in fibromyalgia. The authors concluded that myofascial release demonstrated positive effects on pain and medium effects on anxiety and depression at the end of treatment, in contrast with placebo; effects on pain and depression were maintained in the medium and short-term, respectively. In this case, the patient has chronic pain with central sensitization involving multiple areas in both the upper and lower extremities, specifically, in the legs, knees, and hands. The patients presentation is consistent with fibromyalgia, which is a form of central sensitization to chronic pain. Given the support in the peer-reviewed medical literature, there is evidence to support benefit of myofascial release for patients with fibromyalgia and chronic myofascial pain syndromes. These studies have demonstrated that this therapy can positively improve quality of life measures for patients living with fibromyalgia and myofascial pain syndrome. For these reasons, the requested myofascial release treatment 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 management 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 vibration amplification of sound energy at resonance (VASER) liposuction. There is sufficient support for the requested services in this clinical setting. This patient presents with complaints of progressive difficulty in her ability to function due to pain related to lipedema. She underwent two VASER liposuction procedures, and second procedure was complicated by skin necrosis and skin bullae, indicating both partial and full thickness injury of the bilateral mid-distal inner thighs. The records support that the requested services will be performed to improve function and more closely approximate a normal appearance. Additionally, the requested services are likely to provide more than a minimal improvement in the patients appearance. The timing of the third VASER liposuction depends on the findings of an additional evaluation following the patients recovery from the two liposuction procedures and related complications. Accordingly, the requested VASER liposuction is reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.