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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be twofold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their analysis shows that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Here, this patient with knee osteoarthritis has previously tried viscosupplemntation (i.e., Synvisc injections) with good results. She has tried and failed other conservative treatments. Current medical evidence supports the use of viscosupplementation for patients with this condition. As such, Synvisc injections of the left knee are medically necessary for this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG for a course of five days. Per researchers, MFS is an extraordinarily rare condition, and recurrence of MFS is rarer still. There are no established guidelines or protocols for treatment of recurrent MFS, but additional IVIG therapy would seem reasonable if presentation of symptoms were to persist or recur. In this case, however, the ophthalmologists report indicates that the patient is improving. There is also no documentation of a recent neurological exam that would confirm recurrence/persistence of symptoms. Therefore, additional IVIG therapy is not medically necessary for this patient at this time.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 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: 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 right ear otoplasty. In California, surgery is considered reconstructive (i.e., not cosmetic) if it is performed to approximate a normal appearance on an abnormal structure of the body caused by a congenital defect. Researchers found congenital ear deformities can produce significant social and psychological effects on an individual.  Both children and adults may suffer a damaged psyche secondary to outside ridicule and self-criticism from ears that are malformed. In this case, the patients ear condition constitutes an abnormal structure of the body resulting from a congenital defect. Otoplasty is being requested to correct this condition and approximate a normal appearance. It should also help alleviate the social distress the patient is experiencing as a result of their ear condition. Therefore, otoplasty is a medically necessary reconstructive procedure for this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology with a subspecialty certificate in plastic surgery of the head and neck, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prometheus Anser ADA test. The Prometheus Anser ADA test is a quantitative measurement of serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Accordingly, the Prometheus Anser ADA testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the Prometheus Anser ADA testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Prometheus Anser ADA testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: An enrollee has requested reimbursement and prospective authorization and coverage for posterior tibial nerve stimulation (PTNS). As discussed in the medical literature, PTNS is performed as a salvage procedure. According to the American Urological Association (AUA) incontinence guidelines, PTNS is considered to be an appropriate therapy for patient with intractable irritative lower urinary tract symptoms including frequency and urgency incontinence. However, there is a lack of data demonstrating superior health outcomes with PTNS as compared to the remaining available standard therapies. All told, the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: An enrollee has requested reimbursement for substance use mental health residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines  recommend residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and who  lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this patients case, the records indicate that residential treatment was necessary to develop their recovery skills. The records document that detoxification was needed to stabilize this patient. Rehabilitation at the residential treatment level of care was medically indicated following detoxification to allow this patient to maintain sobriety and reduce their risk of relapse. All told, residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for this patients condition. Therefore, substance use mental health residential treatment center services were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pradaxa. The American College of Chest Physicians (ACCP) 2016 guideline recommends long-term (first 3 months) anticoagulant therapy for patients with DVT of the leg or PE and no cancer. The ACCP suggests Pradaxa (dabigatran), and other medications over vitamin K antagonist (VKA) therapy (all Grade 2B). The ACCP states that several of the direct oral anticoagulants (DOAC) are equally effective. At this time, there are reversal agents available: Praxbind for Pradaxa. These reversal agents are noted to be effective in rapidly reversing the anticoagulant effect of DOACs.In this case, the patient meets the 2016 ACCP criteria for extended anticoagulation based upon recurrent VTE of legs and pulmonary embolism. The patient has been stable on Eliquis for over 12 months without complication or recurrence of VTE. The ACCP clearly states that there is no significant difference in effectiveness for any of the four available DOACs. The potential need for a reversal agent does not warrant changing from one DOAC to another. Patients can moderate their activities and lifestyle to minimize the risk of bleeds. Both Pradaxa and another drug carry a low bleed risk. Under these circumstances, the medication Pradaxa is not medically necessary for treatment of the patients medical condition.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 hematology and medical 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for thoracic facet joint injection and transforaminal lumbar epidural steroid injection. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees thoracic and lower back pain. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The current medical evidence does not recommend facet joint injections in the thoracic spine, as there is limited research on therapeutic blocks or neurotomies in this region.  Per the medical evidence, therapeutic epidural steroid injections are recommended as a possible option for short-term treatment of radicular pain with use in conjunction with active rehabilitation efforts. This patient presents with a history of chronic thoracic spine pain and chronic low back and left radicular leg pain following a motor vehicle accident in 2007. She reports worsening thoracic pain over the past two  years. Clinical examination findings did not document thoracic spine findings of facet mediated pain. There is imaging evidence of slight scoliosis convex to the right, with no discussion of facet joint pathology. She complains of low back pain with radiating burning pain to both legs to the calves with occasional numbness to the feet with compensatory muscle spasms. Clinical examination findings have not evidenced a focal neurologic deficit correlated with reported imaging evidence of L4/5 and L5/S1 mild bilateral neural foraminal narrowing and 2 mm annular bulge/tear at L5/S1. Relative to the thoracic facet injections, there is no clear indication to support the medical necessity of thoracic facet injections at this time. Relative to the lumbar epidural injection, there are no physical examination findings correlated with imaging evidence of nerve root compression and consistent with radiculopathy to support the medical necessity of lumbar epidural injections at this time. Therefore, the requested thoracic facet joint injection and transforaminal lumbar epidural steroid injection are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for penciclovir topical (Denavir) 0.5 mg. The patient notes that when she has herpetic outbreaks, she is treated with oral valacyclovir as well as the topical treatment. Oral valacyclovir effectively penetrates the tissues of the nasopharynx and is formulated to reduce the number of recurrent lesions and decrease the duration of pain. Overall, there is a lack of support for use of an additional topical agent with oral valacyclovir. Accordingly, the requested penciclovir topical (Denavir) 0.5 mg is not medically necessary for treatment of this patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sutent. This patient has a uveal melanoma classified as high risk based on a class 2 genetic profiling. His uveal melanoma involves the choroid. At this time, no standard adjuvant treatment options have been established for use in this clinical setting. However, new data suggests that Sutent may provide benefit in uveal melanoma. A multi-institutional study of 128 patients of which 54 received Sutent showed a significant improvement with a statistically significant overall survival. Given the published peer-reviewed medical literature to support the use of Sutent, the requested Sutent 25 mg daily for 12 month is likely to be more beneficial than any available standard therapy for treatment of this patients medical condition. One reviewer found that Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for transcatheter mitral valve repair and transesophageal echocardiography.Findings:  Three physician reviewers found that this patient has significant symptomatic congestive heart failure secondary to mitral prolapse which is anatomically favorable for either mitral repair surgery or percutaneous mitral clip therapy. Normally, mitral surgery with valve repair would be the most reasonable standard therapy for this condition. However, the enrollee has significant comorbidities which would make surgery much higher risk for this patient. Specifically, the enrollee is diagnosed with a form of hyper-IgE syndrome, for which they take both immunosuppressive and chronic steroid therapy. This syndrome and its treatment regimen predisposes the enrollee to a higher risk of postoperative surgical issues, including both bacterial infections and poor wound healing. Given the increased risk of postoperative complications, along with the known efficacy of the percutaneous procedure, percutaneous mitral clip therapy in specific clinical instances can provide an improved risk/benefit profile for treatment of this condition as a reasonable alternative to a higher risk open heart surgery procedure. In sum, transcatheter mitral valve repair and transesophageal echocardiography are likely to be superior over other treatment options. 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 39-year-old female enrollee has requested authorization and coverage for Botox injections. As discussed by the American College of Obstetricians and Gynecologists (ACOG), vulvodynia is often difficult to treat and requires treatment tailored for each individual patient. Botox is not a first-line treatment for vulvodynia. However, the mechanism of action corresponds with the treatment needs of this patient. Studies have shown that Botox can be helpful for refractory cases of persistent pelvic pain. This patients symptoms have not improved with physical therapy, medications and psychotherapy. Thus, the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested Botox injections are not 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 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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.