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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for brand name Advair Diskus purchased on early of 2021 and prospective authorization and coverage for brand name Advair Diskus. The submitted documentation supports the medical necessity of the medication at issue. Papi and colleagues noted, The goal of asthma treatment is to achieve good asthma control such as to minimize symptom burden and risk of exacerbations. Advair (fluticasone propionate-salmeterol) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of asthma. This medication is included in professional treatment guidelines for the management of asthma. Advair should be used for patients not adequately controlled on a long-term asthma control medication. (U.S. Food and Drug Administration). In this case, the patient has already tried Advair in the past, and demonstrated a positive treatment response with sustained asthma control. Records on early of 2021 state that the patient developed increased asthma symptoms when she switched to Wixela. Therefore, the brand name Advair Diskus purchased on early of 2021 was medically necessary for the treatment of the patients medical condition. Additionally, the requested future brand name Advair Diskus is medically necessary for the treatment of the patients medical condition.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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Emgality 120 mg/ml auto injector.The International Classification of Headache Disorders defines chronic migraine as headache occurring on 15 or more days per month for more than three months, which, on at least eight days per month, has the features of migraine headache. (Headache Classification Committee of the International Headache Society). Prophylactic treatments should be initiated in patients with chronic migraine. Evidence-based prophylactic medications for episodic migraine are often used for chronic migraine. These agents include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebo-controlled trials. These agents can be administered every four weeks (fremanezumab, galcanezumab) by subcutaneous (SC) injection or every 12 weeks by SC (fremanezumab). None of these agents requires dose titration. All may achieve rapid treatment effects over days to weeks, and are effective in patients who have failed prior preventive treatment, as well as in those on concurrent oral preventive treatments. (American Headache Society). Galcanezumab (Emgality) is an injectable preventive therapy approved for episodic and chronic migraine. It is a monoclonal antibody targeting CGRP. Galcanezumab is provided in a 120 mg dose intended for monthly use following an initial loading dose of 240 mg. (U.S. Food and Drug Administration). Indications include a diagnosis of chronic migraine and either (1) inability to tolerate or inadequate response to a six-week trial of at least two oral preventive medications or (2) inability to tolerate or inadequate response to a minimum of two quarterly injection (six months) of onabotulinumtoxinA. In this case, the patient has a history of chronic migraines. However, there is no documentation in the records of trials of other oral preventive medications. This case does not meet AHS criteria for initiation of CGRP monoclonal antibody therapy. For these reasons, Emgality 120 mg/ml auto injector is not medically necessary for the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested computer-assisted navigation. Findings:  The physician reviewer found that Current medical evidence does not support the use of computer-assisted navigation for the treatment of end-stage knee arthrosis by total knee arthroplasty (TKA) over standard arthroplasty without navigation. Yaffe and colleagues found that when TKA was performed by an experienced surgeon, no significant difference was identified at the five-year follow-up mark between patients who underwent computer-assisted TKA versus those who underwent manual TKA. Kim and colleagues reported that while robotic-assisted TKA was introduced to enhance the precision of bone preparation and component alignment with the goal of improving the clinical results and survivorship, at a follow-up of 10 years, there was no differences between robotic-assisted TKA and conventional TKA in terms of functional outcome scores, aseptic loosening, overall survivorship, and complications. The authors further noted that considering the additional time and expense associated with robotic-assisted TKA, they were unable to recommend its widespread use. There is a lack of evidence that computer-assisted navigation improves outcomes. Therefore, computer-assisted navigation is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested computer-assisted navigation 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 requested service 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: 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx Prostate genetic testing provided by Genomic Health, Inc. This patient presented with an elevated PSA as well as prostate cancer. Pathology demonstrated Gleason 3+4=7 in the right base and Gleason 3+3=6 in the left base. The patients provider recommended evaluation with Oncotype Dx Prostate testing for treatment planning. Oncotype Dx reporting demonstrated favorable intermediate risk, with 17% high-grade disease, and 19% non-organ confined disease. The NCCN guidelines for prostate cancer state that there is a lack of randomized controlled clinical trials to support the use of molecular assays to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Per the American Urological Association (AUA) guidelines, Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. Furthermore, the American Society for Clinical Oncology (ASCO) guideline indicated that molecular assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes (Eggener, et al.). While Oncotype Dx may eventually have a role in treatment planning for patients with prostate cancer, there is limited data on clinical outcomes to support its routine use. For these reasons, the Oncotype Dx Prostate genetic testing provided by Genomic Health, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Oncotype Dx Prostate genetic testing provided by Genomic Health, Inc. 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 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ArthroFLEX allograft used during surgery. The records provided for review document that this patient developed marked stiffness of the proximal radioulnar joint as well as the elbow due to trauma with subsequent heterotopic ossification. This condition caused the bony surfaces to stick to one another due to the ossification of the tissues around the bone. The provider dissected the capsule of the elbow and removed the calcified tissues. To ensure that the released tissues did not stick together and result in recurrent stiffness of the proximal radioulnar joint and elbow, the provider performed an interposition arthroplasty. As noted in the medical literature, acellular dermal matrix ArthroFLEX can be used in this clinical setting to prevent the bone surfaces from sticking and to help preserve motion. All told, the ArthroFLEX allograft used during surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the the ArthroFLEX allograft used during surgery was likely to be more beneficial for you than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services provided in the urgent care setting. Per Health and Safety Code section 1345(h), Health Plans must cover urgent care services to prevent serious deterioration of a patients health resulting from unforeseen illness or injury. The records provided for review document that this patient presented for routine care in anticipation of moving abroad for the next two years. Services performed included an annual physical examination, pelvic examination, and colposcopy to address abnormal results from her pelvic examination. Researchers noted that, Patients with an abnormal cervical cancer screening history require surveillance, which differs from routine screening for patients with normal prior screening results. However, none of the services provided were provided for the evaluation or treatment of an unforeseen illness or injury. An annual physical examination, venereal disease testing, and gynecologic care could all have been safely scheduled on an outpatient basis. All told, the services were not urgent care services as defined by California law.  Final Result: The reviewer determined that the services at issue were not urgent care services as defined by California law. Therefore, the Health Plans denial should be upheld. 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary care services. The records provided for review document that this patients medical history and current treatment plan are complex. Her provider has recommended a treatment regimen consistent with current National Comprehensive Cancer Network (NCCN) guideline recommendations. Given the presence of brain metastases, the requested services of a large cancer center with extensive experience in interdisciplinary care is indicated. Specialized cancer centers are designated as such by the National Cancer Institute (NCI) in a highly competitive peer-reviewed process. The documentation reviewed supports treatment at an NCI-designated cancer tertiary care center. Therefore, the requested tertiary care services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in medical oncology with subspecialty certification in hematology 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 a CT scan with contrast of the lower lumbar spine.American College of Radiology (ACR) Appropriateness Criteria for low back pain indicate that for a patient with chronic low back pain with radiculopathy, progressive symptoms, and a history of lumbar surgery, CT of the lumbar spine with IV contrast may be appropriate, however, CT is most appropriate in postfusion patients or when an MRI is contraindicated.In this case, while the patient has chronic low back pain with radiculopathy, progressive symptoms, and a history of lumbar surgery, he is not postfusion, and ACR guidelines indicate that MRI scan is the study of choice to evaluate a patient of this kind when not contraindicated. This patient has already had an MRI scan. An extremely detailed MRI report concerning the nature of the patients pathology is included in the submitted documentation. Under these circumstances, the requested CT scan with contrast of the lower lumbar spine 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 neurological 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 has requested authorization and coverage for minimally invasive lumbar laminectomy and interbody fusion L4-S1. In this case, the patient presents with severe, intractable lower back and leg pain and has failed standard non-operative treatments. She reports chronic pain. Diagnostic imaging shows severe degenerative disc disease at L5-S1, with more moderate degenerative changes at L4-5. In this clinical setting, given that the patient has failed several years of nonsurgical care and that the provider has identified the L4-S1 segments as likely pain generators, the requested service is medically necessary. Therefore, minimally invasive lumbar laminectomy and interbody fusion L4-S1 is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurological 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for transcranial magnetic stimulation (TMS). Researchers note that while TMS may be a safe, effective, brain-based treatment for depression in adolescents that could alleviate substantial morbidity and mortality, there are considerations for neurodevelopment and the unknowns associated with TMS exposure in adolescents. The authors note that larger studies on the clinical tolerability, safety, and clinical effects of TMS in adolescents with depression are needed to provide more systematic data. A study reports that approval by the U.S. Food and Drug Administration (FDA) is limited to adults with major depressive disorder, and that while there is evidence of safe therapeutic use and clinical benefit of repetitive TMS (rTMS) in adolescents with mood disorders, at present, there is insufficient evidence to support routine clinical rTMS use in this population. In this case, the patient is an adolescent with treatment resistant depression. There is a lack of data in current medical literature showing the superior efficacy for the requested service in this clinical setting. Therefore, TMS is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcranial magnetic stimulation (TMS) 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 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: Physician reviewers 1 and 3 are board certified in in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization. Researchers concluded that geniculate artery embolization is a safe and effective treatment approach for the management of recurrent hemarthrosis of the knee following arthroplasty and should be considered first-line treatment following failure of conservative management. Researchers reported that, Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following total knee arthroplasty. However, there is a lack of large-scale, long-term studies documenting the safety and efficacy of the geniculate artery embolization outside of recurrent hemarthrosis post arthroplasty. This patients records do not document any prior knee arthroplasty to support an indication for geniculate artery embolization. Therefore, the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested geniculate artery embolization of the right knee 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 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: 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.