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 methylphenidate (20 mg extended-release).At issue is whether methylphenidate (20 mg extended-release) is medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374.72(a)(3)(A). Adult ADHD, particularly with a history of childhood ADHD, is significantly debilitating and needs to be treated appropriately. Researchers indicate, Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. A researcher states, Amphetamines and methylphenidate and, less often, nonstimulants (atomoxetine, clonidine, and guanfacine) are used to treat ADHD. Moreover, medical literature shows, Severity of ADHD is improved by methylphenidate pharmacotherapy in routine clinical practice. Based on the medical literature, methylphenidate ER 20 mg is effective and safe for the treatment of adults with ADHD. In this case, the patient was diagnosed with ADHD as a child and did well on methylphenidate. Given that their condition worsened when they were off of the medication, the patient is now seeking to resume their treatment for ADHD. The requested medication is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. For these reasons, methylphenidate (20 mg extended-release) is medically necessary for 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 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 Supartz injection series in left knee. 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, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. 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, there is a history of prior viscosupplementation of the left knee with excellent results. Furthermore, the patients current treatment options are limited. The alternative is a total knee arthroplasty, which the patient would like to avoid due to her experience with the right knee replacement and revision. As such, the requested Supartz injection series in the left knee 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 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 reimbursement for FoundationOne CDx genetic testing (CPT code 0037U) provided by Foundation Medicine, Inc., on 10/22/20.Findings: Two out of three physician reviewers found that FoundationOne CDx genetic testing (CPT code 0037U) provided by Foundation Medicine, Inc., on 10/22/20 was likely to have been more beneficial for the enrollee than any available standard therapy.Understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials. For hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative breast cancer, testing for PIK3CA mutations with tumor or liquid biopsy to identify candidates for alpelisib plus fulvestrant should be performed. For patients that have exhausted standard treatments, novel markers may indicate eligibility for clinical trials or compassionate use medications. The use of NGS such as with FoundationOne is likely to be more effective than available standard therapy. Therefore, FoundationOne CDx genetic testing (CPT code 0037U) provided by Foundation Medicine, Inc., on 10/22/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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 authorization and coverage for Intracept procedure for intraosseous basivertebral nerves. As noted in the peer-reviewed medical literature, the use of Intracept procedure has been shown to be safe, effective and durable in multiple randomized controlled trials with follow-up beyond five years. The Intracept procedure is a minimally invasive outpatient procedure that is implant-free and allows for fast recovery. The Intracept procedure also preserves spinal integrity by negating need for extensive tissue exposure and disruption. This patient presents with a three-year history of severe chronic low back pain. The records document that the patient has been treated with conservative therapy including physical therapy, lumbar epidural injections, and medication management without substantial relief of her symptoms. The patients ability to perform activities of daily living have been severely limited due to her condition. Currently, there are no signs or symptoms of radiculopathy or myelopathy. Based on radiographic and MRI findings, the patient is a candidate for treatment with the Intracept procedure. For these reasons, the requested Intracept procedure for intraosseous basivertebral nerves is 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 Intracept procedure for intraosseous basivertebral nerves is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 80 units subcutaneously twice a week. The records provided for review document that this patient presents with idiopathic nephrotic syndrome. The patients provider has recommended treatment with Acthar Gel since the patient has failed treatment with prednisone and Bactrim DS. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of patients with idiopathic nephrotic syndrome. Chakraborty and colleagues found that Acthar Gel has resulted in remission in patients with immunosuppressive and steroid-resistant nephrotic syndrome. Madan and colleagues concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS [nephrotic syndrome] in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has failed conventional first-line treatment with prednisone and Bactrim DS. Therefore, the requested Acthar Gel 80 units subcutaneously twice a week 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Humira 40 mg/0.4 mL.According to the 2019 American College of Rheumatology/Arthritis Foundation Guideline (ACR/AF) for the Treatment of Juvenile Idiopathic Arthritis, in children and adolescents with juvenile idiopathic arthritis and active enthesitis despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), using a tumor necrosis factor (TNF) inhibitor, such as Humira, over methotrexate or sulfasalazine was recommended based on the current medical evidence. The ACR/AF guideline also indicates that while TNF inhibitors are preferred, a trial of methotrexate or sulfasalazine may be warranted for patients with contraindications to TNF inhibitors, patients with mild disease, and patients with concomitant active peripheral polyarthritis. Based on the aforementioned guideline, a nonbiologic disease-modifying antirheumatic drug (DMARD), such as methotrexate, is not mandatory for use prior to TNFi therapy, with Humira in this case.In this case, the patient has seronegative spondyloarthropathy/enthesitis type juvenile idiopathic arthritis with persistent ankle pain and swelling. The medical record indicates the patient tried and failed NSAIDs, such as ibuprofen. Therefore, a TNF inhibitor, such as Humira, is appropriate in this setting according to the guideline. The patient does not have a reported contraindication to TNF inhibitor therapy in the medical record. Furthermore, the patient  has  very active inflammatory arthritis with impaired weight-bearing and ambulation as well as active synovitis and erosive change involving the right ankle on imaging. The presence of erosion indicates the disease is advanced and not mild. In addition. the patients disease is reported to primarily involve the right ankle and polyarthritis is not described in this case. In conclusion, the requested Humira 40 mg/0.4 mL is medically necessary for the treatment for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injection to the pelvic muscles (CPT code 20553  trigger point injection(s) x 1 and HCPCS code J0585  injection, onabotulinumtoxinA 1 unit x 200). A review conducted by Karp and colleagues evaluated the effectiveness of Botox for chronic pelvic pain in the current medical literature. The authors found data supporting that Botox can be safely and tolerably injected into pelvic floor muscles in women as an outpatient procedure. Gari and colleagues noted that there is promising evidence to support the use of Botox in cases of refractory pelvic floor muscle dysfunction. The authors concluded that, Further randomized controlled trials are warranted to standardize the use of Botox as a treatment option for these cases. This patients records document chronic pelvic pain refractory to medication management, physical therapy, and interventional nerve blocks including ganglion impar and pudendal blocks. Moreover, the records document that previous treatment with Botox injections did not provide substantial relief of her pain. Given these findings, the requested Botox injection to the pelvic muscles (CPT code 20553  trigger point injection(s) x 1 and HCPCS code J0585  injection, onabotulinumtoxinA 1 unit x 200) are 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 anesthesiology with subspecialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for continued home health nursing services.According to Bhandari and Swiontkowski, acute subtrochanteric fractures are serious injuries that are generally treated with prompt surgery and rehabilitation. Kubiak and colleagues indicate that weight-bearing restrictions are often necessary to optimize healing while mitigating risk of fracture displacement or implant failure. The authors conclude, Most surgeons recommend a period of protected weight-bearing for patients with calcaneal, tibial plafond, tibial plateau, and acetabular fractures. In this case, the patient sustained a traumatic, acute subtrochanteric fracture that was surgically repaired but required weight-bearing restrictions for optimal healing. The patient has been undergoing rehabilitation to compensate for this weight-bearing restriction on his affected leg. The patient has managed to reach stand-by assistance level for his ambulation using a walker, which is the expected level of functioning for the patients baseline functional status as a middle-aged adult without major disabling conditions. The patient had skilled nursing needs initially on community reintegration, but his spouse has been taught and has learned to provide his once-daily enoxaparin injections and to apply a topical dressing over his surgical incision, which is healing well. There are no ongoing skilled nursing needs. Therefore, continued home health nursing services are not medically necessary for treatment of the patients medical condition.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 physical medicine and rehabilitation 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: An enrollee has requested authorization and coverage for Orthovisc injections in the left knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has a history of prior viscosupplementation, which was beneficial. The patient has not received any viscosupplementation since May 2020. Furthermore, cortisone injections were not effective in the past. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections in the left knee are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gelsyn-3 injection series in the left knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has received viscosupplementation every six months for the past three years and has had good benefit. Furthermore, the patients alternative is a unicompartmental knee arthroplasty. Therefore, the requested Gelsyn-3 injection series in the left knee is medically necessary for treatment of the patients medical condition.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Freestyle Libre Reader and Sensor Glucose Monitoring System.A continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Researchers indicate, Over the last decade, continuous glucose monitoring systems have been demonstrated to be clinically valuable. A continuous glucose monitoring system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Continuous glucose monitoring systems have been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. In this case, the patient has a history of hypoglycemia. Additionally, the patient is having difficulty utilizing finger sticks to test their glucose levels. Therefore, Freestyle Libre Reader and Sensor Glucose Monitoring System is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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.