Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab. Treatment for autoimmune autonomic ganglionopathy (AAG) is complicated due to its rarity. Mckeon and Benarroch note that AAG is a peripheral autoimmune autonomic disorder that manifests with acute or subacute onset of generalized or selective autonomic failure. The authors further note that recognition of an autoimmune basis for autonomic disorders is important as they have the potential to improve with immune therapies. Nakane and colleagues report that some patients with AAG improve with immunotherapies such as intravenous immune globulin (IVIg) therapy, corticosteroids, or plasma exchange. In a study including nine patients, Bouxin and colleagues suggested that rituximab (alone or in association with other treatments) could provide efficacy in treating AAG when plasma exchange and/or IVIg were not effective enough. Although rituximab has not been evaluated on a large scale in randomized trials due to the rarity of AAG, the use if rituximab in this clinical setting is supported by current medical literature regarding the auto-immune nature AAG and its response to immunologic regimens, along with case reports showing the efficacy of rituximab in the setting of concurrent plasma exchange. Therefore, rituximab is 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 rituximab 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 medication 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 neurology with sub-specialty certification in vascular neurology and is actively practicing. Physician reviewers 2 and 3 are board certified in neurology 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

An enrollee has requested authorization and coverage for two sessions of somatic therapy per week.At issue in this case is whether the two sessions of somatic therapy per week are medically necessary to treat the patients medical condition. as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the of the patient, treating physician, or other health care provider.The literature supports somatic therapy at least once weekly and up to twice a week for an indefinite duration of treatment. Given this patients past medical history, it would be prudent to provider a more intensive outpatient treatment, which can be tapered down over time, to prevent any further decompensation and help her to regain her baseline level of functioning. Since the trauma symptoms are the ones triggering her suicidality and preventing her from being able to return to work, it is imperative that these are addressed specifically through intensive outpatient therapy. In this patients case, two sessions of somatic therapy per week are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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, two sessions of somatic therapy per week are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality autoinjector 120 mg/mL. The records provided for review document that this patient sustained facial trauma in an accident a few years ago that has required extensive surgery. The patient now presents with complaints of migraines. The provider charted that the patients migraine symptoms are no longer improved with gabapentin. The patients provider has recommended treatment with Emgality and topiramate. Migraine is an episodic disorder, the centerpiece of which is a severe headache generally associated with nausea and/or light and sound sensitivity. Emgality is a calcitonin gene-related peptide (CGRP) antagonist. Recent studies have reported that Emgality is safe and effective in preventative migraine management. Moreover, Emgality is U.S. Food and Drug Administration (FDA) approved for migraine prophylaxis. Given the established effectiveness and safety of Emgality as well as this patients history, the requested treatment regimen including topiramate and Emgality is appropriate. Therefore, the requested Emgality autoinjector 120 mg/mL 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 neurology with subspecialty certification in vascular 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 patient has requested authorization and coverage for dextroamphetamine-amphetamine salts IR 20 mg tablets, quantity 90 for 30 days. The provider noted that the patients ability to function is significantly improved with dextroamphetamine-amphetamine salts IR 20 tablets, quantity 90 for 30 days, compared to treatment at a lower dosage. Adult ADHD, particularly in patients with a history of childhood ADHD, can be significantly debilitating and requires continuous treatment. The patient requires a higher dosage given the patients tolerance, which has likely increased over time with this class of medication. The documentation supports that dextroamphetamine-amphetamine salts IR is an effective and safe treatment option for this patient based on current medical literature and recommendations (Cortese). For these reasons, the requested dextroamphetamine-amphetamine salts IR 20 mg tablets, quantity 90 for 30 days, are 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. California Health and Safety Code 1345(h) states that Health Plans must cover urgent care services to prevent serious deterioration of a patients health resulting from unforeseen illness or injury for which treatment. This patients records document that he presented to a provider in Israel with complaints of unintentional weight loss, constipation, melena, and loss of appetite. The provider noted concern for colorectal cancer and recommended a colonoscopy to be performed as soon as possible. Current medical literature supports the use of fast-track colonoscopy for the evaluation of this patients change in bowel habits, gastrointestinal bleeding, and unintentional weight loss, all of which are concerning for colorectal cancer (Gregory). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines support the use of colonoscopy in this patients clinical setting as a delay in the diagnosis of colorectal cancer can be detrimental (Early, et al.; Lee, et al.). Given the patients drop in hemoglobin, an evaluation for possible sources of lower gastrointestinal bleeding was indicated (Strate and Gralnek). Given the patients presentation and history, the colonoscopy helped to prevent serious deterioration of the patients health resulting from unforeseen illness or injury. Accordingly, the colonoscopy was provided for the treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the services were for the treatment of an urgent medical condition as defined by California law. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology 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 an Aimovig 70 mg/mL autoinjector. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inadequate response to topiramate. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration (FDA) has approved the use of Aimovig, a CGRP antagonist, for the preventive treatment of migraines in adults. In this case, the patient has a history of chronic migraines with inadequate response to topiramate and nortriptyline. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Aimovig 70 mg/mL autoinjector is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 patient has requested authorization and coverage for C6-7 right-sided radiofrequency ablation (RFA). The records provided for review document that this patient presents with chronic right-sided facetogenic neck pain status post anterior cervical discectomy and fusion at C5-6. The patient was diagnosed with facetogenic pain via medial branch blocks. She underwent treatment with RFA at C3-4, C4-5, and C5-6 with 80% relief of her neck pain. Further treatment with medications and physical therapy have been unsuccessful. The patients current pain represents recurrence of pain from the medial branch of C6-7 that was last treated with RFA with eight months of relief. In light of the recurrence, the provider has recommended RFA of the medial branch at right C6-7. Burnham and colleagues reported that in a study of 87 patients treated with RFA, 70% reported improvement at six month follow-up. Overall, cervical medial branch RFA has been demonstrated to be a safe and effective treatment for facetogenic pain with positive medial branch blocks, as in this patients case. Given this support, the requested C6-7 right-sided RFA 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient multidisciplinary pediatric feeding program. Current medical literature on pediatric feeding disorders supports the use of multidisciplinary programs that incorporate behavioral intervention with nutritional management. Romano and colleagues report that management of non-organic feeding disorders may be on an inpatient or outpatient basis. In an evidence-based systemic review, Gosa and colleagues concluded that joint nutrition and behavior intervention programs, systematic desensitization, and operant conditioning behavioral therapy approaches may be effective in improving the functional feeding and swallowing outcomes in children. In this case, the patient has a limited repertoire of accepted foods, without apparent dysphagia and with ongoing normal growth. While the patients diet suggests deficiency in multiple micronutrients, the records do not show trials of outpatient feeding therapies without improvement. Given the availability of therapy options in outpatient settings, the requested services are not medically indicated. Therefore, an inpatient multidisciplinary pediatric feeding program is 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 pediatrics with sub-specialty certification in pediatric gastroenterology 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: A patient has requested authorization and coverage for Orthovisc injection series in the right 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 a history of lasting benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the requested Orthovisc injection series in the right 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: The patient has requested authorization and coverage for Hyalgan or Supartz. Findings: This patient presents with a history of right knee pain due to progressive degenerative changes as demonstrated on magnetic resonance imaging (MRI). Treatment has included an unloader brace, Naproxen, topical diclofenac, Norco, and ibuprofen. The provider has recommended treatment with viscosupplementation with Hyalgan or Supartz injections of the right knee for osteoarthritis. 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 patients clinical setting, the remaining treatment options are limited. In this clinical setting, treatment with either Hyalgan or Supartz is appropriate. Given these findings, the requested Hyalgan or Supartz 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a hyaluronan injection in each 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 patients options are limited. The patient has tried and failed other conservative treatments. Therefore, the requested hyaluronan injection in each knee is medically necessary for the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  A patient has requested authorization and coverage for brand name Zoloft.Findings: The use of a SSRI, serotonin-norepinephrine reuptake inhibitor (SNRI), tricyclic antidepressant (TCA), benzodiazepine, or CBT as the initial treatment for panic disorder is strongly supported by demonstrated efficacy in numerous randomized controlled trials. If a patients first unsuccessful treatment is with an SSRI or an SNRI, a recommended approach is to switch to a different SSRI or SNRI. If the patients symptoms do not respond to two different SSRIs or SNRIs, switching to or adding other classes of medication that have demonstrated efficacy for panic disorder may be considered. In this case, the patient has not had full remission of symptoms even on the generic sertraline. Additionally, the records do not document that the patient has tried an SNRI, which would likely be more beneficial than a brand name SSRI at higher than approved doses. Additionally, studies have shown that the generic and brand name sertraline (Zoloft) are bioequivalent so there would not be any further gains made for this patient at the brand name of this medication compared to the generic. For these reasons, brand name Zoloft is not medically necessary for treatment of this patient. The requested medication is not in accordance with the generally accepted standards of mental health and substance use disorder care. The requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is 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.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 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.