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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for (1) acupuncture services, and (2) acupuncture services (including scalp acupuncture, Jing Zheng, traditional Chinese medicine and Chinese herb therapy). In a systematic review and meta-analysis, Tu and colleagues concluded, Acupuncture was effective and safe in the patients with flaccid hemiplegia after stroke. Yu and colleagues reported, From the available evidence, acupuncture may have beneficial effects on improving dependency, global neurological deficiency, and some specific neurological impairments for people with stroke. Hu and colleagues report, Scalp acupuncture therapy combined with exercise therapy can significantly improve the ability of stroke patients to participate in daily activities. In this case, in an application for independent medical review, the patient reported having undergone acupuncture treatment that was helpful. While the provider noted excellent progression, the acupuncture services overlapped with other therapies. Despite being requested, the submitted records did not document pre-acupuncture and post-acupuncture baselines in activities of daily living-function for comparison purposes. The records did not include progress notes by the acupuncturist documenting any measurable, progressive, significant, objective functional improvement or quantifiable responses to treatment obtained with the acupuncture sessions already completed. Physical therapy progress notes reported that the patient progressed with the rehabilitation instituted. In this clinical setting, given the lack of documentation of specific benefits directly attributed to the use of acupuncture, scalp acupuncture, and other techniques used by the acupuncture provider, the requested services are not medically indicated. Therefore, (1) acupuncture services, and (2) acupuncture services (including scalp acupuncture, Jing Zheng, traditional Chinese medicine and Chinese herb therapy) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. McClintock and colleagues note that there is an abundance of data pertaining to the safety and efficacy of TMS for individuals with major depressive disorder. The American Psychiatric Association (APA) guidelines for the treatment of major depressive disorder recognize the safety and efficacy of TMS in the treatment of patients with a prolonged course of depression. In this case, the records document treatment refractory depression, as the patient has failed three antidepressant trials in addition to psychotherapy. The provider has recommended treatment with TMS.  While the Health Plan indicates that the patient is diagnosed with bipolar disorder due to a prescription of Lamictal, the records note that the patient has been diagnosed with recurrent and severe major depressive disorder. Lamotrigine is prescribed as an adjunct for refractory depressive symptoms, based on the established treatment algorithms, and does not indicate that the patient has a diagnosis of bipolar disorder. Given that current medical literature supports the use of TMS for the treatment of refractory depression, the requested services are medically indicated. In this patients case, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service 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. Therefore, TMS services  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial Botox injections. Mehta and colleagues note that temporomandibular disorders (TMD) are associated with substantial morbidity, affecting quality of life and work productivity, and that the goals of TMD management are to alleviate pain and to improve jaw function and quality of life. The authors further explain that standard noninvasive management includes self-care and education, physical therapy, occlusal splints, behavioral therapy, and adjunctive pharmacotherapy, while for patients with TMD symptoms refractory to noninvasive management, treatment options may include trigger point muscle injections, botulinum toxin injections, intra-articular injections, or, in some patients, surgery such as arthrocentesis, arthroscopy, arthroplasty, or temporomandibular joint (TMJ) reconstruction. Awan describes botulinum toxin (Botox) as an exotoxin produced from Clostridium botulinum that blocks the release of acetylcholine from the cholinergic nerve end plates resulting in inactivity of the muscles or glands innervated. In a review of the current evidence pertaining to Botox use in non-cosmetic head and neck conditions, the author reported findings showing evidence of the efficacy of Botox in the treatment of TMJ disorders. Abdi explains that complex regional pain syndrome (CRPS) remains a relatively mysterious chronic pain disorder, characterized by pain in an area that is disproportionate in time or degree to the usual course of any known trauma or other lesion. The author notes that a multidisciplinary approach is suggested for the management of CRPS, with appropriate interventions including physical therapy, occupational therapy, pharmacotherapy, psychosocial and behavioral therapy, and, for patients with refractory pain, trigger/tender point injections and regional sympathetic nerve block. The author does not mention Botox as a typical treatment modality for CRPS. In this case, the patient has a TMJ disorder and CRPS that developed after double jaw surgery, and the provider has recommended a trial of Botox into the masseter muscles to address the patients TMJ disorder. Given that current medical literature supports the efficacy of  Botox in TMJ disorders, the requested services are medically indicated. Therefore, facial Botox injections 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for AMONDYS 45 (casimersen) weekly infusions.Findings: Three out of three physician reviewers found that the requested medication is likely to be more beneficial than any other available standard treatments for the enrollee's medical condition.Duchenne muscular dystrophy (DMD) is a rare, progressive, neuromuscular disease. The disorder is inherited in an X-linked recessive fashion and is caused by loss-of-function mutations in the DMD gene coding for dystrophin, a cytoskeletal protein that stabilizes the plasma membrane of muscle fibers. Most treatments currently available for DMD are palliative and are aimed at prolonging the patients ability to walk and at improving breathing and cardiac function. Treatment with corticosteroids has been found to be the most effective option for patients, resulting in improved muscle strength, prolongation of the ability to walk, and better pulmonary function. However, corticosteroids only delay disease progression, and treatment is associated with significant side effects, including weight gain, osteoporosis, and cataracts (Hendricksen, R., et al.).Casimersen (Amondys 45) is a phosphorodiamidate morpholino oligomer designed to bypass frameshift DMD mutations and produce internally truncated, yet functional, dystrophin protein in patients amenable to exon 45 skipping. On February 25, 2021, the U.S. Food and Drug Administration (FDA) approved the drug via the accelerated approval pathway (Fast Track and Priority Review designations). Amondys 45 also received Orphan Drug designation. The FDA based their approval on interim efficacy at Week 48 of the Phase 3 of the ESSENCE trial, which is still ongoing and expected to conclude in 2024. Interim results at week 48 showed that the patients who received Amondys 45 had a statistically greater increase in dystrophin protein levels in skeletal muscle compared to patients on placebo (P =0.004). Wagner and colleagues have reported that casimersen was well tolerated in participants with DMD amenable to exon 45 skipping. Under these circumstances, the requested AMONDYS 45 (casimersen) weekly infusions are likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatments for the patient's medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 reimbursement for positron emission tomography (PET). According to the American College of Radiology (ACR) recommendations for imaging of the axilla, ultrasound is an appropriate imaging modality for evaluating nodal disease in patients with breast cancer. As noted by the ACR, ultrasound is especially beneficial when the abnormality is palpable, as it allows for directed biopsy, and a pathologic diagnosis. In this clinical setting, ultrasound is considered the first-line imaging modality for evaluation of a palpable abnormality. In addition, there is a lack of support for the use of PET in the evaluation of this patients axilla. Overall, PET has noted limitations in detecting nodal disease in patients with breast cancer. For these reasons, the PET was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification in diagnostic radiology 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 and prospective authorization and coverage for sclerotherapy services. The records provided for review document that this patient presented with spider veins of bilateral lower extremities and lymphedema. Evaluation with ultrasound ruled out reflux and deep vein thrombosis. The patients providers impression included was that the patients leg swelling was not likely due to the spider veins. The provider recommended treatment with compression stockings and elevation. The patient underwent two treatment sessions with sclerotherapy, at which time their pain score was 0/10. As discussed in medical literature, sclerotherapy is not likely to be more beneficial than standard treatment modalities for treatment of spider veins without evidence of venous reflux. Based on the documentation provided for review, the sclerotherapy services were not and are 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 services at issue were not and 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 reviewer 1 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in general surgery with subspecialty certification in vascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain.Findings:  The physician reviewer found that patient presents with a history of Morgellons disease with reported neurological symptoms. Morgellons disease is a dermatological condition characterized by the presence of multicolored microscopic fibers in skin lesions or lying under unbroken skin (Fesler, et al.). According to the best available scientific evidence, Morgellons disease is considered a dermopathy associated with tick-borne /disease. In addition to fiber production, some patients may experience stinging, biting, and crawling sensations. Systemic symptoms may include fatigue, joint pain, cognitive difficulties, and neuropathy (Middelveen, et al.). This patients provider has recommended evaluation of the patients Morgellons disease with MRI of the brain. However, the peer-reviewed medical literature does not recommend MRI of the brain as part of the routine evaluation of patients with Morgellons disease. Moreover, the records provided for review do not include details of the patients history, physical examination, or assessment of the patients symptoms to support an indication for evaluation with an MRI of the brain. For these reasons, the requested MRI of the brain is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Repatha SureClick injections. The American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for low density lipoprotein (LDL) cholesterol lowering for management of atherosclerotic cardiovascular disease risk (Lloyd-Jones, et al.). Per the ACC guidelines, Repatha may be considered when the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia. The records provided for review do not include documentation that the patient has been unable to achieve an LDL goal of less than 70 mg/dL while on a statin plus ezetimibe. Therefore, the requested Repatha SureClick injections are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled clinical trials on the treatment of patients with IBS-D (Schoenfeld, et al.). In addition, the American College of Gastroenterology (ACG) guidelines for the treatment of IBS state that Xifaxan has been shown to be safe and effective for use in this patients clinical setting (Ford, et al.; Cangemi, et al.). The clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days. For these reasons, the requested Xifaxan 550 mg tablet (three tablets a day for 14 days) 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 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 reimbursement for genetic testing. The records provided for review document that this patient presented with uterine cancer, which was determined to have loss of MSH2 and MSH6 on staining. Genetic testing for Lynch syndrome is recommended in patients with a history of uterine cancer and immunohistochemistry showing loss of expression of one or more of the mismatch repair (MMR) genes, including MSH2 and MSH6. This patients tumor showed loss of staining of MSH2 and MSH6. As there is significant overlap among inherited cancer predisposition syndromes, it is becoming increasingly common to evaluate patients at risk for inherited cancer predispositions with larger genetic testing panels, as in this patients clinical setting. LaDuca and colleagues concluded that, Opportunities to improve upon identification of patients at risk for hereditary cancer predisposition include revising BRCA1/2 and Lynch syndrome testing criteria to include additional clinically actionable genes with overlapping phenotypes and relaxing testing criteria for associated cancers. All told, the genetic testing was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics 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 reimbursement for bilateral reduction mammoplasty.The submitted documentation supports the medical necessity of the services at issue. Researchers report that reduction mammoplasty has a positive impact on a range of symptoms associated with macromastia, including greater improvement in back pain, neck pain, and poor posture, even with lower volume resections and regardless of body surface area-calculated adjustments. Likewise, the American Society of Plastic Surgeons (ASPS) guidelines on reduction mammoplasty note that reduction mammoplasty has been shown to improve quality of life. The guidelines further note that evidence is inconclusive on whether increased body mass index is associated with increased risk of complications. Researchers note that while many insurance carriers continue to deny coverage for reduction mammoplasty unless a minimum weight of 500 grams of breast tissue per breast is resected during surgery, a distinct cohort of women who are clinically appropriate candidates may not meet this criterion. In this case, the patient had a prior breast reduction with inadequate tissue removal to relieve her symptoms of neck and back pain, and with complications that resulted in significant scarring of the breasts. The records noted that 1,083 grams were removed from the right breast, and 1,130 grams were removed from the left breast specimen. Therefore, bilateral reduction mammoplasty was medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the records document an abnormal structure of the body caused by macromastia and complications from prior breast reduction surgery. The bilateral reduction mammoplasty was performed to relieve symptoms of macromastia and managed significant cutaneous scarring as a result of complications of the prior breast reduction surgery and provided a significant improvement in the appearance of the patients breasts. Therefore, the bilateral reduction mammoplasty was reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the bilateral reduction mammoplasty was medically necessary for treatment of the patients medical condition and was reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.