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

Nature of Statutory Criteria/ Case Summary: This patient is being seen for chronic pain in the upper, mid and lower back, pelvis, and lower extremity. The patient rates the pain 7-8/10 on a 1-10 scale, and experiences difficulties with the activities of daily living due to the pain. The patient has tried ibuprofen, meloxicam, naproxen, gabapentin, various opioids, Cymbalta, lumbar epidural injection and physical therapy. The patients current medications are Norco and baclofen. The provider is requesting lidocaine patches. At issue is whether the lidocaine patch is medically necessary to treat the patients medical condition. Researchers studied the effectiveness of the 5% lidocaine patch as compared with a placebo (a patch with no drug in it) in chronic back pain (CBP) patients in a randomized double-blind study. Overall, the effects of a lidocaine patch on CBP pain could not be distinguished from that of placebo (no drug). Therefore, the lidocaine patch is not medically necessary for this patient.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and pain management 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for intravenous (IV) Gammagard for home use (1.4 gm/kg divided over three days initially, followed by 0.8 gm/kg divided over two days every four weeks). Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of medications. IVIG is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. The studies above note some benefit of IVIG in patients with small fiber neuropathy, though these patients have serologic evidence of autoimmunity. In this case, the patient has a clinical picture consistent with a small fiber neuropathy, a possible underlying autoimmune condition. However, the records do not include documentation of blood test markers associated with autoimmunity or inflammation. Therefore, IV Gammagard for home use (1.4 gm/kg divided over three days initially, followed by 0.8 gm/kg divided over two days every four weeks) is not likely to be more beneficial for treatment of the patients small fiber neuropathy than any available standard therapy. Final Result: The reviewers determined that the requested medication is 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Linzess 145 mcg capsules. The enrollee was having abdominal pain and a change in bowel habits that includes alternating diarrhea and constipation. The change in her bowel habits was over a 6-month period. She has a history of kidney stones and renal stent. The patient also complained of rectal bleeding with most bowel movements and complained of rectal pain. On physical examination by her gastroenterologist, there was tenderness with palpation of all abdominal quadrants. Her gastroenterologist reported the patient has tried a high fiber diet, water, and Miralax without any positive results and the patient reported that she feels that she retains stool. The gastroenterologist prescribed the medication Linzess 145 mcg capsules. This patient has chronic idiopathic constipation, which has failed to improve with high fiber intake and water consumption. The medication Linzess (generic name linaclotide) is the next Food and Drug Administration (FDA) approved step for this patient, as this medication is recommended for a patient with irritable bowel syndrome or a patient who has chronic idiopathic constipation. Therefore, the medication Linzess 145 mcg capsule is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 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 Nivolumab (Opdivo) 240 mg intravenous (IV) every two weeks and bevacizumab (Avastin) 2.5 mg/kg IV every two weeks. The U.S. Food and Drug Administration (FDA) has not approved the combination of Opdivo, Avastin, trametinib, and lapatinib for the treatment of metastatic cholangiocarcinoma. Moreover, there is a lack of medical literature or guidelines to support the safety and effectiveness of this therapeutic regimen. Further, Avastin and Opdivo are not within the standard of care for the treatment of metastatic cholangiocarcinoma as noted by the National Comprehensive Cancer Network (NCCN) guidelines. The records indicate that this patient has been treated with some of these medications with positive response. However, given the limited data demonstrating the efficacy of the requested medications in this clinical setting, the continued use of Avastin and Opdivo is not supported. For these reasons, the requested Opdivo 240 mg IV every two weeks and Avastin 2.5 mg/kg IV every two weeks are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Relizorb cartridges (immobilized lipase). The enrollee has cystic fibrosis and pancreatic insufficiency. He underwent a bilateral lung transplant with two episodes of transplant rejection in June 2017 and March 2019. His physician prescribed the medication Relizorb cartridges (immobilized lipase). The physician reports this medication will ensure proper nutrient intake and digestion of fats, and maintain adequate energy and protein stores. The physician reports this is necessary for his immune responses and to improve graft survival rate. This particular patient would benefit from the use of Relizorb during her nighttime tube feeds. The use of Relizorb is approved by the Food and Drug Administration (FDA) in children and is supported by studies to be safe and effective thereby elevating the use of this device to standard of care. Therefore, the medication Relizorb cartridges (immobilized lipase) is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with irritable bowel syndrome with diarrhea (IBS-D). The patient reported diarrhea, nausea, and unintentional weight loss. The patient underwent a colonoscopy that revealed non-bleeding internal hemorrhoids. The random colon biopsies obtained were noted to be negative for adenomatous change or malignancy. The patient reported diarrhea and abdominal cramping, which improved after bowel movements. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted loperamide was ineffective. A computed tomography scan of the abdomen and pelvis showed a distended gallbladder, diverticulosis, and a stable right lung nodule. An ultrasound of the abdomen, showed multiple gallstones in a nondilated gallbladder. The patient has requested authorization and coverage for Xifaxan 550 mg three (3) tablets daily for fourteen (14) days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Xifaxan 550 mg three (3) tablets daily for fourteen (14) days is medically necessary for the treatment of the patients medical condition. Ford and colleagues stated, We suggest the non-absorbable antibiotic rifaximin for reduction in global irritable bowel syndrome (IBS) symptoms, as well as bloating in non-constipated IBS patients. Authors reported, In a phase three study of patients with relapsing symptoms of IBS-D, repeat rifaximin treatment was efficacious and well tolerated. The authors also noted, Rifaximin was approved by the U.S. Food and Drug Administration (FDA) in May 2015 for the treatment of IBS-D in adults. In this case, the patient has been diagnosed with IBS-D. The patient reported diarrhea and cramping abdominal pain relieved after bowel movements. The patient has tried and failed treatment with loperamide. The medical evidence supports the requested medication in this clinical setting. Therefore, Xifaxan 550 mg three (3) tablets daily for fourteen (14) days 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 internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 30-day CardioNet mobile cardiac outpatient telemetry (CPT 93229). The patient has a low risk of a life-threatening arrhythmia based on his age, personal history, and family history. The records report that the patients echocardiogram was normal and he has no history of syncope. Current guidelines generally recommend external patient triggered or automated loop recorders for patients with infrequent symptoms. Use of MCOT real time monitoring is reserved for symptomatic patients with a high likelihood of life-threatening arrhythmias requiring immediate action or attention. This patient has infrequent but longstanding dizziness episodes without syncope. The records do not include any prior investigations for arrhythmia or evidence of structural heart disease. Based on this clinical scenario, the patient has a low likelihood of life-threatening arrhythmias as the cause of his symptoms. Thus, use of MCOT, as opposed to an external automated or patient triggered loop recorder, would not be considered an appropriate initial diagnostic test in the detection of a possible arrhythmia causing these isolated dizziness episodes. This is especially true in a patient who is otherwise at low risk for life-threatening arrhythmias that would require immediate or urgent real time interventions when noted on an MCOT monitor. Given these findings, the 30-day CardioNet MCOT (CPT 93229) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the 30-day CardioNet MCOT (CPT 93229) 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 internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with a helicobacter pylori infection. The patient reported epigastric pain. The patient had been taking meloxicam for neck pain. The treatment plan included starting pantoprazole and performing Helicobacter pylori testing. The patient underwent stool antigen testing for Helicobacter pylori infection, and the results were positive. The patient has requested reimbursement for Pylera (120 capsule blister pack) received. The Health Plan denied the request and reported the medication at issue was not medically necessary for the treatment of this patient. At issue in this case is whether Pylera (120 capsule blister pack) received was medically necessary for the treatment of the patients medical condition. Researchers reported, Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. The authors also noted, For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole. In this case, the patient has not tried and failed treatment with the preferred antibiotics in addition to acid suppression therapy (i.e., proton pump inhibitor, H2 receptor blocker or bismuth). The medical evidence does not support the medication at issue in this clinical setting. Therefore, Pylera (120 capsule blister pack) received was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gynecomastia reconstruction surgery.In this case, malignancy is not suspected. Furthermore, records reflect that the patient has breast enlargement due to residual fatty tissue in the breast area from exogenous obesity rather than true gynecomastia. He does not have unilateral or bilateral grade III or IV gynecomastia present, and there is no complaint of pain and discomfort due to distention and tightness from hypertrophied breasts. Under these circumstances, the requested gynecomastia reconstruction surgery is not medically necessary to treat the patients medical condition.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; or (2) to create a normal appearance, to the extent possible. In this case, fatty tissue in the breast area is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to the gain or loss of body mass. In addition, no functional loss is present, and the appearance of the patient is normal and consistent with the gain and loss of weight. Accordingly, the requested gynecomastia reconstruction surgery is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile outpatient cardiac telemetry (MCOT) (CPT 93229). This patient has low risk of a life threatening arrhythmia based on age, the prolonged length of her symptoms, and no prior cardiac history or family history of sudden death or congenital arrhythmias. Current guidelines generally recommend external automated loop recorders for patients with infrequent syncope and the use MCOT real time monitoring for patients with syncope and a high likelihood of life-threatening arrhythmias requiring immediate action or attention. This patient has experienced infrequent episodes and the records do not include documentation of prior investigations for arrhythmia. Therefore, the use of real time monitoring with MCOT, as opposed to an external automated loop recorder, would not be an appropriate initial diagnostic test in the detection of a possible arrhythmia causing these isolated episodes. This is especially true in a patient who is at low risk for life-threatening arrhythmias that would require immediate real time interventions. All told, the MCOT (CPT 93229) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MCOT (CPT 93229) was 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 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 internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for genito-urinary biofeedback therapy. This enrollee was diagnosed with polyuria, chronic interstitial cystitis, and dyssynergia on. He reports urinary frequency, up to 20 times per day, and bladder pain. A cystoscopy did not show a reason for his symptoms. The enrollee reports he is unable to go out or do any normal activities. Genito-urinary biofeedback therapy is medically necessary to treat this enrollees condition of bladder dysfunction and detrusor sphincter dyssynergy.  The combination of biofeedback with pelvic floor manual therapy has shown improvement and benefit in bladder and bowel dysfunction.  This is a minimally invasive therapy that can significantly improve the enrollee's quality of life, with minimal side effects.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in urology 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 similar medical condition.