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 left occipital radiofrequency ablation (RFA). Findings:  The physician reviewer found that the peer-reviewed medical literature, Urits and colleagues compared treatment options for occipital neuralgia. The authors found that RFA, peripheral nerve stimulation and surgical management have proven to have varying degrees of efficacy; however, they do demonstrate the potential benefits of decreased recurrence, increased functionality and overall improvement compared with conservative treatments. Hoffman and colleagues analyzed pain reduction in 39 patients treated for occipital neuralgia with radiofrequency ablation using the visual analog scale (VAS). The authors reported findings supporting that radiofrequency is effective at reducing pain scores for six months in patients with occipital neuralgia. In this case, the patient has chronic left-sided occipital neuralgia that has failed to respond to conservative care including medication management using non-steroidal anti-inflammatory drugs (NSAIDs), baclofen, gabapentin, and tricyclic medications. The records show that the patient has responded well to occipital nerve blocks and pulsed RFA treatments with improvement of symptoms for a meaningful duration up to three months. Given these findings, the requested left occipital RFA is 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 requested left occipital RFA 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 reviewers 1, 2, and 3 are board certified in anesthesiology with subspecialty certification in pain management 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 patient has been diagnosed with osteoarthritis of both knees. The provider noted that the patient had received a series of Orthovisc injections which provided relief for nine months. She was treated with viscosupplementation of both knees using Synvisc. The patient has requested reimbursement for Synvisc injections in both knees that were provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc injections in both knees that were provided on were medically necessary for the treatment of this patients medical condition.  Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit with prior viscosupplementation injections provided that lasted nine months. The medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc injections in both knees that were provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The patient has been diagnosed with bilateral knee osteoarthritis, and is requesting Synvisc One injection in the right knee.  Findings: Medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when 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, including a corticosteroid injection and physical therapy, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc One injection in the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 immunoglobulin therapy with Cuvitru. The records provided for review do not support a diagnosis of specific antibody deficiency. The providers notes indicate that the patients pre-Pneumovax streptococcal pneumonia antibody titers were 13/14 and labeled as low and that his post titers were 7/14. Protective titers of 13 out of 14 demonstrates an adequate level of antibody levels and protection to streptococcal pneumoniae. Although the provider noted the presence of purulent rhinorrhea, there is a lack of evidence of active or chronic infection with computed tomography (CT) sinus scans or positive cultures. Moreover, there is no report of recurrent antibiotic therapy or attempts at treating the patients rhinorrhea and chronic sinusitis with nasal corticosteroids. For these reasons, the requested immunoglobulin therapy with Cuvitru is 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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 a continuous positive airway pressure (CPAP) machine. Recommendations on managing obstructive sleep apnea include weight loss, CPAP treatment as initial therapy, and mandibular advancement devices as alternative therapy. In this case, the patients sleep study did not show evidence of sleep apnea. Specifically, a sleep study showed normal apnea-hypoxia index and no evidence of nocturnal oxygen desaturation during the night of observation. Based on this, there is  insufficient information to support a CPAP machine as medically indicated in this clinical setting. Therefore, the requested CPAP machine is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 internal medicine with sub-specialty certifications in pulmonary disease and critical care 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 Botox injection.The medical literature does not support that the requested service is medically necessary. The pathophysiology of myofascial pain remains uncertain, and multiple neurologic, myogenous, and psychological theories have been postulated. Although there is strong anecdotal evidence supporting the use of Botox to treat myofascial pain, many clinical trials have fallen short of producing conclusive results and further studies are needed to establish protocols for use. Studies noted that there are conflicting reports in the literature regarding the efficacy, safety, and predictors of therapeutic response to Botulinum toxin type A (BoT-A) therapy for management of refractory masticatory muscle pain. They performed a retrospective chart review involving 116 participants and concluded that BoT-A therapy provides significant relief for approximately one third of patients with refractory masticatory muscle pain. In this case, the patient reports pain, numbness, and a burning sensation on the right side of the face, and she has been given a diagnosis of sprain of the temporomandibular joint (TMJ) on the right side. As noted above, while there is strong anecdotal evidence supporting the use of Botox to treat myofascial pain, many clinical trials have fallen short of producing conclusive results and further studies are needed to establish protocols for use. Under these circumstances, the requested Botox injection is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 prescription medication Zioptan 0.0015%, one droplet in each eye, once a day. Findings:  The physician reviewer found that in a comparison of bimatoprost, latanoprost, travoprost, and tafluprost that all four drugs equally and significantly reduced the intraocular pressure in patients with primary open-angle glaucoma. In this case, the patient has tried and failed Alphagan, latanoprost, and preservative-free dorzolamide-timolol combination drops. Given that there is a lack of reasonable alternatives for treating the patients glaucoma, Zioptan is medically indicated. Therefore, the prescription medication Zioptan 0.0015%, one droplet in each eye, once a day 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 ophthalmology 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

The patient has requested authorization and coverage for corneal collagen cross-linking procedure. Medical studies on cross-linking measure prior documented disease progression in order to scientifically determine whether the treatment is effective. Researchers found that corneal collagen cross-linking is a safe and effective method for halting the deterioration of keratoconus, while slightly improving visual function. Researchers found long-term stability of keratoconus after cross-linking without relevant side effects. In this case, given the patients vision loss, examination findings, and the natural progression of keratoconus, cross-linking is medically indicated. Therefore, the requested corneal collagen cross-linking procedure is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nonemergency medical transportation (NEMT) gurney transportation to and from dialysis.At issue is whether nonemergency medical transportation (NEMT) gurney transportation to and from dialysis is medically necessary. Gurney (litter) vans are transportation vehicles that can accommodate a gurney for patients who are unable to sit upright for the duration of the journey. In this case, the patient is deconditioned and has a prior history that includes stroke, atrial fibrillation, hypertension, congestive heart failure and diabetes mellitus. The patient has been hospitalized in the previous months for post-dialysis complications and possible stroke. The submitted documentation includes a home health evaluation following the patients most recent hospitalization. This evaluation notes that the patient required maximal assistance getting in and out of cars and that he was a fall risk with difficulty ambulating on uneven surfaces. The same evaluation notes that the patient was able to ambulate with supervision. Records indicate that the patient uses a manual wheelchair and four wheel walker (FWW) for in home mobility, and it has been noted by the patients spouse and caregiver that the patient ambulates to the bathroom. The Health Plan has approved wheelchair van transportation with basic life support for the patient. Based on the limited documentation provided, there is no substantiation that the patient is not able to sit up in a transport vehicle for transportation to and from the dialysis center. Under these circumstances, the requested nonemergency medical transportation (NEMT) gurney transportation to and from dialysis is not medically necessary based on the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary based on the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a COVID-19 antibody test. The Centers for Disease Control (CDC) does not currently recommend antibody testing as the sole basis for diagnosis of acute infection. The CDC states that policies regarding testing are made at the state and local levels. The California Department of Public Health states that there are four tiers of priority for antibody testing. Tiers 1 and 2 focus on individuals with current symptoms. Tier 3 is for asymptomatic individuals who are essential workers or educational workers. Tier 4 is for individuals who are asymptomatic but at risk of getting the infection. Currently, there are over 91 manufacturers of serologic tests for SAR-CoV-2, without well-delineated performance characteristics. In their review of serologic tests, researchers further suggest that false positive rates are concerning. Finally, given the uncertainty of the immunology of the virus, the interpretation of serologic findings can be problematic. In this case, the patient does not fit California Department of Public Healths four tiers of priority for testing. Further, the first cases of COVID-19 were recognized in December 2019. Thus, it is unlikely that the patient was exposed to COVID-19 in California earlier. Therefore, the requested COVID-19 antibody test is not medically necessary for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic test, also known as F1CDx. The records provided for review document that this patient was diagnosed with pancreas ductal adenocarcinoma. A CT scan demonstrated a 2.5 cm solid mass in the pancreatic head, as well as multiple subcentimeter cystic lesions in the pancreatic tail. The genetic mutations present in pancreatic cancer can provide prognostic significance and can help direct therapy. According to the National Comprehensive Cancer Network (NCCN) guidelines, Germline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. Genetic counseling is recommended for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status. Moreover, the NCCN states that providers should test for actionable somatic findings including, but not limited to fusions (ALK, NR G1, and TRK, ROS 1), mutations (BRAF, BRCA 1/2, HGR 2, KRAS, PAL B2), and mismatch repair (MMR) deficiency, which are included in the FoundationOne test. Researches reported improved progression-free survival in patients treated with regimens selected by molecular profiling when compared to patients on standard chemotherapy regimen. Given this support, the FoundationOne CDx comprehensive genomic test, also known as F1CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the FoundationOne CDx comprehensive genomic test, also known as F1CDx was 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 likely to be more beneficial for evaluation 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 internal medicine with subspecialty certification in medical oncology 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 intravenous Entyvio.The medical literature supports that the requested medication is medically necessary. Entyvio is supported as primary therapy for the treatment of Crohn's disease. Entyvio has shown efficacy in patients with Crohn's disease, even if there has been inadequate response to other therapies. In the GEMINI II trial, Entyvio proved efficacious for induction of remission in a randomized controlled trial of 368 patients, as well as a large cohort of 747 patients. It has also proven effective for maintenance of remission, achieving a 39% remission rate in patients who had failed prior therapies. Systematic reviews found that Entyvio is significantly more effective for inducing remission than placebo. The use of Entyvio is supported by American College of Gastroenterology guidelines in patients with Crohn's disease regardless of whether other therapies have been attempted or failed. In this case, the patient has Crohns colitis and has had unexplained neurologic symptoms (blurry vision) while on Humira, and the use of Stelara is less appropriate than Entyvio given the association of Stelara with posterior reversible encephalopathy syndrome. Entyvio, in contrast, is gut-selective and additionally does not appear to cross the blood-brain barrier. Accordingly, the requested intravenous Entyvio is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Huggies brand incontinence diapers. Daytime urinary incontinence is common in the pediatric population and affects approximately 7-10% of children aged five to thirteen years. Risk factors for incontinence can be genetic, demographic, environmental, behavioral, or physical. In this case, the patient is 17 months old, and is not yet expected to be continent. As part of routine infant and toddler care, diapers are not medically indicated for the patient at this time. Therefore, Huggies brand incontinence diapers are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested supplies 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 critical care 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.