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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clonazepam (Klonopin) 0.5 mg tablets (120 tablets per 30 days). There is a lack of evidence in the medical literature to support the use of benzodiazepines for the treatment of chronic anxiety. Darker and colleagues noted, Long-term use of benzodiazepines is not generally recommended and can lead to physical and psychological dependence and withdrawal symptoms. Researchers further outlined the long-term risks of benzodiazepines. This patient has a history of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, and cannabis use disorder. Per chart review, there were no vital signs to support that the patient is experiencing benzodiazepine withdrawal. Given the lack of evidence-based data on the use benzodiazepines for the long-term treatment of generalized anxiety disorder, the requested clonazepam (Klonopin) 0.5 mg tablets (120 tablets per 30 days) 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 psychiatry with subspecialty certification in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral brachioplasty. According to the American Society of Plastic Surgeons (ASPS), When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. This patient has excess skin on her upper arms from massive weight loss. She complains of discomfort and intertrigo under her arms, but there is no report of appropriate medical treatment of intertrigo or of failure of appropriate medical treatment of intertrigo. Active intertrigo is not present on physical examination. The patient does not have a functional problem with intertrigo under her arms that has been demonstrated to be resistant to appropriate medical treatment. Based on the evidence-based literature, the requested bilateral brachioplasty is not 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. This patients lax skin under the arms is not an abnormal condition of the body that is the result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. The lax skin is a normal structural change that is an accommodative response to the gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested procedure will not provide a more than minimal improvement in the patients appearance. All told, the requested bilateral brachioplasty is not reconstructive in nature 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient was admitted for alcohol and benzodiazepine withdrawal management. He was treated with a Librium taper. He had finished the Librium taper and his CIWA was 8 with stable vital signs. He reported ongoing symptoms of withdrawal including restlessness, anxiety, poor concentration, and insomnia. The patient has chronic back pain, which has been a trigger for his use of alcohol and other substances. The provider noted that the patient experienced mild to moderate symptoms that should not have interfered with his recovery treatment. The patient has a long history of depression, suicidal ideation, and at least one suicide attempt. The patient was reportedly suicidal with thoughts of overdosing while in the RTC. He participated in groups and able to attend to his activities of daily living. The patient was willingly engaged in treatment as a proactive participant, aware of having an addiction problem, and was committed to addiction treatment and changing his substance use. The patient engaged in frequent use of alcohol and benzodiazepines. He was experiencing significant cravings to drink alcohol, which was treated with naltrexone. This is his first treatment attempt. The patient lives with his girlfriend, who is sober. Using the ASAM criteria, the patient did not meet the criteria for biomedical, readiness to change, or recovery environment requirements. Thus, the RTC level of care services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with expertise in addiction 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Breast DCIS Score Assay (CPT 0045U) provided by Genomic Health. This patient has estrogen receptor (ER) and progesterone receptor (PR) positive left breast ductal carcinoma in situ (DCIS). According to the National Comprehensive Cancer Network (NCCN) guidelines, standard of care treatment includes breast conservation therapy followed by whole or partial breast radiation, or total mastectomy with or without sentinel node biopsy. However, there is a paucity of data demonstrating the clinical utility of the Oncotype DX in lieu of standard risk profiling for evaluation of this patients risk for recurrence or development of ipsilateral breast cancer. All told, the Oncotype DX Breast DCIS Score Assay (CPT 0045U) provided by Genomic Health was not 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 Oncotype DX Breast DCIS Score Assay (CPT 0045U) provided by Genomic Health 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 reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Zolinza 100 mg. The records provided for review document that this patients treatment regimen has included multiple standard therapies for high-risk neuroblastoma, including temozolomide and irinotecan, radiation, and dinutuximab. The patient is noted to maintain a strong performance status. The patients provider has recommended Zolinza as part of his treatment regimen to be taken with Accutane. Zolinza is a histone deacetylase inhibitor used in the treatment of cutaneous T-cell lymphoma. Additional data from medical literature reports that when combined with retinoids, Zolinza produces additive antitumor effects in preclinical studies of neuroblastoma. Similarly, researchers found that studies suggest that histone deacetylase inhibitors restore tumor sensitivity to retinoids and have synergistic anti-tumor activity when combined. Given this support in the peer-reviewed medical literature, the requested Zolinza 100 mg 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 certifications in medical oncology and hematology 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 enrollee requested coverage for the Cosentyx 150mg/ml syringe. The enrollee has a history of severe psoriasis and psoriatic arthritis. The patient has tried and failed topical steroids, UVB (ultraviolet B) phototherapy and Otezla. The patient's dermatologist states that she drinks alcohol and; therefore, disease-modifying antirheumatic drugs (DMARDS) such as Cyclosporine and Acitretin should be avoided. The standard of care currently is to treat both psoriasis and psoriatic arthritis together with the same medication that targets both conditions. Most of the newer systemic medications have been approved by the Food and Drug Administration (FDA) to treat both diseases. Left untreated, psoriatic arthritis can cause pain and disabling joint destruction. Alcohol, even in small quantities, can cause other medications, such as Acitretin, to convert into a substance that remains in the body and is difficult to excrete for over three years. Therefore, Cosentyx is necessary as it does treat both of the patients conditions of severe psoriasis and her psoriatic arthritis.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in dermatology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services.At issue is whether the services provided were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury.This patient had no way of knowing the extent of his acute knee injury and whether further deterioration would take place if he did not seek immediate care. Furthermore, he needed the brace to help him walk. With regard to the management of multiple knee ligament injuries, which was not the case here, there is ongoing debate about the timing of surgery, the procedure performed, and post-operative rehabilitation. Therefore, immediate evaluation is necessary. Additionally, there is ongoing debate regarding the use of platelet-rich plasma for knee sprains. The superficial medial collateral ligament and other medial knee stabilizers are the most commonly injured ligamentous structures of the knee. An initial history and physical examination, such as performed in urgent care, is helpful in determining the diagnosis and the treatment plan. Therefore, the services provided were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury.Final Result: The reviewer determined that the services at issue were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury. 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 requested authorization and coverage for Stelara 90 mg every four weeks. The patient has been diagnosed with Crohns disease of the ileum and abdominal pain. Medical literature states that patients with moderate-to-severe Crohns disease that was resistant to tumor necrosis factor (TNF) antagonists had an increased rate of response to induction with ustekinumab, as compared with placebo. Patients with an initial response to ustekinumab had significantly increased rates of response and remission with ustekinumab as maintenance therapy. In this case, the patient has tried and failed multiple biologic and conventional alternatives and had disease symptoms on Stelara dosing every eight weeks. The patient had a low Stelara level and lack of anti-Stelara antibodies. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Stelara 90 mg every four weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS guideline, this patient meets the criteria for IOP services. This gives the patient a composite score which is consistent with medically monitored community based services. 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 psychiatry with subspecialty certification in addiction 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

The patient has requested authorization and coverage for Trexall. The patient has been diagnosed with alopecia areata (AA). Researchers reported that AA is an autoimmune disorder causing non-scarring hair loss. The authors also noted low-dose methotrexate appears to be an effective and well-tolerated treatment for recalcitrant AA multiplex. In this case, the patient has been diagnosed with AA and has been treated with steroid injections, steroid solutions, and Rogaine, which the patient reported were no longer effective. The Health Plan reported that Trexall will not be covered until the patient has tried other treatments first, such as generic methotrexate. There is no documentation in the record that states the patient has tried and/or failed treatment with generic methotrexate. The generic medication methotrexate and its branded version Trexall are chemically the same molecules and have the same pharmacologic and therapeutic activities. They can be used interchangeably for the same conditions. The only difference is the dose per tablet, but this is not enough to warrant one over the other for the treatment of this patient. The medical evidence does not support the requested medication in this clinical setting. Therefore, Trexall is not medically necessary for the 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 dermatology 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 Synvisc injections to the right knee. The patient has been diagnosed with bilateral knee osteoarthritis. 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 excellent pain relief from a series of Synvisc injections. Furthermore, the patients options are limited, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections to the right knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dupixent 300 mg/2 mL.Atopic dermatitis is a complicated immunologic disorder that primarily involves T helper 2 (TH2) cell dysfunction. Dupixent is a monoclonal antibody targeted therapy that significantly reduces disease and its associated symptoms. The U.S. Food and Drug Administration has approved Dupixent for the treatment of atopic dermatitis. When patients have moderate to severe atopic dermatitis, it is often difficult to manage them with topical agents alone. Systemic therapy is often indicated. The Health Plans denial noted that the patient has not tried and failed at least one oral disease-modifying anti-rheumatic drug, such as cyclosporine. Cyclosporine is a short-term treatment and is not meant to be used long-term to treat atopic dermatitis. It would not be considered standard of care to treat a patient with cyclosporine prior to treatment with Dupixent. All told, Dupixent 300 mg/2 mL is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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.