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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing (DecisionDx-Melanoma). Current medical literature does not support the use of DecisionDx-Melanoma testing for the staging or treatment of thin melanomas over standard treatment with a wide local excision. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment for thin melanomas do not include the use of DecisionDx-Melanoma testing. The American Academy of Dermatology (AAD) also does not include the use of molecular genetic testing for the treatment of primary cutaneous melanoma. In this clinical setting, the use of DecisionDx-Melanoma testing would not have changed the management of this patient. Therefore, gene testing (DecisionDx-Melanoma) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the gene testing (DecisionDx-Melanoma) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 reviewers 1, 2, and 3 are board certified in dermatology 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 requested authorization and coverage for Humira 80 mg/0.8 mL weekly. In a study assessing the efficacy and safety of adalimumab in patients with moderate-to-severe ulcerative colitis, Sandborn and colleagues included as part of the protocol a dose escalation, if response was not adequate on Humira 40 mg every two weeks, to weekly therapy. Colombel and colleagues report that remission was maintained in patients with moderate-to-severe active ulcerative colitis with long-term adalimumab therapy for up to four years. Wolf and colleagues report that escalation to weekly adalimumab dosing demonstrates clinical benefits for patients who have lost response to therapy, noting a response rate of 25% in patients with dosage escalations to weekly therapy after failing therapy given every two weeks. The American Gastroenterological Association (AGA) guidelines for management of ulcerative colitis recommend an increase in drug dosage when there is loss of response to anti-tumor necrosis factor (TNF) medication and a subtherapeutic drug level, as in this case. Given that a reduction of Humira dosage or a discontinuation of Humira may result in disease flare, disease complications, hospitalization, or dysplasia which may increase the risk for colorectal cancer, and as insufficient disease control due to insufficient drug dosing may increase these risks, the requested medication regimen is medically indicated. Therefore, Humira 80 mg/0.8 mL weekly 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SpaceOAR hydrogel placement. Hydrogel spacers may be used during radiation treatment of the prostate to increase the space between the rectum and prostate and to decrease the amount of radiation that is delivered to the rectum. In a randomized, phase III trial of patients undergoing radiation therapy for prostate cancer, Hamstra and colleagues found a benefit in the use of a hydrogel spacer in reducing adverse effects, rectal dose, toxicity, and quality-of-life declines related to bowel and sexual side effects. National Comprehensive Cancer Network (NCCN) guidelines endorse the use of a hydrogel space in patients undergoing radiotherapy for prostate cancer. Therefore, SpaceOAR hydrogel placement was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the SpaceOAR hydrogel placement at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 radiation 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Ajovy injections. As noted in the medical literature and by the American Headache Society (AHS), Ajovy injections are indicated for patients who have demonstrated failure of at least two medications such as topiramate, divalproex sodium, a beta blocker, a tricyclic antidepressant, or a serotonin norepinephrine reuptake inhibitor. Goadsby and colleagues reported that their study demonstrated the long-term safety, tolerability, and efficacy of Ajovy in the management of patients with migraine. However, the records provided for review do not adequately document failure of two or more medications from this list of preventative treatments for migraines. Thus, the patient does not meet the criteria for treatment with a calcitonin gene related peptide (CGRP) monoclonal antibody. Based on the current medical literature and AHS guidelines, the requested Ajovy 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. Applying Section 1317.1(a)(2)(A), the services provided were emergency medical services. Per the American Urological Association (AUA) and Endourological Society guidelines, a trial of spontaneous passage is reasonable in patients amenable to conservative therapy with less than 10 mm distal ureteral stones in whom pain is well controlled (Assimos, et al.). However, the records provided for review document that this patient reported significant pain when he presented to the emergency department. The AUA guidelines state that in these patients, clinicians should recommend ureteroscopy as first-line therapy. This patient underwent ureteroscopy as recommended by the AUA guidelines. Regarding stent placement, the AUA guidelines report that, Following ureteroscopy, clinicians may omit ureteral stenting in patients meeting all of the following criteria: those without suspected ureteric injury during ureteroscopy, those without evidence of ureteral stricture or other anatomical impediments to stone fragment clearance. In this case, given the presence of significant edema precluding completion of ureteroscopy and stone removal, ureteral stent placement was appropriate as recommended in the current guidelines and medical literature (Pradere, et al.). Overall, studies have shown that emergent ureteroscopy has a high success rate, with a low complication rate (Zargar-Shoshtari, et al.). A delay in treatment of this patients distal ureteral stone could have placed his health in serious jeopardy (Haas, et al.). For these reasons, the services provided were emergency services provided for the treatment of an emergent medical condition as defined by California law.Final Result: The reviewer determined that the services were emergency medical services 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for food tolerance induction program (TIP) services. The records provided for review document that this patient has a history of food allergies. The patient has been started on treatment with a tolerance induction program (TIP). Oral food challenges and oral food desensitization programs are offered by a multitude of providers. The standard of care in this clinical setting includes measurement of IgE levels to specific foods for an individual patient. However, an extensive array of blood tests and oral desensitization to a multitude of foods in the absence of a history of anaphylaxis is not supported by the peer-reviewed medical literature or clinical guidelines. Furthermore, there is a lack of evidence in favor of oral dosing protocols for foods that are considered intolerances or IgE-mediated allergies. For these reasons, food TIP services 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 requested services 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 internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of good response to viscosupplementation with Synvisc injections of both knees. Furthermore, treatment with oral and topical non-steroidal anti-inflammatory drugs (NSAIDs) has not provided substantial relief of the patients symptoms. The patients remaining treatment options include total knee arthroplasty. The provider has recommended repeat viscosupplementation with Synvisc injections of both knees. On review of the current medical literature, the patient is a suitable candidate for repeat viscosupplementation. For these reasons, the requested Synvisc injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric oxygen treatment. The records provided for review report a history of anal fissure, skin tags, and hemorrhoids. The provider noted that the patient underwent skin tag removal in August 2021 and January 2022. The patients provider has recommended further treatment with hyperbaric oxygen therapy. There are adequate studies to support hyperbaric oxygen therapy for the treatment of patients with anal fissures and Crohns or ulcerative colitis that have failed conservative treatment (Lansdorp, et al.). Numerous studies also support hyperbaric oxygen therapy for the treatment of patients with radiation related rectal disease (Andren and Bennett). However, this patients records do not document a history of inflammatory bowel disease or treatment with radiation therapy. There is a paucity of support in the peer-reviewed medical literature for the utility of hyperbaric oxygen therapy in the treatment of this patients anal fissure. Therefore, the requested hyperbaric oxygen treatment is not medically necessary for 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 family medicine with subspecialty certifications in preventive medicine, and undersea and hyperbaric 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for osimertinib (Tagrisso). The U.S. Food and Drug Administration (FDA) approves the use of osimertinib for the treatment of patients with metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC). In this case, the patient has a diagnosis of glioblastoma. The National Comprehensive Cancer Network (NCCN) guidelines for central nervous system cancers do not support the off-label use of osimertinib for the treatment of glioblastoma, favoring referral to clinical trials instead. There is a lack of clinical trials supporting the use of osimertinib in this clinical setting over standard therapies such as alternating electric field therapy and bevacizumab. Therefore, osimertinib (Tagrisso) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for six months of weekly speech therapy (one hour per week). The records provided for review document that this patient has childhood apraxia of speech (CAS), mild intellectual disability, attention deficit hyperactivity disorder (ADHD), and a behavior disorder. The patient has been treated with weekly speech therapy and the provider has recommended continued services. Morgan and colleagues noted that, CAS affects a childs ability to produce sounds and syllables precisely and consistently, and to produce words and sentences with accuracy and correct speech rhythm. In common with many young patients with disabilities who were converted to therapy by telehealth during the pandemic, the patient has demonstrated difficulty attending to therapy sessions. Summers and colleagues found that physical distancing requirements and closure of schools and services in the context of the COVID-19 pandemic may be particularly challenging for families with children with neurodevelopmental disorders. This patients re-evaluation performed on 9/8/21 occurred after 19 months of telehealth services. Given the patients low scores on the Goldman-Fristoe Test of Articulation both before and after the pandemic, as well as the providers reports that the patients behavior issues have impeded participation in speech therapy, the weekly speech therapy services were and are appropriate to address this patients CAS. All told, six months of weekly speech therapy (one hour per week) was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with special qualification in child neurology and expertise in neurodevelopmental disabilities 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for Gamifant (emapalumab-lzsg) infusions Gamifant (emapalumab-lzsg) infusions. The records provided for review document that this patient has severe systemic juvenile idiopathic arthritis with recurrent episodes of macrophage activation syndrome and hemophagocytic lymphohistiocytosis (MAS-HLH). The patient was treated with Gamifant during the most recent hospitalization, which was discontinued prior to discharge as the episode of MAS-HLH had improved. The patients provider has recommended additional doses of Gamifant to complete an 8-10 week course. As noted by the U.S. Food and Drug Administration (FDA), Gamifant is indicated for the treatment of patients with primary HLH with refractory, recurrent, or progressive disease or intolerance to HLH therapy. Gamifant is recommended for use during an episode of HLH and should be continued until the patient no longer requires therapy for the treatment of HLH. Based on the available data in the medical literature, the requested additional doses are appropriate for this patient given the severity of disease. A case report by Gabr and colleagues involved a patient with macrophage activation syndrome who was treated as an inpatient with Gamifant and then received four additional weekly doses of Gamifant. The authors reported that this treatment regimen resulted in the patients disease going into remission. Moreover, this patient has exhausted most, if not all, therapies indicated for the treatment of patients with systemic juvenile idiopathic arthritis and macrophage activation syndrome. For these reasons, the requested Gamifant (emapalumab-lzsg) infusions are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for subacute inpatient skilled services. Anoxic brain injury, including due to cerebral hypoperfusion during cardiac arrest, is a condition with a challenging clinical course and guarded outcomes. Smania and colleagues report that while functional and cognitive impairments in patients with severe traumatic, cerebrovascular, or anoxic acquired brain injury may improve with time and rehabilitation, patients with cerebrovascular and anoxic acquired brain injury may have a more challenging clinical course. In this case, the patient sustained a severe anoxic brain injury following cardiac arrest. The records do not document any indication of clinically significant cognitive recovery. The patient has not been able to actively participate meaningfully in rehabilitation interventions to date and is not expected at this time to be able to participate in therapies going forward. Overall, the patient has a poor prognosis for functional recovery and has required total care on an ongoing basis since the event.  Given that the patients care needs require custodial level of care and as the patient has stabilized with respect to his care needs, including his tracheostomy care, supplemental oxygenation needs via tracheostomy collar/mask, tube feeding, skin care, and bowel/bladder care, the services at issue were not and are not medically indicated. Therefore, subacute inpatient skilled services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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.