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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series in both knees.Findings: Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, Platelet Rich Plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of chronic osteoarthritis of both knees. Documentation reflects that conservative treatment has failed to relieve the patients pain with the exception of viscosupplementation that was beneficial for several years. Records show that the patient has a history of substantial relief from prior injections on multiple occasions. Furthermore, the patients options are limited, with the alternative being surgery. Under these circumstances, the requested Orthovisc injection series in both knees is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's 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 the medication Orencia 125 mg/mL ClickJect autoinjector.American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis recommend that if disease activity remains moderate or high despite diseasemodifying antirheumatic drug (DMARD) monotherapy, patients should use combination traditional DMARDS, or add a tumor necrosis factor inhibitor (TNFi) or a non-TNFi biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone. The ACR guidelines indicate that in moderate to high uncontrolled rheumatoid arthritis, TNFi therapies, such as Humira and Enbrel, are appropriate for use. The guidelines also indicate that non-TNFi biologic therapies, which include Orenica, are also appropriate. The guidelines clearly indicate that TNFi and non-TNFi therapies are both appropriate for these cases of uncontrolled rheumatoid arthritis in no particular order of preference. In this case, the patients rheumatoid arthritis has been uncontrolled despite DMARD therapy including sulfasalazine, methotrexate and hydroxychloroquine. The patient continues to report severe pain and inflammation affecting multiple joints including her hands, wrist and right elbow. This is indicative of moderate to high rheumatoid arthritis disease activity. As noted above, ACR guidelines indicate that non-TNFi biologic therapies such as Orencia are appropriate under these circumstances. Accordingly, the requested medication, Orencia 125 mg/mL ClickJect autoinjector, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 rheumatology, 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 Xeljanz 5 mg. A study reported patients with alopecia areata frequently experience marked impairment in psychological well-being, self-esteem, and may be more likely to suffer from psychiatric comorbidities. In this case, the patients alopecia areata has progressed to alopecia universalis, affecting scalp, facial, and body hair. The patient has tried and failed standard treatment for alopecia areata, and the provider has recommended tofacitinib to treat the patients severe disease. Given that current medical literature supports the use of Janus kinase (JAK) inhibitors following failed treatments of first and second line therapies, in this clinical setting, the requested medication is medically indicated. Therefore, Xeljanz 5 mg 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for physical therapy services provided by Core Performance Physical Therapy. There is a lack of evidence-based practice guidelines in current medical literature on the duration, intensity, and delivery of rehabilitation modalities following total knee arthroplasty. Artz and colleagues reported that a systematic review showed that while interventions including physiotherapy and exercise showed short-term improvements in physical function in patients after total knee replacement, this conclusion was based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Bandholm and colleagues found that studies of post-operative exercise-based interventions have not found superiority of one exercise regime over another. Davila Castrodad and colleagues noted that total knee arthroplasty is among the most common elective procedures performed worldwide and despite the many rehabilitation modalities available, the optimal rehabilitation strategy had yet to be determined. Wang and colleagues reported that following primary total knee arthroplasty comparable outcomes were demonstrated between patients in self-directed home exercise programs compared to those receiving outpatient physical therapy. In this case, the patient underwent extensive physical therapy. Her functional level and remaining deficits did not require ongoing skilled professional physical therapy and could have safely and effectively been met with an independent home exercise program. Therefore, physical therapy services provided by Core Performance Physical Therapy were not medically necessary for the 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco 5-325 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy. The American Society of Interventional Pain Physicians (ASIPP) have advised patients to Establish appropriate physical diagnosis and psychological diagnosis if available to support an indication for treatment with opioid medication. In this case, the patient has chronic low back pain due to lumbar radiculopathy and spondylosis of the spine. The provider charted that the patient has not demonstrated any aberrant or drug seeking behaviors and that Norco has been effective in managing the patients pain and allowing for the performance of activities of daily living. Based on the available medical records for review, the requested Norco 5-325 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 anesthesiology with subspecialty certification in 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 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 bilateral breast augmentation. Bilateral breast augmentation is medically necessary for many transgender females to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports breast augmentation to help alleviate the distress associated with an incongruent physical appearance and gender identity. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The records provided for review document that this patient is committed to feminine transformation as evidenced by her treatment with feminizing hormones. The patient reports persistent gender dysphoria related to masculine facial features associated with social dysfunction. The patient meets the WPATH criteria for gender dysphoria and indication for bilateral breast augmentation based upon clinical documentation of her gender dysphoria and related distress. Given these findings, the requested bilateral breast augmentation is supported by the WPATH as 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 psychiatry with expertise in transgender health 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 patients parent has requested authorization and coverage for Nutropin AQ Nuspin. Findings: Per the U.S. Food and Drug Administration (FDA), indications for growth hormone therapy include idiopathic short stature, which is defined as a height z-score below -2.25 standard deviations (SDs) below the mean. The records provided for review document that this patients height z-score is -2.1 SDs below the mean. In addition, the patients predicted adult height has remained within the normal range for females. The patients clinical course has been consistent with mild constitutional delay of growth and development. Thus, the patient does not meet the diagnostic criteria for idiopathic short stature. Given these findings, the requested Nutropin AQ Nuspin 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 pediatrics with subspecialty certification in pediatric endocrinology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent health care services. Per the California Code of Regulations (CCR) section 1300.67(g)(2), Urgently needed services are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plans service area. The records provided for review document that this patient presented for treatment of exacerbation of degenerative arthritis of the right knee or the hallux rigidus of the left great toe. Both of the patients diagnoses are degenerative and there was no likelihood of serious deterioration of the health of the patient from waiting while treatment with conservative treatment modalities. The patients right knee condition is an exacerbation of the underlying medial compartment and patellofemoral degenerative arthritis associated with a degenerative tear of the medial meniscus. There was a trace effusion which did not need aspiration. There is a lack of support for urgent medical services or urgently needed services to prevent serious deterioration of the health of the patient. The second issue was hallux rigidus of the left great toe which is also a degenerative condition and did not constitute an urgent medical condition. As noted in the medical literature, degenerative tears of the medial meniscus are a common condition that can be safely and effectively managed without surgery (Sonesson, et al.). Hallux rigidus also does not constitute an urgent medical condition (Ho and Baumhauer). In light of the foregoing, the medical services were not provided for the treatment of an urgent medical condition as defined in California CCR section 1300.67(g)(2). Final Result: The reviewer determined that the services at issue were not provided for the treatment of an urgent medical condition. Therefore, the Health Plans denial should be upheld. 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 Facial Feminization Surgeries.Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life (Ainsworth, T., and Spiegel, J.). The World Professional Association for Transgender Health (WPATH) has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. The WPATH has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition (WPATH, 2016).In this case, the patient has submitted multiple documents that support her claim that the requested facial feminization surgeries are medically necessary. Records indicate that the patient has previously had gender reassignment surgery and reported no major disruptions with her transition. Records indicate that patient has been a regular and engaged client in therapy and has an established diagnosis of gender dysphoria. The provider has confirmed that the patient would like to continue her transition through facial feminization surgery in order to feel safer and more comfortable. Under these circumstances, the requested Facial Feminization Surgeries (CPT code 30420, Rhinoplasty, primary w/major septal repair; CPT code 21122, Genioplasty 2/> sliding osteotomies; CPT code 67900, Right repair of brow ptosis; CPT code 67900, Left repair of brow ptosis; CPT code 21175, Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead; CPT code 21139, Reduction forehead-contouring and setback of anterior frontal sinus wall; CPT code 20902, Bone graft, any donor area major/large; CPT code 61782, Stereotactic computer-assisted procedure/cranial, extradural; CPT code 21025, Excision of bone, mandible; CPT code 15733, Muscle, myocutaneous or fasciocutaneous flap-head and neck with named vascular pedicle; CPT code 15769, Grafting of autologous soft tissue by direct excision; and CPT code 15773, Grafting of autologous soft tissue by liposuction, each additional 25 cc injectate) are medically necessary to treat the patients medical condition (gender dysphoria).Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Magnetic Resonance Imaging (MRI) of left breast (CPT-77049). Findings:  The physician reviewer found that the Magnetic Resonance Imaging (MRI) of left breast (CPT-77049) at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Magnetic Resonance Imaging (MRI) of the breast is an important imaging modality for the detection of breast cancer. The high sensitivity of MRI has led to its increased use in cancer detection in patients with dense breasts and as supplemental imaging to increase the rate of cancer detection in women with dense breasts (Melnikow, J., et al.). Although question remains whether supplemental MRI improves health outcomes, American College of Radiology (ACR) Appropriateness Criteria for Breast Cancer Screening indicate that MRI of the breast may be appropriate for patients at intermediate risk (15-20% lifetime risk). In addition, American College of Radiology (ACR) Appropriateness Criteria for Breast Implant Evaluation indicate that MRI of the breast is usually appropriate for the evaluation of silicone breast implants with suspected implant complication. In this case, the patient had a history of silicone breast implants in 2014, and she presented with a chief complaint of chest pain in the middle of her chest and on the left side by her armpit. Notes also show that the patient had a family history of breast cancer. Under these circumstances, breast MRI was appropriate for the patients medical condition. Accordingly, the Magnetic Resonance Imaging (MRI) of left breast (CPT-77049) at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing (CPT 81599). The records document that this patient has a diagnosis of melanoma. According to the National Comprehensive Cancer Network (NCCN) guidelines, a melanoma with Breslow depth of 0.8 mm is clinically stage 1B. Treatment includes possible sentinel lymph node biopsy and wide local excision. Histopathology demonstrated features that could be consistent with metastatic disease.  The patients provider recommended the DecisionDx-Melanoma assay to estimate his risk of recurrence. Based on the results the patient has the lowest risk of recurrence at five years. In the medical literature, Swetter and colleagues noted that routine molecular testing including the DecisionDx-Melanoma is discouraged until better use criteria are defined. Current data support standard staging procedures such as sentinel lymph node biopsy in this clinical setting. Accordingly, the DecisionDx-Melanoma genetic testing (CPT 81599) 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 DecisionDx-Melanoma genetic testing (CPT 81599) 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 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.