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 HP Acthar Vial. Acthar Gel, an adrenocorticotropic hormone (ACTH) analogue, is U.S. Food and Drug Administration approved for treatment of symptomatic sarcoidosis at a recommended dose of 40-80 units intramusculary or subcutaneously every 24-72 hours. Sarcoidosis is a systemic granulomatous disease of unknown etiology. Over the past few years, there have been advances in understanding of sarcoidosis. These include observations about the etiopathogenesis, diagnosis, and treatment of the disease. The first-line treatment is recommended to be glucocorticosteroids. However, the patient has tried and failed these options without success. In addition, the patient is diabetic and long-term use of steroids is not recommended. According to the peer-reviewed medical literature, repository corticotropin treatment, or Acthar, is prednisone sparring and has shown to have associated improvement in diffusing capacity of the lung for carbon monoxide (DLCO), positron emission tomography (PET) scan, and patient-reported outcome measures with sarcoidosis. Acthar has been shown to stimulate the melanocortin receptors (MCRs), which have anti-inflammatory activities. Although there is a risk with toxicity, the treatment has proven to be an effective treatment for patients with sarcoidosis. It was noted that the patient has tried and failed prior treatments and it is reasonable and appropriate for the patient to undergo Acthar gel treatment at this time. Given the above, the request for HP Acthar Vial is medically necessary for treatment of the patients medical condition. 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 pulmonary disease 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 Xeljanz XR 11 mg daily. In regards to the use of Xeljanz (tofacitinib) for the treatment of rheumatoid arthritis (RA), the 2015 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis recommends methotrexate (MTX)+/- TNF inhibitor (TNFi) as the next treatment in those who have failed MTX alone. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe RA. There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. Findings showed that Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNF alpha inhibitors. There are currently no studies looking at failure of a first TNFi agent and a different biologic agent. Given safety data and efficacy rates, a second TNFi with or without MTX of non-TNF biologic +/- agent is recommended over Xeljanz.(Singh, et al.). In this case, the patient has failed methotrexate, Humira and meloxicam. It is noted that she has failed one TNFi.  She has not failed a second TNFi or a non-TNF biologic agent as recommended by the 2015 ACR guidelines. At this time, the records fail to demonstrate a contraindication of a second TNFi trial. The literature demonstrates safety and efficacy of TNFi over Xeljanz given the long-term experience with the medication.  The literature fails to demonstrate any head to head trials showing Xeljanz is more effective than a TNFi. As such, the request for Xeljanz is not medically necessaryFinal 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 sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for an ultralight manual wheelchair. The request for an ultralight manual wheelchair is not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient has a mobility deficit. However, the documentation does not reveal that this mobility deficit cannot be helped by the use of an appropriately fitted manual wheelchair or that the patient has failed an appropriately fitted standard manual wheelchair. The physical therapy mobility evaluation reveals that the patients needs can be met with his current wheelchair and that he should have an evaluation in the future to assess his functional needs as he has not yet demonstrated the ability to be functional in general wheelchair use. The documentation does not support that an ultralight manual wheelchair is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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 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: An enrollee has requested authorization and coverage for ultraviolet light therapy. The submitted documentation supports the medical necessity of the requested services. She has tried and failed therapy with topical steroids, calcipotriene and Otezla. The medical records indicate that her psoriasis is moderate to severe in severity and includes some guttate lesions. This makes it difficult to use topical therapies alone as treatment, given the widespread areas on which to apply the medication. The use of ultraviolet light therapy to help widespread psoriasis has been well-established and is often required as a prerequisite treatment before systemic treatments are approved. The medical evidence supports the requested services in this clinical setting. Therefore, the requested ultraviolet light therapy is 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 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: An enrollee has requested authorization and coverage for tizanidine 2 mg capsules for the quantity of 60 capsules for 30 days. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. Tizanidine is a central alpha-2 adrenoceptor agonist that has been approved by the United States Food and Drug Administration (FDA) for treatment of spasticity. Although there is a theoretical construct supporting the medication as an anxiolytic, namely the medications action of blocking neurons from releasing neurotransmitters which in turn reduces adrenergic activity, the medication is not approved for unspecified anxiety disorder and is not commonly used for anxiousness. Thus, the use of tizanidine in this case is considered off-label.  This patient has a formal thought disorder and is nonadherent with his antipsychotic medication which often decompresses secondary mood and anxiety symptoms for those with schizophrenia.  Further, there is no evidence or input from the provider that formulary equivalents would be inappropriate, unsafe or inadequate. Selective serotonin reuptake inhibitors and serotonin presynaptic agonists are first-line treatments for anxiety disorders, while medications such as hydroxyzine, gabapentin and low-dose quetiapine are often used on an as needed basis when benzodiazepine medications are contraindicated.  Therefore, for tizanidine 2 mg capsules for the quantity of 60 capsules for 30 days is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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 reimbursement for skilled nursing facility services. Chronic leg wounds in the setting of venous stasis can be difficult to heal, with many wounds persisting beyond six months.  The cornerstones of care include compression and keeping wound beds moist to promote autolytic debridement, angiogenesis and formation of granulation tissue. The records in this case indicate that the patients leg wounds were improving very slowly on the treatment regimen, which consisted of topical dressings without requiring skilled nursing services for application, as well as intermittent outpatient visits for debridement. The records do not indicate that the patient required treatments that could not have been provided in the community setting. The prognosis for his clinical course and outcomes would have remained guarded on account of his underlying conditions which included severe congestive heart failure, possible lymphedema and deconditioning, with compromised ability to ambulate.  Ongoing skilled nursing facility level care would not have been expected to marginally improve his clinical course or outcomes over community-based care. The records do not otherwise document services that the patient needed in an inpatient setting that could not otherwise have been delivered in the community setting. Therefore, skilled nursing facility services 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 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 reimbursement for substance abuse residential treatment center detoxification services. The submitted documentation supports the medical necessity of the services at issue. Upon presentation, the patient was in active withdrawal. His blood pressure was elevated.  He was disheveled in appearance, irritable in his disposition and restless in his behavior. His mood was anxious. He was nauseated, sweating and not sleeping well. Further, he had history of psychiatric comorbidity. He did not have a safe and sober housing or a supportive social network. He was abusing multiple substances and was at high-risk for a complicated withdrawal syndrome.  Based on this clinical data, admission for supervised detoxification was safe, appropriate and consistent with good medical practice. The services and setting were reasonably expected to improve the patients condition, prevent a more serious episode of illness and establish a patient-centric comprehensive outpatient treatment plan. Additionally, the duration of detoxification services aligned with community standards. Therefore, substance abuse residential treatment center detoxification services 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 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 authorization and coverage for sphenopalatine ganglion nerve block injections. Sphenopalatine ganglion blocks have only anecdotal case reports supporting their use in this situation. Researchers surveyed the literature about refractory trigeminal neuralgia and concluded that there is insufficient evidence for peripheral techniques including nerve blocks in this clinical setting. The American Academy of Neurology (AAN) guidelines on trigeminal neuralgia do not identify the use of sphenopalatine ganglion blocks as an effective therapy. Thus, the requested ganglion nerve block injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested sphenopalatine ganglion nerve block injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  All three 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: A 37-year-old female enrollee has requested authorization and coverage for a consultation with a podiatrist. Review of criteria indicates that a referral is medically necessary when the nail requires further testing and that the patient has failed systemic medications. Due to the risks and complications of the systemic medications, the nail condition requires further testing to establish an indication for their use. Since further testing to confirm that antifungal medication has not been performed, the requested podiatry referral is medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in podiatry 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 reimbursement for residential mental health and eating disorder treatment program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Around the dates in question, the patient had made progress in his eating disorder. The patient was motivated to continue treatment and was actively participating in treatment. The patient was medically stable and did not require 24-hour supervision. Given that the patient was not medically compromised, there is data supporting that treatment in a residential treatment center setting does not provide advantages over outpatient management. It is the standard of care to treat patients in the least restrictive environment possible. Per the records, this patient required treatment for his anorexia nervosa, depression, and anxiety. However, he could have been safely and effectively treated in a less restrictive environment. Therefore, residential mental health and eating disorder treatment program services 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 psychiatry with expertise in child and adolescent 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 17-year-old female who reportedly presented to her provider in crisis. Per the provider, the patient was previously treated with Zoloft for six months. The patient became suicidal and was treated at the partial hospitalization program (PHP) level of care. In September 2017 she was hospitalized with thoughts of harming others. The patient was diagnosed with obsessive compulsive disorder (OCD) and she started medication trials. Due to her presentation, the provider recommended a different therapist who specializes in cognitive behavioral therapy (CBT) for treatment of OCD. Notes indicate the patient prefers Adderall to Vyvanse. Her parent has requested reimbursement for psychiatric emergency services. The Health Plan has denied this request indicating the enrollee did not receive psychiatric emergency medical services. At issue in this case is whether the enrollee received psychiatric emergency medical services on the date(s) of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The available documentation reports the patient underwent medication changes while in treatment. However, the notes do not describe any symptoms that were emergency related. The patient has OCD symptoms and her medications were being adjusted to address these symptoms. There is no indication that the patient was experiencing suicidal or homicidal ideation or aggression. There is no indication that the patient was experiencing psychosis. These symptoms are typically considered emergencies in psychiatric care (case study). There was no indication of dangerous symptoms that would require inpatient psychiatric acute-care for this patient. It does not appear that there any documented symptoms that were in need of treatment on an emergent basis. Thus, the services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Euflexxa injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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.