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 reduction mammaplasty. Findings:  The physician reviewer found that Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. The American Society of Plastic Surgeons (ASPS) recommends reduction mammaplasty authorization based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs. Per the ASPS guidelines, this patient does not meet the criteria for reduction mammaplasty. The patient complains of low back, shoulder, and neck pain, and intertrigo. However, shoulder grooving is not demonstrated in the photographs provided for review. In addition, there is a lack of evidence that the patients intertrigo has been unresponsive to medical management. Furthermore, there is no report of chronic breast pain due to weight of the breasts, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. In the absence of fewer than two ASPS quality of life signs, the requested reduction mammaplasty is not medically necessary for 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: to improve function; or to create a normal appearance, to the extent possible. This patient has significant breast ptosis without significant breast hypertrophy. Based on the available documentation, a reduction mammaplasty would not improve the patients function. Moreover, the patients appearance is within the wide range of normal for female breasts and the requested mammaplasty would not provide a more than minimal improvement in the patients appearance. Therefore, the requested reduction mammaplasty is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary or reconstructive in nature 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for deep transcranial magnetic stimulation (dTMS). In the peer-reviewed medical literature, TMS is indicated for patients with severe, recurrent major depressive disorder that has not responded to traditional medication and psychotherapy treatment. For this patient, TMS had worked successfully in the past. This patient presented to her provider with worsening of symptoms. For this course of TMS, the patient received treatment with dTMS, which involves a different coil and different depth of treatment, than rTMS. Current medical literature supports this intervention and has shown significant improvement in symptoms compared to rTMS. This patient has completed full treatment with PHQ-9 falling by 46% and resolution of suicidality attained. Therefore, dTMS was medically necessary to treat the patients condition. Additionally, dTMS was medically necessary as defined in Health and Safety code section 1374(a)(3)(A). Specifically, dTMS was medically necessary to decrease disability and correct or ameliorate the patients behavioral conditions. The services at issue were in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were appropriate in terms of type, frequency, extent, site, and duration. Based on the records, the services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine-tetracaine and Vaniqa.Hirsutism has been linked to PCOS and can present in varying clinical degrees for patients. Hirsutism has varying degrees of impact, and treatment options need to be individualized. Vaniqa (eflornithine) is a topical option for the treatment of hirsutism in women. Eflornithine cream can reduce hair growth by irreversible inhibition of ornithine decarboxylase, an enzyme important for normal hair growth. It is approved by the U.S. Food and Drug Administration (FDA) for the removal of facial hair in women. Clinical trials have found that combining eflornithine with laser hair removal results in a more rapid response than laser treatment alone. Electrolysis can be painful, and topical anesthetic creams such as EMLA or LMX (lidocaine cream) may be helpful in reducing pain when electrolysis is performed in sensitive areas.In this case, the patient suffers from severe hirsutism that requires daily care for facial hair growth. The patient also has documented depression, anxiety and suicidal ideation as a result of her hirsutism. The patient's severe hirsutism has significantly impacted her quality of life in both her mental and physical health. Records reflect that the patients degree of symptoms and impact are quite significant, and treatment should not be considered as purely cosmetic. The patient has tried alternative treatments with no significant improvement in symptoms, and she would now like to proceed with Vaniqa and electrolysis. Under these circumstances, lidocaine-tetracaine and Vaniqa are medically necessary to treat the patients mental health condition.Final Result: The reviewer determined that the requested medications are medically necessary to treat the patients mental health condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 and prospective authorization and coverage skilled nursing facility (SNF) services and acute rehabilitation level of care services. Minor spontaneous spinal hematomas occurring in the thoracic spine may be managed with observation and conservative measures. However, larger spinal hematomas with significant neurological compromise generally require surgical intervention with spinal decompression and hematoma evacuation. Functional impairments related to residual paraplegia and neurogenic bowel and bladder require complex, individualized rehabilitative measures. This patients records document that she developed acute paraparesis due to a hematoma following anticoagulation for a pulmonary embolus. The patient underwent spinal decompression and hematoma evacuation. She presents with severe persistent paraparesis. Functionally, she has undergone extensive inpatient rehabilitation, but she has remained non-ambulatory and dependent for transfers. The records demonstrated that she has not made significant improvement with respect to self-care. An indwelling urinary catheter has remained in place due to her difficulties with transfers. There is a lack of documentation of medical, nursing, or rehabilitation issues that require ongoing care in an inpatient rehabilitation facility. Given the patients level of neurological recovery and limited ability to participate in therapies toward functional progress, she remains at a custodial level of care, which does not support acute rehabilitation level of care services. Given these findings, the SNF services and acute rehabilitation level of care services were not and are not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30-day supply of Nexlizet 180-10 mg tablets. Based on the available documentation, this patient presents with several risk factors for cardiovascular disease including diabetes, with a high 10-year risk of developing symptomatic cardiovascular disease. The patient is on maximally tolerated statin therapy and his low density lipoprotein (LDL) cholesterol remains elevated at 252 mg/dL. These factors suggest that the patient has heterozygous familial hypercholesterolemia. In a situation where a patients LDL is close to the goal of 70 mg/dL, ezetimibe alone is a reasonable treatment approach. However, based on the known lipid lowering efficacy of ezetimibe when added to statin therapy, it is unlikely that this patient would reach goal with this regimen. Treatment with Nexlizet is likely to provide a 40% or greater reduction in the patients LDL and get him closer to his treatment goal. Oral therapy is preferred in this patients clinical setting, and Nexlizet is supported as an appropriate alternative to the addition of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. Given this patients elevated cardiovascular risk and elevated LDL levels while on high-dose statin therapy, the addition of Nexlizet is within the standard of care. Therefore, the requested 30-day supply of Nexlizet 180-10 mg tablets 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 certification in cardiovascular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acessa procedure. The records indicate that this patient has a history of pain and menstrual bleeding attributed to her fibroid uterus. The patient has requested treatment with the Acessa procedure. Studies support the safety and efficacy of the Acessa procedure for patients who meet specific clinical criteria. This patients uterus has several fibroids that are less than 3 cm and her fibroids are intramural, which fall within the guidelines. However, there is a lack of data that reduction of this patients fibroids, most of which measure less than 2 cm, will result in adequate symptomatic improvement. Moreover, the records suggest that the patient has adenomyosis, which would not be improved with the Acessa procedure. In this clinical setting, the standard of care remains hysterectomy or myomectomy. Therefore, the requested Acessa procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Acessa procedure is 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 Ultomiris (ravulizumab-cwvz), or in the alternative, Solaris (eculizumab).Findings:  The physician reviewer found that current development shows that complement inhibition in renal disease is actively pursued in several clinical studies. Initial proof of concept comes from the inhibitor Soliris. The records provided for review document that this patient has a chronic condition that requires treatment. Without therapy, the patients glomerulonephritis is likely to recur. Restarting therapy prior to recurrence will prevent further loss of long-term renal function. The change to the Ultomiris, which is every eight weeks, instead of every two week treatment with Soliris, will also have a significant impact on the patients quality of life. Given these findings, the requested Ultomiris (ravulizumab-cwvz) 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 certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Brand name Topamax. A retrospective study by Lang and colleagues observed that in previously seizure-free patients, switching the manufacturer of antiepileptic drug (AED) therapy was associated with a higher risk for seizure recurrence. The authors concluded that it is prudent to avoid switching the manufacturer of anticonvulsants in seizure-free patients. In a review of the evidence for and against switching AED therapy, Studies noted that, Patients with highly labile seizure control or optimal seizure control (i.e. seizure-free or their seizure frequency has been markedly reduced) should not be switched to generics and should be maintained on their usual brand version for their AED therapy. In this case, the patients seizures were controlled on brand name Topamax. The provider reported that the patient experienced an increase in the frequency of auras and side effects on the generic formulation of Topamax. Based on the current medical literature, it is advised that patients should not be switched to the generic formulation when a patients seizures have been controlled on a brand name medication. For these reasons, the requested brand name Topamax is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 neurology 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 authorization and coverage for Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure. While lumbar spinal fusion has long been considered the gold standard for the treatment of lower back pain related to isolated degenerative disease, a wealth of current medical literature supports the use of lumbar disc arthroplasty for the treatment of this condition. Researchers note that while lumbar fusion may result in adjacent segment degeneration and acquired spinal instability, total disc replacement significantly improves the state of lumbar function and alleviates the pain of degenerative disc diseases, improving the patients quality of life. The authors conclude that lumbar disc arthroplasty is superior to lumbar fusion in improved clinical success, reduced pain, patients' satisfaction, shortened hospital stay, operating time and a lessened rate of complications. Researchers found in a comparison of the efficacy and safety of total disc replacement, lumbar fusion, and conservative care in the treatment of single-level lumbar degenerative disc disease, that Activ-L substantially improved ODI success, back pain, and patient satisfaction when compared with other therapies for single-level lumbar degenerative disc disease. In this case, the patient has tried and failed several nonsurgical therapies including medications, physical therapy, spinal injections, and activity modifications. In this clinical setting, an abundance of medical literature supports the use of lumbar disc arthroplasty for the preservation of motion at the treated segment, preservation or improvement in spinal alignment, and for avoiding the potential of adjacent segment disease. Therefore, an Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 and 2 are board certified in neurological surgery and are actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication Acthar Gel. Findings: Research has performed a case review of five patients with refractory dermatomyositis and polymyositis who experienced a disease exacerbation and either failed or were unable to tolerate the side effects of previous therapy with steroids, intravenous immunoglobulins, and steroid-sparing drugs. Other researchers noted that although anecdotal reports suggested that Acthar Gel could be considered as a therapeutic option, further investigation was warranted. Given that current medical literature does not support the use of Acthar Gel in treating refractory polymyositis or in replacing the use of steroids for the treatment of polymyositis, the requested medication is not medically indicated. Therefore, the medication Acthar Gel 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg tablets. Based on the available records, this patient has alopecia areata that has responded well to treatment with Xeljanz. Prior treatment has included finasteride, prednisone, and methotrexate. Available treatment options for patients with alopecia areata are limited, especially for those with multifocal involvement, where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy, and conventional immunosuppressants are oftentimes inadequate. There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors such as Xeljanz for the treatment of alopecia areata. In one open-label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring (Jabbari, et al.). Similarly, Liu and colleagues found that 77% of patients achieved a clinical response, and 58% had an estimated 50% change in SALT score. Overall, the current data demonstrates that Xeljanz is safe and effective for use in this patients clinical setting. Therefore, the requested Xeljanz 5 mg tablets 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. Credentials/Qualifications: The reviewer is board certified in dermatology with subspecialty certification in dermatopathology 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.