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 readmission to acute rehabilitation, focusing on physical therapy, occupational therapy, and pain management. There is a paucity of evidence to support intensive rehabilitation interventions during the period of immobilization and weight bearing restrictions following distal lower extremity fractures (Lin, et al.; and Moseley, et al.). The focus of rehabilitation during this rehabilitation period is to acquire compensatory skills to manage functionally in as independent a manner as possible given the acute impairment and comorbid conditions. Following a unilateral ankle fracture in the absence of other significant concomitant injuries, patients who are able-bodied at baseline do not generally require inpatient rehabilitation at all as they can manage in the community with axillary crutches or a walker after discharge from the acute hospital. In the present case, the patient sustained a left ankle fracture-dislocation that required surgeries, immobilization, and non-weightbearing restrictions. The patient did not sustain any other significant documented injuries and the patients upper limb function was assessed to be intact. The patient was at a high functional level. Specifically, he required stand by assistance for transfers and ambulating 150 feet with a walker. By the completion of his acute inpatient rehabilitation course, he was at an independent to contact guard assistance level for his basic self-care and mobility. This level of function can be addressed with community-based rehabilitation, either in the home or as an outpatient. Home-based rehabilitation also provides the patient an opportunity to practice and improve his self-care skills and his mobility tasks in his actual home setting, which is more directly applicable to his functional needs than practicing these tasks in a rehabilitation facility. Given these findings, the requested readmission to acute rehabilitation, focusing on physical therapy, occupational therapy, and pain management 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 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 Ubrelvy 100 mg. The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks. Mullin and colleagues report that calcitonin gene-related peptide (CGRP) receptor antagonists are a newer drug class with treatment benefits in migraine therapy. The U.S. Food and Drug Administration (FDA) describes Ubrelvy (generic name ubrogepant) as a CGRP receptor antagonist indicated for the acute treatment of migraine with or without aura in adults, with recommended doses of 50 mg or 100 mg taken orally, as needed. In a randomized trial to evaluate the efficacy, safety, and side-effect profile of ubrogepant, Dodick and colleagues concluded that a higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at two hours after the dose. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive medications. Given that current medical literature supports the use of Ubrelvy, an alternative treatment in a different medication class, for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, Ubrelvy 100 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Durolane injection into both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 relief from prior injections received two years ago. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Durolane injection into both knees 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 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: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL pen (two pens per 28 days).  Findings:  The physician reviewer found that (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and Dupixent is the preferred therapeutic option by dermatologists in the community. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. In this case, given that the patient has a diagnosis of atopic dermatitis appears to be a good candidate for Dupixent, the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL pen (two pens per 28 days) 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio (vedolizumab) 300 mg injection at weeks zero, two, and six, followed by 300 mg every four weeks.  Findings:  The physician reviewer found that  Entyvio has a different mechanism of action than anti-tumor necrosis factor (TNF) medications and other immunosuppressants and is effective for the treatment of moderate-to-severe ulcerative colitis. The American College of Gastroenterology (ACG) guidelines on the treatment of ulcerative colitis support the use of Entyvio  in patients with moderate-to-severe ulcerative colitis. In a randomized, double-blind, placebo-controlled trial of vedolizumab (brand name Entyvio) is induction and maintenance therapy for ulcerative colitis, Faegan and colleagues intensified dosage to more frequently than every eight weeks for patients who had not achieved remission by week six, dosing these patients with Entyvio every four weeks rather than every eight weeks. The authors further noted that Entyvio proved effective for both induction and maintenance of remission, with remission in over 40% of patients after one year. Loftus and colleagues reported regarding the long-term use of Entyvio that increased dosing frequency to every four weeks was beneficial in patients who had loss of response to dosing every eight weeks. Williet and colleagues observed that low trough levels of Entyvio at week six were associated with lower efficacy, indicating a need for increased dosage to every four weeks.  While current medical literature supports the dose escalation, there is a lack of support for re-induction dosing of Entyvio in this clinical setting. Therefore, Entyvio (vedolizumab) 300 mg injection every four weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for continuation of care at an inpatient hospital facility. The records provided for review document that this patient was treated with oral anticoagulation for deep vein thrombosis (DVT), wound care with dressing changes for leg wound, and oral antibiotics. The patient has not required any additional care to support an indication for continued inpatient hospital stay services. The provider reported that the patient has improved, is afebrile, and on oral medication. Based on the peer-reviewed medical literature, the patients treatment regimen as planned is appropriate, and there is a lack of indication for requested inpatient hospital services. Therefore, the requested continuation of care at an inpatient hospital facility 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Tecentriq 1200 mg provided on 7/23/21, 8/13/21, 9/24/21 and prospective authorization and coverage for Tecentriq 1200 mg every 21 days.The National Comprehensive Cancer Network guidelines for small cell lung cancer states that the standard of care for extensive stage small cell lung cancer is carboplatin, etoposide, and atezolizumab (Tecentriq), with Tecentriq continued as maintenance therapy. In this case, the patient has extensive stage small cell lung cancer which may have arisen out of his high-grade prostate cancer. The medical literature indicates that small cell cancer, regardless of origin, are treated like small cell lung cancers, which explains the patients normalized prostate-specific antigen (PSA) despite metastatic disease. Therefore, Tecentriq 1200 mg provided on 7/23/21, 8/13/21, 9/24/21 and forward for every 21 days was and is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was and 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 medical oncology 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 parent of an enrollee has requested authorization and coverage for Tobii Dynavox SC Tablet (Speech Generating Device, E2510).At issue in this case is whether Tobii Dynavox SC Tablet (Speech Generating Device, E2510) is medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.The American Speech-Language-Hearing Association (ASHA) states, Eligibility policies and practices often preclude children and adults with severe disabilities from accessing needed communication services and supports. The authors also state, It is the position of the National Joint Committee for the Communication Needs of Persons With Severe Disabilities that eligibility for communication services and supports should be based on individual communication needs. Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Morin and colleagues indicate, Using high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. Ganz states, Augmentative and alternative communication (AAC) provides a means of effective communication to individuals with autism spectrum disorder (ASD), many of whom are unable to use conventional speech effectively. Ganz concludes, People with ASD stand to greatly benefit from AAC, particularly with current AAC technologies.In this patients case, Tobii Dynavox SC Tablet (Speech Generating Device, E2510) is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested device is clinically appropriate in terms of type, frequency, extent, site, and duration. Moreover, the requested device is 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. Therefore, Tobii Dynavox SC Tablet (Speech Generating Device, E2510) is medically necessary for treatment of the patients 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 varicocele vein embolization.Findings: Three out of three physician reviewers found that varicocele vein embolization is not likely to be more beneficial for you than any available standard therapy.Per the guidelines on varicocele management, medical literature would support interventions to manage chronic testicular discomfort rather than assigning the source of pain to a varicocele that is not demonstrated on diagnostic evaluation. Medical literature shows treatment algorithm on a subclinical varicocele that is not present on imaging does not support repeat venography and embolization. Standard treatment protocols for testicular discomfort with medication (anti-inflammatory, or pain pathway disruptors such as tricyclics), direct nerve ablation via injection, or surgical denervation would be more likely to provide benefit in this patients case. In this case, the patient has persistent pain and short-lived pain resolution after both varicocele procedures. However, there was a lack of prominent visible recurrence or persistence on physical examination or venography. Therefore, varicocele vein embolization 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 service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All 3 reviewers are board certified in board certified in urology. All reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rifaximin 550 mg, one tablet three times a day for 14 days. The records provided for review document that this patient has a diagnosis of bacterial overgrowth in the setting of inflammatory bowel disease, diarrhea predominant (IBS-D). Rifaximin has been demonstrated to be safe and effective for the treatment of IBS-D and this medication is U.S. Food and Drug Administration (FDA) approved for this indication (Schoenfeld, et al.). In the TARGET-3 trial of over 1,000 patients, rifaximin proved effective with significant symptom improvement in IBS-D (Lembo, et al.). Additionally, rifaximin has data demonstrating its efficacy in the treatment of small intestinal bacterial overgrowth (SIBO) (Gatta, et al.). The FDA-approved dosage for IBS-D based on clinical studies is 550 mg three times daily for 14 days. Per the FDA approval, the medication can be used for two similar courses 10 weeks apart. However, this patients records do not include documentation of recurrent symptoms after a 10-week interval since completion of the prior rifaximin dose. Therefore, the requested rifaximin 550 mg, one tablet three times a day for 14 days is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Orthovisc injections provided by Kavoos Nazeri, M.D. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the services at issue were medically indicated. Therefore, Orthovisc injections provided by Kavoos Nazeri, M.D., 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 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.