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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Vytorin 10-40mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. A review of the records indicates the enrollee has been prescribed Vytorin at least since 8/15/13. The enrollee has a medical history of hypertension, high cholesterol, cardiac catheterization with stenting (1/3/91), and gout. The enrollee was seen for yearly examinations on 8/15/13, and 11/2/17. Vytorin has combination of statin and ezetimibe. This medication was tested in research study that measured Carotid Intimal Medial thickness (IMT). This study did not show an outcome benefit for Vytorin despite lower lipid levels when on the combination. Since then Vytorin has been used much less often. Guideline updates from 2017, reviewed more recent studies show that despite evidence for benefit in lowering cholesterol levels, the benefit of ezetimibe over intense statin treatment is not yet established. For these reasons it has not been proven that Vytorin is better than other standard lipid treatments. Therefore, the requested Vytorin is not medically necessary. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The American Psychiatric Association (APA) treatment guidelines state that RTC level of care, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The records document that this patient required a safe and stable living environment in order to develop recovery skills following relapse after one month of sobriety. Thus, the patient qualified for American Society of Addiction Medicine (ASAM) Level III treatment, which is consistent with RTC level of care. All told, RTC was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Thus, the RTC services provided were medically necessary for treatment of this patients medical condition. 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 reimbursement for the Prometheus laboratory testing. Findings:  Three physician reviewers found Based on the current peer-reviewed medical literature, the Anser IFX test has not been demonstrated to be safe and effective for the management of Crohns disease. The presence of antibodies does not result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established. Furthermore, studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The only randomized trial comparing management of failure with dose intensification versus antibody/drug level-guided testing found no significant difference in clinical effectiveness when testing was used to guide therapy. Accordingly, the Prometheus laboratory testing 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 Prometheus laboratory testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient hospitalization provided by UCLA Resnick Neuropsychiatric Hospital. The submitted documentation fails to demonstrate that the RTC services provided were medically necessary for treatment of this patients behavioral health issues. Based on the information provided in the records, the patient did not meet the criteria for continued RTC services. The patient was not a danger to himself or others. In addition, he did not have auditory or visual hallucinations. Moreover, the patient was reportedly able to care for himself. Given these findings, the patient was a candidate for treatment in a less restrictive treatment setting. Thus, the RTC services provided were not medically necessary for treatment of this patients medical condition. 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 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 Otezla tablets. The submitted documentation supports the medical necessity of the requested medication. Otezla is used to treat psoriasis and is consistent with standards of care. The requested medication is U.S. Food and Drug Administration (FDA) approved for this indication and is considered safe. According to a study, apremilast (Otezla) is effective for the treatment of psoriasis. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested Otezla tablets are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the ReWalk Personal 6.0 Lower Extremity Robotic Exoskeleton.Findings:  Three physician reviewers found there is a lack of support for the requested device in this clinical setting. The published evidence indicates that powered exoskeletal devices aimed at enabling upright ambulation in persons with paraplegia are not an efficient, reliable or practical means of mobility for this population. This type of device is associated with high feasibility challenges. There are multiple risks associated with use of this device as a mobility device outside of very controlled environments, such as a physical therapy gym, including, but not limited to, the risk of fall, risk of becoming stranded (due to mechanical failure, loss of power, etc.), and risk of the potentially serious, adverse health-related sequelae associated with these events. This increased exposure to potential adverse sequelae is unnecessary given that a much more established, reliable, efficient and safe means of mobility is readily available, such as a manual wheelchair.There is a lack of proven health benefit of standing and intermittent passive walking using an externally powered exoskeleton to passively move the lower limbs.  Standard of care for achieving appropriate levels of cardiovascular and musculoskeletal exercise in the setting of this patients condition would be performing regular physical activity using volitionally active musculature, including, but not limited to, propulsion of a manual wheelchair, wheelchair sports and other adaptive sports/exercise activities. There is no expected marginally significant health benefit of standing and ambulation using an externally powered exoskeletal device over natural, self-powered activity and exercise.  While there are potential benefits of use of this type of device with respect to bone or soft tissue health, there is as yet no proven benefit of use of this type of device with respect to any clinically-significant outcomes. The available, published data are scarce and low quality. In sum, the ReWalk Personal 6.0 Lower Extremity Robotic Exoskeleton is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for air ambulance service provided on 12/27/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees epilepsy.At issue in this case is whether the requested air ambulance service was medically necessary for treatment of the enrollees medical condition.In most cases, air ambulance transport is reserved for use in emergent situations in which ground transport is not feasible or readily available. Such situations from the neurology perspective include (but are not limited to), intracranial hemorrhages, strokes requiring endovascular therapy or other conditions requiring acute surgical intervention. In this case, the clinical documentation provided for review suggests that the patient presented to the hospital with a prolonged seizure and altered mental status for which he was successfully intubated and sedated at the initial hospital. He was said to have been loaded with medication. There was no mention of continued/further seizures. The patients computed tomography scan of the head was also negative for any acute process. In such a clinical setting the standard of care would have been to stabilize the patient and to treat their seizure (or possible status epilepticus--if present). If it was felt that a higher level of care was necessary for the ongoing management of the patient's condition, then the current standards of care indicate that the patient should be transferred to the closest available medical center. In this case, the patient appears to have had his condition stabilized at the originating facility. In this setting the patient would likely have been able to have been transported via ground ambulance to a local facility (local to the originating site) that provides a higher level of care such as those identified by the Health Plan. Rather, in this case, the patient was transported approximately 600 miles back to the United States for a non-emergent medical condition. This trip would have otherwise been considered to have exceeded the patients clinical needs. Nor was the inter-facility transport provided/performed to the closest medical facility able to provide adequate medical services for the patients condition. The air ambulance services provided in this case would not be considered to have furnished services consistent with the generally accepted standards of practice or care. Therefore, the service would not have been medically necessary.Final Result: The reviewer determined that the requested service 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 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: An enrollee has requested authorization and coverage for Repatha 140 mg injections, every two weeks. The submitted documentation supports the medical necessity of the requested medication. This patient has documented obstructive coronary disease and hyperlipidemia with an LDL significantly greater than the goal of less than 70 mg/dL despite maximally tolerated statin medication and a trial of ezetimibe. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria.  In this setting, PCSK9 inhibitors have been shown in several randomized controlled trials to be safe and effective at lowering LDL cholesterol and have been associated with improved cardiac outcomes. Therefore, Repatha 140 mg injections, every two weeks, are 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 internal medicine with sub-specialty 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: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested reimbursement for MRI-guided stereotactic laser ablation therapy for the treatment Hypothalamic Hamartoma. The patient had a history and thorough work up that included a neurological assessment and magnetic resonance imaging (MRI) of the brain. The patients MRI revealed a hypothalamic mass compatible with Hypothalamic Hamartoma (HH), which is considered a rare condition. The patients clinical history of gelastic seizures lasting long enough to be characterized as status gelasticus is incontrovertible. The patients diagnosis of HH was radiologically confirmed and fit well with the patient's presentation and clinical history. The patient underwent reasonable trials of anti-epilepsy drugs (AEDs) which were instituted without success, raising the specter of medically refractory seizures. While the clinical course and kinetics of disease pathogenesis of HH may be highly variable, the patient clearly had an aggressive presentation and clinical history for HH. Under these circumstances, the absence of immediate medical attention could reasonably have been expected to result in placing the patients health in serious jeopardy, or caused serious impairment to bodily functions and/or serious dysfunction of any bodily organ or part, and the patient therefore had an emergency medical condition. Furthermore, the patient required care, treatment, and surgery to relieve or eliminate the emergency medical condition on the date of service. Accordingly, the services provided were emergency medical services as defined by California law.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology, with special qualification in child 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microwave ablation of the lung. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees lung cancer. A review of the records indicates the enrollee has been diagnosed with lung cancer. The enrollee is being treated for a slow growing left upper lobe pulmonary nodule. A CT lung cancer screening reported to have shown suspicious nodule(s), and an enlarging left upper lobe pulmonary nodule. A biopsy was recommended, and the patients treatment plan included CT guided microwave ablation. The enrollee has noted that the alternative therapy is left upper lobectomy by thoracic surgery, which is more invasive, more expensive, and has a longer recovery with higher risk of complications. The submitted documentation does not support that the requested treatment is medically necessary at this time. Currently, there are no peer-reviewed studies that indicate a better outcome with  thermal ablation (radiofrequency ablation or microwave ablation) for a lesion with scar and atypia versus standard medical treatments of serial CT scans or chemotherapy (if the cancer is small cell). In this case, the size and location of the lesion, would make him a candidate for the requested treatment if there were biopsy proven non-small cell lung cancer. At this time, the patient may still be followed with repeat CT, followed by repeat biopsy if there continues to be growth. If biopsy then yielded histologically proven non-small cell lung cancer and the patients circumstances were otherwise unchanged, the requested treatment would be more consistent with medical literature. Accordingly, microwave ablation of the lung is not medically necessary for treatment of the patients medical condition at this time.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 both diagnostic radiology and interventional radiology 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 anesthesia services (CPT code 00811QZ). The submitted documentation supports the medical necessity of the services at issue. Guidelines from the American Society of Gastroenterology (ASGE) and from the American Society of Anesthesiology both support the use of sedation in patients with a history of anxiety and substance abuse. ASGE guidelines state that patient use of drugs or alcohol are among the patient-specific risk factors that may determine whether the assistance of anesthesia providers is needed in GI endoscopy. In this case, the submitted documentation reflects that the patient was taking venlafexine for anxiety and used marijuana recreationally. Under these circumstances, anesthesia services (CPT code 00811QZ) were medically necessary for treatment of the patients medical condition.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 anesthesiology 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 a rhinoplasty. Functional rhinoplasty has proven to be an effective method for relieving nasal obstruction. By addressing specific structural abnormalities of the nose, nasal breathing can be improved. In a patient like this with a history of nasal trauma, nasal obstruction, deviation of the nose and deviation of the septum, specific maneuvers like osteotomies, septoplasty and placement of cartilage grafts can restore nasal breathing and create a normal appearance to the nose. This procedure is functional and is supported as medically necessary for this patient. Moreover, the condition constitutes an abnormal structure of the body. There is a deviation of the nose to the right and the septum to the left. These deformities impact nasal breathing. The patient does have a history of nasal trauma. The purpose of the surgery is to restore nasal anatomy to improve nasal function. This procedure will provide a more than minimal improvement in the patients appearance, as well. Given these findings, the requested rhinoplasty provided with the authorized septoplasty and turbinate reduction is reconstructive in nature and medically necessary. Final Result: The reviewer determined that the requested service is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in plastic and reconstrutive 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.