Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant for treatment of the enrollees patent foramen ovale (PFO).Findings: Three physician reviewers found that based on the records provided, the patient with a cryptogenic stroke, patent foramen ovale and no documented contraindication to antiplatelet therapy. Although there is an association with patent foramen ovale and cryptogenic strokes, the medical literature does not consistently demonstrate improved outcomes with patent foramen ovale closure compared to medical therapy. For example, the CLOSURE 1 trial by Furlan and colleagues did not demonstrate relative benefit of patent foramen ovale closure using a Starflex device compared to medical therapy. Similarly, Carroll and colleagues showed no significant benefit of closure of a patent foramen ovale using the Amplatzer occluder compared to medical therapy alone in the intention-to-treat analysis. Therefore, the use of percutaneous closure devices for treatment of a patent foramen ovale in the setting of a documented transient ischemic attack or cryptogenic stroke is not indicated, except in specific circumstances where alternative therapies such as aspirin or warfarin are not tolerated, alternative therapies are contraindicated and alternative therapies have failed. In this case, there is no documented contraindication to antiplatelet therapy. Guidelines also do not recommend patent foramen ovale closure in this clinical setting (Messe, et al). For the reasons provided, the request for the percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant are 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: All three physician reviewers are certified in internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for Epclusa 400/100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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 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: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer has found that the current medical evidence supports the requested medication regimen in this clinical setting.  According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Epclusa once daily, for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery. Findings:  The physician reviewer found that, based on the documentation submitted for review, the request for bariatric surgery is not medically necessary. The patient does not meet standard criteria for bariatric surgery for failure to document morbid obesity with a BMI of 40, or a BMI of 35 or greater that is associated with serious obesity co-morbid conditions such as diabetes, hypertension or sleep apnea. The patient has no documented history of any serious obesity co-morbid condition with a BMI that is 35.96 kg/m2. As such, the medical necessity for the requested surgery is indicated for in this clinical setting. Final Result: The reviewer determined that the requested surgery 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Yaz for treatment of her bleeding with other birth control medications.  Findings:  The physician reviewer found that for the symptoms that the patient has described, most oral contraceptive pills will improve her symptoms. However, there is evidence that those oral contraceptive pills with drospirenone are superior for women with for acne and premenstrual mood deterioration. As this patient has tried multiple oral contraceptive pills including the formularys generic for Yaz, without adequate control of her symptoms, it is reasonable for the patient to be continued on Yaz as it provides the best control of her symptoms. Also, taking the medication in a continuous manner works to improve migraine symptoms. For the reasons provided, the request for Yaz 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser hair removal for treatment of the enrollees gender dysphoria.Findings:  The physician reviewer found that facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical condition where terminal hair grows in female in areas that are normally found in males. This would include the face, and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, the records noted that hormone therapy has not been effective in improving this patients medical condition. Therefore, laser hair removal is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal make-up of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. Therefore, for all these reasons, laser hair removal is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary and are 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric services provided. Findings:  The physician reviewer found at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates 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 services at issue were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency consists of a patient who is an imminent danger to himself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation, homicidal ideation, delusions, and delirium. Per the documentation submitted for review, the patient had none of these symptoms. The patient has a history of intermittent suicidal ideation. However, his last episode of suicidal ideation was two weeks prior to admission. The patient had an episode of self-cutting one week prior to admission. However, upon admission to the IOP, the patient denied any suicidal or homicidal ideation. Moreover, there was no psychiatric evaluation performed on admission. The documentation included a risk assessment, but this is not a psychiatric evaluation. There was no psychiatric assessment or diagnosis given. A medical and psychiatric history was also not obtained. Moreover, the documentation submitted for review does not demonstrate that the patient was a danger to himself or others. For the reasons provided, 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. In this case, the patient presented to the emergency department with acute onset of abdominal pain that had persisted and was accompanied by diarrhea. She was tachycardic on arrival. Laboratory testing revealed a significant leukocytosis and hematuria. This prompted CT imaging to rule out acute surgical pathology. The patients tachycardia was treated with intravenous fluids. Symptoms of ongoing abdominal pain with diarrhea in a patient with tachycardia and a leukocytosis meets the definition of an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for GeneSight genotype testing performed for evaluation of the enrollees behavioral health conditions.Findings:  The three physician reviewers found that the submitted documentation does not demonstrate the superior effectiveness of the services at issue.  The documentation provided does not indicate specific medication doses used, length of medication trials or combinations of medications tried and failed. The records do not document that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence-based psychotherapy trials.  It is also not clear whether the patient has attempted psychotherapy. The literature supports outpatient treatment as well as family therapy in managing suicidal ideation and behaviors for adolescents. The current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis, such as dialectical behavioral therapy.  The medical evidence does not support the use of pharmacogenomic testing in this clinical setting. Kirchheiner and colleagues noted there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice.  Thus, GeneSight genotype testing performed was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in psychiatry 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 Orthovisc injections for treatment of the enrollees osteoarthritis in both knees. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for the requested services. Current evidence based medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis who have failed conservative treatment, and state there is no maximum amount of injections established by high quality scientific evidence. However, in this patients case, the patient did not have a significant improvement in symptoms for six months or more to support repeat injections. The submitted records documented less than two weeks of pain relief. She has been treated with at least two prior courses of viscosupplementation. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for the treatment of her pure hypercholesterolemia.  Findings:  The physician reviewer found that this patient has evidence of early established peripheral vascular disease based on carotid ultrasound findings. She has marked increase of total cholesterol and LDL cholesterol. She has been intolerant of statin medications (atorvastatin, pravastatin and simvastatin) with development of severe myalgia.  Her LDL cholesterol remains elevated, putting her in the pharmacologic treatment range. In addition, she has a significantly elevated Apo B level, which places her at increased risk of developing ischemic disease. It is unlikely that ezetimibe alone would provide the necessary risk reduction given the inability to pair it with any statin therapy. Given this overall risk, Repatha 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fluorouracil toxicity and chemotherapeutic response 5 mutation testing for evaluation of his rectal carcinoma. Findings: Three physician reviewers found there are rare genetic abnormalities that affect the metabolism of 5-FU, or its derivative. One such deficiency is dihydropyrimidine dehydrogenase, an enzyme critical to the metabolizing of 5-FU. The degree of deficiency is variable such that 5-FU can still be used, in reduced doses, with certain levels of deficiency, but not with more severe degrees of deficiency. These mutations are rare, thus routine testing is not recommended prior to undergoing 5-FU treatment.  Since 5-FU is an important component of adjuvant chemotherapy for colon cancer, it would be of clinical benefit to assay this patients enzymatic status before continuing with 5-FU therapy. Given these findings, the fluorouracil toxicity and chemotherapeutic response 5 mutation testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Results:  Three reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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.