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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates.  Newer treatment agents have become available over the past few years, including teriparatide (Forteo), which was initially approved for treatment of osteoporosis in 2002.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone.  Recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high-risk for fracture, defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy.  The current medical evidence supports the requested medication in this clinical setting.  All told, Forteo is medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 durable medical equipment (DME) hearing aids/molds for the left ear CROS system hearing aid for treatment of the enrollees bilateral sensorineural hearing loss. Findings:  The physician reviewer found that a CROS hearing device is utilized for a patients hearing improvement when there is a sudden change of hearing unilaterally. The DME requested includes one device that serves as a microphone to pick up ambient sounds on one side of the head, and the other device serves to send the messages received into the good hearing ear by routing the signals received from one device to the other side. With this technology, the patients good ear can hear sounds from both sides of the head with improvement of hearing. According to the current medical literature, the use of a CROS type hearing instrument for patients with single-sided deafness can improve sound awareness and localization. These types of hearing instruments have been shown to be beneficial to improve hearing. However, other types of hearing instruments such as a bone anchored hearing device achieved better clinical results. Generally, these devices are utilized for patients with profound type sensorineural hearing loss in one ear. There should be good residual hearing in the contralateral ear. In this case, the patient does have relatively normal hearing in the left ear but moderate hearing impairment in the contralateral right ear. The Health Plan has approved the patients request for a hearing aid for the affected right ear. Given the lack of an indication for the DME for the left ear, the requested DME hearing aids/molds for the left ear CROS system hearing aid is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 a circumferential body lift (upper), thigh lift with custom garment, arm lift with custom garment, and breast lift/augmentation. Findings:  The physician reviewer found that based on the medical documentation provided, there is insufficient documentation to fully define a functional deficit related to this patients soft tissue excess following weight loss. The patient states that she has some functional compromise associated with the lower abdominal excess, but this is not clearly supported by the records provided for review. The body contouring procedures requested are generally considered cosmetic intervention, as supported by the reference from the American Society of Plastic Surgeons (ASPS) except in rare circumstances for the arms, thighs and breasts. To satisfy the criteria for medical necessity, there should be documentation of chronic rashes unresponsive to typical dermatologic treatment or other functional issues unresponsive to conservative management. This is not present in the medical records provided for review. A study noted that massive weight loss leads to functional and aesthetic deformity that can be corrected with body contouring surgery. However, based on the medical records provided, there is not a clear functional deficit related to the massive weight loss in the areas of concern that has failed specific dermatologic treatment. The documentation provided for review does not include evidence of recurrent rashes or detail specific dermatologic medications. As there is not a well-supported functional deficit detailed in the medical records that the patient has failed specific dermatologic treatment, brachioplasty, augmentation/mastopexy, bilateral thigh lift and abdominoplasty with lower body lift, are not medically necessary. In addition, the patients condition does not constitute an abnormal structure of the body. Although the patient has moderate soft tissue excess of the breasts, abdomen, thighs and arms, this should not be considered an abnormal structure of the body, but rather a normal consequence of significant weight loss. Thus, the procedures do not satisfy reconstructive principles which is supported by the peer-reviewed references. The patients condition should be considered one of an aesthetic problem and thus not medically necessary or reconstructive in nature. Moreover, the requested surgery will not provide a more than minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the requested surgery is not reconstructive in nature and 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that the Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein levels, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin resistance score, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Final Result: Two 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultra-lightweight titanium frame wheelchair, TiLite Aero Z (K0005), upgraded titanium frame (K0108), litespeed aluminum wheels (K0108), TiLite SlipStream Single Sided Fork (K0108), anti-tippers (E0971), adjustable skin protection seat cushion (E2622), positioning back cushion (E2620), side guards (E0956, E1028), and leg straps (K0038) for treatment of the enrollees paraplegia. Findings:  The physician reviewer found that the available records do not provide detailed documentation related to the patients physical examination, particularly with respect to his neurological, musculoskeletal or functional examinations.  There is only one physical examination provided for review, which noted that the patient was propelling himself in a wheelchair, with no further pertinent documented findings.  There was no documentation related to an examination of the patients wheelchair.  The seating and mobility evaluation at a medical supply vendor was replete with errors, including the patients gender and neurogenic bladder management method.  There was a lack of documentation regarding specifics about the patients current wheelchair. There is, overall, insufficient, conflicting and inaccurate information in the documentation available for review.  The data presented are insufficient to establish the medical necessity of an ultralight manual wheelchair with the requested componentry/accessories at this time.  A wheelchair prescription should include documentation of an appropriately detailed pertinent physical examination, detailed functional evaluation, and a clear and comprehensive discussion of the patients current durable medical equipment if replacement equipment is being requested.  All told, the requested ultra-lightweight titanium frame wheelchair, TiLite Aero Z (K0005), upgraded titanium frame (K0108), litespeed aluminum wheels (K0108), TiLite SlipStream Single Sided Fork (K0108), anti-tippers (E0971), adjustable skin protection seat cushion (E2622), positioning back cushion (E2620), side guards (E0956, E1028), and leg straps (K0038) are not medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the pneumococcal conjugate vaccine PCV 13 for treatment of the enrollees post-procedural hypothyroidism. Findings:  The physician reviewer found that in this case, the patient does not meet any of the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) recommended indications for pneumococcal conjugate vaccine. This criteria include patients with immunocompetent disorders such as cerebrospinal fluid (CSF) leak, cochlear implant, 65 years of age or older, or asplenia. As such, the request for pneumococcal conjugate vaccine PCV 13 is not medically necessary for treatment of this patients medical condition. 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 certifications in allergy and immunology and 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the GeneSight Psychotropic test for evaluation of the enrollees autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). Findings:  2/3 of the physician reviewers found that clinical trials showing the efficacy of psychotropic testing in improving health outcomes have not been completed. Moreover, documentation that the standard of care for medication management of ADHD was not provided for this patient and there is a lack of data that deviating from standard of care to provide genetic testing to identify alternative medications was appropriate. Given that there is no documentation of the patient being treated with any stimulant medication for ADHD or one from each major class prior to attempting Strattera or alpha 2 agonists, there is inadequate clinical justification based on substantial medical research to support genetic screening tests in this clinical setting. All told, the GeneSight Psychotropic test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic 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.Physician reviewer number two is board certified in diagnostic 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.Physician reviewer number three is board certified in diagnostic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni or Zepatier, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. There is a need for NS5A resistance testing prior to Zepatier in patients with genotype 1a. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is indicated and Zepatier is supported for use in this clinical setting. Thus, the requested Harvoni is not medically necessary for treatment of this patients hepatitis C virus. 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department (ED) services provided on 4/11/16.Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The emergency department services provided on 4/11/16 were not necessary for treatment of an emergency medical condition. In this case, the patient presented with generalized weakness and a burning sensation throughout her body for many months. Although she admitted to shortness of breath, this had been minor and intermittent. The patient was minimally tachycardic on arrival and this resolved without treatment. She had already been evaluated by her primary care provider earlier that day. Given that the patients symptoms were not sudden or acute in onset, the services in dispute do not constitute emergency services.  Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. 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.