Persius/hicric huggingface dataset:
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 urgent care services for treatment of an emergency medical condition.Findings:  The physician reviewer found that the 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 urgent care services were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with a sore throat and normal vital signs. There is no documentation supporting the patient was experiencing an acute onset of symptoms. 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genomic sequencing analysis for evaluation of the enrollees metastatic invasive ductal adenocarcinoma. Findings:  Two physician reviewers found that there are currently a variety of assays evaluating genomic and molecular abnormalities which explore an individual patients cancer cells for a specific alteration that could be the target of a specific therapy. However, there is a paucity of evidence that such assays bring benefit to the patient in addition to clinical judgment. There are a variety of non-randomized studies that do not suggest benefit of the use of these assays. Given the lack of evidence to indicate that this assay would be of benefit to this patient, the genomic sequencing analysis provided 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 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: All physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Augmentative and Alternative Communication (ACC) device (Nova Chat 8) for treatment of the enrollees autism spectrum disorder and apraxia of speech. Findings:  The physician reviewer found that the requested device is medically necessary for treatment of the patients medical condition. AAC interventions are used for children with autism, often as stand-alone communication interventions for those who are minimally verbal. Colleagues suggest that AAC can be helpful for children with autism. In addition, the study by colleagues also found that there is growing evidence for the potential benefits of AAC for children with autism. Thus, the research shows that AAC is likely to benefit this patient with diagnoses of autism and apraxia of speech. Moreover, the documentation shows that the patient views iPad as a device to play and he has not shown the same level of skill development from the IPad. For the reasons provided, the requested device has been established as medically necessary for treatment of the patients autism and childhood apraxia of speech. Final Result: The reviewer determined that the requested device 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 digital breast tomosynthesis for evaluation of her breast cancer screening. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  There is a family history of breast cancer in a paternal grandmother who was diagnosed.  The patient has a history of a prior benign ultrasonically guided core biopsy of the right breast. She underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Scattered benign appearing nodularity and calcifications were noted. Her breast tissue was described as dense. The patient requested reimbursement for the breast tomosynthesis portion of the examination. The Health Plan denied reimbursement as investigational for purposes of evaluating this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breast tissue was described as dense.  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. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service 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: All three reviewers are board certified in diagnostic radiology 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: 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: Three 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 breasts that have been described as dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis, especially when there are no prior mammograms. 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 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: All three reviewers are board certified in diagnostic radiology 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: 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 risk for breast cancer. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 35 hours per week of one-on-one applied behavioral analysis (ABA) therapy, 15 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism. Findings:  The physician reviewer found that the patient has behavioral issues that include disruptive behavior and vocal stereotypy. There is sufficient support that ABA therapy is effective for addressing these behaviors. Thus, ABA services are clinically indicated. However, the patients maladaptive behaviors have not changed or slightly increased per the most recent progress report.  Based on the clinical documentation submitted for review, a reduction in ABA hours is appropriate for this patient. A rapid reduction in services can increase maladaptive behaviors. Thus, 32 hours per week of one-on-one ABA therapy, 15 hours per month of supervision and two hours per month of parent training provided were and is medically necessary and appropriate for treatment of the patients autism. Final Result: The reviewer determined that a portion of the services at issue were and are 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Lyrica (pregabalin) for treatment of the enrollee, who has history of joint and muscle pain. Findings:  The physician reviewer found that studies have shown that neuropathic pain varies in its severity and its effect on patients. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting.  In this patients case, not all treatment options were noted to have been utilized. The submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. The medical evidence supports that prior to prescribing controlled substances, certain criteria need to be met. In this patients case, multiple minimal requirements for controlled substance prescribing have not been performed. In addition, the submitted records do not show that other non-opioid medications classes have been optimized or tried. As such, the medical necessity of the requested medication as a primary treatment strategy has not been established. For all these reasons, Lyrica (pregabalin) 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 anesthesiology with sub-specialty certification in pain 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis performed for a breast cancer screening.  Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  She has a family history of breast cancer with a mother who was diagnosed with breast cancer. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, she had a hand-held whole breast sonography. The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breast tissue was described as heterogeneously dense. The Health Plan has denied reimbursement for bilateral digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, her breast tissue was described as heterogeneously dense. 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. Therefore, bilateral digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service 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: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Urolift device.Findings:  Two physician reviewers found that with obstructive prostatism which was previously treated with a partial transurethral resection of the prostate and Botox injections. The Botox treatment resulted in urinary retention. He underwent a cystoscopy which revealed erythema in the urethra membranous. There were no strictures and lateral lobe hypertrophy of the prostate.  His provider recommended Urolift device for the relief of his prostatic obstruction. The patient underwent placement of the Urolift device and is requesting reimbursement from the Health Plan. The Health Plan denied reimbursement indicating that the Urolift device is investigational for treatment of this patient. The Urolift device has been approved by the American Urological Association (AUA) and the U.S. Food and Drug Administration. The Urolift is an outpatient procedure that has minimal blood loss and immediate relief of prostatic obstruction with little chance of retrograde ejaculation or impotence. These benefits make it a superior choice when compared with other surgical approaches for this patients prostate problems.  As such, the device at issue is effective for treatment of patients in this clinical setting. Final Result: Two reviewers determined that the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in urology 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 and ribavirin for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, patients with cirrhosis are high priority for treatment.  The guidelines recommend Epclusa and ribavirin for 12 weeks as first-line therapy for genotype 3 patients with decompensated cirrhosis (or patients with Childs-Pugh Class B), regardless of prior therapy. Final Result: The reviewers 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for treatment of the enrollees major depressive disorder, recurrent, severe without psychotic features, and generalized anxiety disorder.  Findings:  The physician reviewer found that applying the child and adolescent level of care utilization system (CALOCUS), which is an accepted, national standard for determining the appropriate level of care for children and adolescents, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. The patient endorsed passive suicidal ideation but denied any suicidal plan. The patient has a history of two suicide attempts. The patient had a co-morbidity of cannabis use which is likely contributing to her current psychiatric presentation. However, she has no other medical conditions that require significant medical monitoring. The patients parents are supportive. The patient has a limited ability to deal with stressors. Recovery has been maintained for moderate periods of time, but only with strong professional support. Developmental pressures create stress which the patient feels are very overwhelming. The patient is ambivalent about relationship with her providers. She frequently missed outpatient appointments and was on occasion non-compliant with treatment. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.