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

Nature of Statutory Criteria/Case Summary: An enrollee has requested real time heart monitor (heart monitor, connected to a lab by cellular phone) (CPT code 93229) for evaluation of the her palpitations. Findings:  Two physician reviewers found that based on the records provided, the patient presented with intermittent near weekly palpitations. In this circumstance, if additional evaluation for a dysrhythmia was indicated, then prolonged serial 48-hour Holter monitoring or offline self-activated or auto-triggered cardiac event monitoring would be sufficient in recording cardiac rhythm during symptoms. In this patients case, there is no documentation that these devices have already been tried and failed for evaluation of her current symptoms. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Continuous real time monitoring by telemetry services was not appropriate in this case since off-line analysis of a patient-activated or auto-triggered event recorder would have been sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques. 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services on an emergent basis or urgent basis. Findings: The physician reviewer found that 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. 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. OCD is a chronic psychiatric condition with varying degrees of impairment characterized by intrusive thoughts, or obsessions, and, time-consuming and ego-dystonic repetitive behaviors, or compulsions. Like most long-lasting mental illnesses, there may be times when OCD is more problematic than others. In this case, the IOP level of care was indicated as the patient was prominently symptomatic despite appropriate treatment in the outpatient setting. The patient was enduring an acute-on-chronic exacerbation of illness. Considering the infringement on activities of daily living and suicidal ideation in context of previously established OCD and the recommendation for IOP services from the treating provider, immediate medical attention was needed. The presence of an acute deviation from baseline with suicidal ideation is consistent with a psychiatric emergency medical condition. The patient had a severe mental illness and needed immediate IOP treatment. The services at issue were necessary for treatment of a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient received psychiatric 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 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 Afirma Gene Expression Classifier test for evaluation of his thyroid nodule. Findings:  Three physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turned out to be benign. The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy. Because it is sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can therefore preclude such surgical procedures. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech and sign language therapy services for treatment of the autism and language delay. Findings:  The physician reviewer found that the request for speech and sign language therapy has not been established as medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has been treated with more than two years of speech therapy, however he has not made any significant improvement in his functional communicative skills. The patient has not retained learned signing. The patients lack of retention does not support continued speech and sign language therapy. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the 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. Additionally, the guidelines report resistance associated variants are only relevant in certain instances in treatment naive patients, such as treatment with simeprevir or elbasvir/grazoprevir. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. 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 Xiidra (lifitegrast ophthalmic solution 5%), 60 single use containers for treatment of his chronic dry eyes. Findings:  The physician reviewer found that the medical literature supports anti-inflammatory therapy for treatment of dry eye disease. Lifitegrast (Xiidra) is the latest anti-inflammatory treatment approved for dry eye disease (Holland, et al). This patients record supports his diagnosis of dry eye disease. The records document that this patient used artificial tears as well as punctal plugs. Xiidra does not work for every dry eye patient, and the current standard approach is to conduct a trial of the medication. As such, a one month to two month trial of Xiidra is warranted to see if there is clinical improvement in the dry eye symptoms/signs. For these reasons, prescribing Xiidra is medically necessary in this patient. If the patient responds well to this trial, then long term treatment would be indicated. 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 ophthalmology 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

Standard ReviewA transgender female enrollee has requested authorization and coverage for consultation, voice evaluation and laryngoscopy for feminizing voice training. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees gender dysphoria.  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. Nature of Statutory Criteria/Case Summary: The documentation provided does not support the medical necessity for the requested services in this clinical setting. There is evidence in the medical literature to support voice training in female transgender individuals to alleviate dysphoria that may interfere with their ability to communicate with others. The literature also shows that voice resonance drops in puberty after exposure to testosterone and that estrogen replacement therapy may not reverse that change. However, while it was noted in the Independent Medical Review application that this patient experienced being misgendered, documentation in the clinical reports are lacking to support that her symptoms of gender dysphoria have been exacerbated due to her low pitch voice. A provider noted that the patient was interested in vocal training.  At her next visit with the provider, the clinical notes indicated that the patient was stable on current doses for hormone therapy. Also at this visit, the provider prescribed progesterone at 100 mg dosing. On the other hand, there was no documentation provided as to how this patients voice affected the status of her gender dysphoria. At a later visit, the patient was seen for symptoms with cough. The clinical notes involving her gender dysphoria treatment included an increase of estradiol to 8 mg with testosterone fully suppressed. However, there was a lack of documentation as to voice feminization therapy. While the studies may show that there are female transgender individuals who are fearful of speaking because of the male resonance quality of the voice, this has not been noted in the submitted clinical documentation for this patient. As such, the documentation provided does not support the medical necessity for the requested services. For these reasons, the requested consultation, voice evaluation and laryngoscopy for feminizing voice training are not medically necessary for the evaluation of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein blood testing for evaluation of the enrollee who has a history of coronary artery disease and dyslipidemia. Findings: All three physician reviewers found that the patient has a history of hyperlipidemia, hypothyroidism and coronary artery disease. She underwent advanced lipoprotein testing. The Health Plan denied reimbursement for the advanced laboratory lipoprotein testing. Per the Health Plan, the services at issue were investigational for the evaluation of this patient. Based on the records provided the patient has known coronary artery disease and hyperlipidemia. In this circumstance of known coronary disease, guidelines for the management of 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 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, 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. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. 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: Reviewers 1, 2, and 3 are board certified in in internal medicine with sub-specialty certification in cardiovascular disease and are 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 cooling device durable medical equipment (DME) for treatment of the enrollees anterior cruciate ligament (ACL) tear. Findings: Two of the three physician reviewers found that in one medical literature, they concluded that the limited evidence available is insufficient to draw definitive conclusions on the effectiveness of cryotherapy for outcomes other than reduction in pain 48 hours after surgery. The study noted that there is a need for well designed, good quality randomized trials to answer other questions related to this intervention and increase the precision of future systematic reviews. Another study found that patients using a temperature controlled continuous cold flow device showed significantly better results the first post-operative day. The authors reported that further studies with higher number of patients and longer follow-up are required to assess the beneficial effects on rehabilitation of the routine use of this device. This patient was scheduled for left ACL reconstruction surgery with allograft. A water circulation cold pad with pump was recommended for post-surgical cold therapy. Overall, there is a lack of large volume long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs in ACL reconstruction surgery, especially with allograft. Final Result: The reviewers determined that the device at issue was 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: Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 Imlygic and Keytruda treatment of his metastatic melanoma. Findings:  The physician reviewer found that Ipilimumab, nivolumab, and pembrolizumab are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune attack from circulating lymphocytes. The latter two antibodies bind to programmed death 1 (PD-1) and the ipilimumab binds to cytotoxic T-lymphocyteassociated antigen 4 (CTLA-4). The provider recommends Imlygic in combination with Keytruda. However, there is a lack of peer-reviewed literature supporting this combination. Keytruda or Imlygic monotherapy is clinically indicated, however the combination of Imlygic and Keytruda is not supported as medically necessary. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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 rituximab (Rituxan) for treatment of her lupus.  Findings:  The physician reviewer found that There is a lack of support in the documentation provided and in the medical literature for the requested medication in this clinical setting.  This case involves a patient with active neuropsychiatric SLE. A review by researchers looked at the EXPLORER trial for depleting B cells in patients with moderate to severely active extra-renal SLE. Their study did not demonstrate a difference between placebo and rituximab in the primary and secondary end points. They noted the following, A beneficial effect of rituximab on the primary end point was observed in the African American and Hispanic subgroups. Safety and tolerability were similar in patients receiving placebo and those receiving rituximab. They concluded that Further evaluation of patient subsets, biomarkers, and exploratory outcome models may improve the design of future SLE clinical trials.  A review by other researchers evaluated the LUNAR study as to the, efficacy and safety of rituximab in a randomized, double-blind, placebo-controlled phase III trial in patients with lupus nephritis treated concomitantly with mycophenolate mofetil (MMF) and corticosteroids.  They concluded Although rituximab therapy led to more responders and greater reductions in anti-dsDNA and C3/C4 levels, it did not improve clinical outcomes after one year of treatment. The combination of rituximab with MMF and corticosteroids did not result in any new or unexpected safety signals. More recently, a systemic review by  other researchers  showed some short term benefits in patients with extra-renal SLE.  The authors concluded that Rituximab has been shown to be safe and effective in the treatment of non-renal SLE, especially in terms of disease activity, immunologic parameters and steroid-sparing effect. However, it can only be recommended for organ-specific manifestations such as arthritis and thrombocytopenia. High-quality studies are needed in order to consider the long-term effects of re-treatment on different organ-specific manifestations. The review failed to demonstrate significant improvement for patients with neuropsychiatric SLE like in this patients case. While the records indicate that she has failed Plaquenil and cyclophosphamide, the results of such medications are not noted.  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 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.