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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Dilaudid and magnetic resonance imaging (MRI) for treatment of her medical condition.  Findings: The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. In clinical practice, it is common to encounter patients with headache who have undergone multiple imaging procedures. These often involve exposure to ionizing radiation. In this case, the patient underwent previous imaging which was noted to be normal. Thus, another imaging study is not medically indicated. In addition, the request for Dilaudid is not clinically indicated for the treatment of the patients medical condition. The use of opiate medication for acute and rescue therapy for migraines is not supported in the medical literature due to risks of medication overuse, chronification of migraine that is more likely in patients using narcotics, and the availability of many other therapies that may be effective. While occasional use of an opiate would not lead to rebound headache, there is some evidence that use of narcotics may permanently alter the central pain pathways and promote worsening of migraine. Alternative acute therapies which may be considered include subcutaneous sumatriptan, zolmitriptan nasal spray, occipital nerve blocks, intravenous (IV) magnesium, and IV dihydroergotamine.  Moreover, Opioids and combination analgesics containing opioids should not be used routinely. Given, the above, Dilaudid is not medically necessary for the treatment of this patients migraines.  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 physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that 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 (CT) 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.  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. Thus,  breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in diagnostic radiology and are actively practicing. All three 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 partial hospitalization level of care services and intensive outpatient level of care services for treatment of her behavioral health condition.  Findings: The physician reviewer found that based on the clinical documentation submitted, partial hospitalization services and intensive outpatient level of care services were not medically necessary for treatment of the patients medical condition. There is a lack of objective evidence demonstrating that continuation with a lesser intensity of care would not have offered either an expectation of improvement, or prevention of deterioration. The patients level of symptomatology did not justify partial hospitalization services, nor did her symptoms suggest intensive outpatient would have been medically necessary onward. There was no documentation of suicidal ideations or homicidal ideations. The patient has a diagnosed disorder; however she did not require medication management. The patient did not have any serious psychosocial functional or interpersonal skills deficits. Moreover, she was active in therapy reporting few to no affective symptoms and was maintaining a healthy body weight. The patient had shown improvements in all domains by and there was no reasonable expectation that continued partial hospitalization services or intensive outpatient level of care services would produce any further significant improvements. Given the above, the services at issue were not medically necessary for the treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician 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 breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed  as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) 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.  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. Furthermore, any extra radiation dose is not an issue in this patient as the 2D images were synthetically reconstructed from the tomosynthesis. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 radiology with sub-specialty certification in diagnostic radiology and are actively practicing. All three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that 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 (CT) 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms.  Thus, breast tomosynthesis was not likely to have been of greater benefit than other modalities.  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 reviewers are board certified in diagnostic radiology and are actively practicing. All three 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:  The parent of an enrollee has requested vision therapy and accompanying equipment for a vision therapy home exercise program for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that this patient has reading problems which may be partly related to convergence insufficiency.  In this patients case, it is appropriate to treat the convergence insufficiency.  In patients who have failed standard therapy, such as pencil push-ups, office-based vision therapy has been shown to be effective.  However, there is a lack of evidence indicating that the home equipment offers additional benefit over standard home exercises. Therefore, the superior efficacy of the requested vision therapy has been established.  However, the accompanying equipment for a vision home exercise program is not likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined that a portion of the requested services and equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:  All three reviewers are board certified in ophthalmology and are actively practicing. All three 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 Sovaldi and Daklinza 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. In treatment-naive genotype 3 patients (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested medical services on an emergent or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. The submitted documentation demonstrates the patient reasonably believed she was experiencing an emergency medical condition. In this case, the patient had been evaluated recently for chest pain. A subsequent CT scan reading noted an aortic aneurysm. In this case, the patients chest pain may have been caused by the dissection of such aneurysm. The patient was specifically instructed to call or return to the emergency department. Despite the lack of symptoms during the patients repeat visit, the fact remains that when she was instructed to return to the emergency department, it was reasonable for her to believe that the absence of immediate medical attention could result in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. In sum, a prudent layperson in the patients circumstances would have sought immediate medical attention.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested IgG Babesia microti, Ehrlichia chaffeensis IgG, IgG anaplasma phagocytophilum, IgG EBV, IgG HHV6, Babesia, Ehrlichia, anaplasma, EBV, HHV6, antibiotic therapy and hyperbaric oxygen therapy for evaluation and treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has no evidence of any current infection.  He has none of the infections for which he is requesting therapy.  There is no evidence that the requested prolonged antibiotics or hyperbaric oxygen therapy are of use in any of the infections for which he is requesting therapy.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested IgG Babesia microti, Ehrlichia chaffeensis IgG, IgG anaplasma phagocytophilum, IgG EBV, IgG HHV6, Babesia, Ehrlichia, anaplasma, EBV, HHV6, and hyperbaric oxygen therapy are not medically indicated in this patients case.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and 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 infectious 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis allows radiologists to separate glandular elements from architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For this reason, the addition of breast tomosynthesis to two-dimensional imaging was likely of more benefit to the patient than had the examination been done with two-dimensional imaging alone.  Therefore, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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. All three 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 Harvoni for treatment of her hepatitis C virus (HCV).  Findings: The physician reviewer found that while this patients records may not support advanced fibrosis, current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Also per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load.Afdhal and colleagues state, once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. In patients with viral loads less than 6million IU/mL, ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis (Kowdley) However, given that the patients viral load exceeds 6million IU/mL, a 12 week course of Harvoni is clinically indicated. Therefore, the requested Harvoni 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 internal medicine with sub-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 inpatient psychiatric hospitalization for treatment of his medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to self or others, although he was mildly disruptive.  He was not violent and did not physically threaten others.  He still had thought blocking and remained psychotic, but the delusional ideation had improved to the point where he was guarded and mildly grandiose.  He did not attend to his activities of daily living.  His medications required adjustment and changes.  However, the patient appeared to be at his baseline level of functioning.  All told, inpatient psychiatric hospitalization  was not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza to be used in conjunction with Sovaldi for treatment of his hepatitis C virus. Findings: The physician reviewer found that per 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 state that patients with cirrhosis are high priority for treatment. According to the guidelines, this patient is interferon-ineligible due to a pre-existing medical condition. The guidelines recommend that cirrhotic treatment-naive patients with genotype 3 hepatitis C should be treated with Daklinza and Sovaldi (with or without ribavirin) for 24 weeks. This is based partially on the results of the ALLY-3 study, which demonstrated poor cure rates (only 58%) after 12 weeks of therapy. For these reasons, the requested treatment with Daklinza and Sovaldi is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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.