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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Linzess for treatment of the enrollees chronic idiopathic constipation.  Findings: The physician reviewer found that according to the American Gastroenterological Association (AGA), the first-line of therapy for patients with constipation should be an osmotic agent, and then a stimulant laxative should be tried. The guidelines also state that a newer agent such as Linzess should be considered when symptoms do not respond to such laxatives. In multicenter, randomized, blinded, placebo-controlled Phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements in patients with chronic constipation, but was associated with adverse effects. The prescribing information approved by the U.S. Food and Drug Administration (FDA) recommends the dose of 145 mcg per day rather than 290 mcg daily and cautions that the medication is contraindicated in patients with mechanical obstruction. This patient is noted to have a history of fecal impactions and has not reportedly been treated with an osmotic laxative. Given these findings, the requested Linzess 290 mcg is not supported as medically necessary for treatment of this patients chronic idiopathic constipation. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient psychiatric services provided and prospective authorization and coverage for future intensive outpatient psychiatric services for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that the patient was not experiencing post-acute withdrawals.  This reported use of Klonopin 100 mg per day is unlikely due to the excessively high nature of the dosage.  He was not a danger to self or others. He was medically and psychiatrically stable, and was on anti-craving medication. The issues of emotional dysregulation did not require intensive outpatient program treatment.  By community standard, that is dealt with on an outpatient basis in a dialectical behavior therapy setting. Posttraumatic stress disorder issues did not require intensive outpatient program treatment, as these issues are also dealt with on an outpatient basis.  He remained motivated and engaged.  He was aware of his triggers and utilized coping skills.  He did require ongoing treatment.  However, this could have been accomplished on an outpatient basis with community support in the form of 12-step meetings and sponsor contact. 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for unilateral extremity study, transcatheter embolization and left foot ultrasound. 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 services provided were not necessary for treatment of an emergency medical condition. Congenital vascular malformation of the foot when symptomatic presents with pain and swelling. Surgical and endovascular therapy are appropriate therapy for the lesions. Direct injection therapy has also been shown to be effective.  In this case, the medical management provided was clinically indicated. However, the services performed were not emergent. In sum, the documentation submitted for review does not support emergent services were provided on that date. For the reasons provided, the patient did not receive emergency medical services on the date of service at issue. 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 vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services provided at Second Nature Uintah. Findings:  The physician reviewer found that this patient demonstrated chronic and acute symptoms of multiple comorbidities and polysubstance abuse likely secondary to underline psychiatric illness. As a result of her primary psychiatric illnesses, she experienced severe trauma and demonstrated multiple symptoms typical of trauma including self-harm, impulsive suicidal thoughts and gestures, as well as symptoms of eating disorders and impulsive sexual acting out. She was at risk for recurrent self-destructive behavior including suicidal gestures. The records state that she became suicidal even as she was being transported to the residential treatment center. Patients with substance abuse disorders often meet criteria for other diagnoses and comorbidities. In an effort to prevent relapse for such patients, they should be afforded an opportunity to separate themselves from their former companions who are their enablers. A proper and well-disciplined youth outdoor program can be particularly useful in helping adolescent patients separate themselves from the toxic environment in which they had been using illicit substances. Moreover, the adolescent who successfully completes such a challenging program can effectively reestablish her sense of autonomy, which is critical in recovery from the trauma associated with sexual assault. For these reasons, the services provided at Second Nature Uintah were medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for emergency medical services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. 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 medical services provided from  were necessary for treatment of an emergency medical condition. In this case, the patient presented in active labor with full cervical dilation. Given that the fetus was in a breech presentation, cesarean delivery was appropriate. Moreover, it would not have been medically safe to transfer her to another hospital. For the reasons provided, the emergency medical services provided meet criteria for emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two (2) psychotherapy sessions per month for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there are several evidence-based psychotherapeutic interventions for bipolar illness such as cognitive behavioral therapy, family therapy and interpersonal and social rhythm therapy. Additionally, due to abuse history, the patient may meet diagnostic criteria for posttraumatic stress disorder (PTSD). Trauma-focused psychotherapies represent the gold-standard treatment for individuals diagnosed with PTSD. The evidence-based therapies for PTSD, such as prolonged exposure and cognitive processing therapy, much like the therapies for bipolarity, are typically delivered in time-limited fashion on a weekly basis. Considering that different therapeutic modalities may be necessary throughout the course of a chronic, complex mental illness burden, an updated psychological assessment and outpatient treatment plan is indicated to determine the patients current clinical status and treatment needs. In the absence of an updated psychological evaluation, the request for two psychotherapy sessions per month are not medically necessary for treatment of the patients medical condition. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld 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. In general, emergency medical services are indicated in an acute psychiatric syndrome and typically delivered in a specialized acute inpatient unit. In addition, a common exclusionary criterion for IOP programming is the presence of a psychiatric emergent condition. Although the level of care in this case was reasonably expected to improve the patients condition and prevent a more serious episode of illness, the patient did not receive emergency medical services during the dates of service at issue. The episode of care originated in the outpatient setting before progressing from the more restrictive environment afforded by the residential facility to the IOP level of care. The patient had no change in diagnoses. He had an unremarkable mental status examination.  His thought processing was logical, organized and goal directed. His appearance was appropriate and his behavior was cooperative. He denied any suicidal ideation or homicidal ideation, and there was no mention of psychosis, intoxication, withdrawal, agitation or paranoia. In sum, although anxious, the patient was not experiencing an acute psychiatric syndrome. Final Result: The reviewers determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 trastuzumab (Herceptin) chemotherapy for treatment of the enrollees basal cell carcinoma. Findings: The physician reviewer found that Herceptin is a human monoclonal antibody against the HER2 cell surface protein. It is commonly used in breast cancer that has HER2 amplification but its use has expanded to gastric cancer and gastroesophageal junction cancer. HER2 amplification is rare in small bowel adenocarcinomas. Herceptin was tested in ovarian cancer in a phase II trial performed by the Gynecologic Oncology Group (GOG) showing one complete response and two partial responses among 41 assessable patients with an overall 7.3% response rate. Von Hoff and colleagues reported on a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The use of targeted therapy in this patient is medically necessary and appropriate. Given this support, the requested Herceptin is supported as medically necessary for treatment of this patients small bowel adenocarcinoma. 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 medical oncology 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 Afirma Gene Expression Classifier testing for evaluation of the enrollee, who has a history of micropapillary carcinoma of the thyroidFindings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration 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 turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Final Result: Three reviewers determined that the testing 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 a thoracic epidural steroid injection for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has multiple medical problems, including chronic pancreatitis, celiac plexus syndrome, and thoracic back pain. The clinical records included a notation of a pinched thoracic nerve root as well as disc herniation at L5-S1. There is no notation of thoracic radiculopathy. The records noted a possibility of discitis of the thoracic levels identified, which would be a contraindication to performance of epidural steroid injection into the thoracic levels. Manchikanti and colleagues noted thoracic epidural injections are recommended for thoracic discogenic, disc-related, post surgery syndrome or spinal stenosis pain with fair albeit rather weak evidence. The current medical evidence does not support the requested services in this clinical setting.  All told, the requested thoracic epidural steroid injection is not medically necessary for the treatment of this patient.Final Result: The reviewers 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for continuous passive motion (CPM) machine for ten days. Findings:  The physician reviewer found that although continuous passive motion (CPM) is not routinely used after ACL reconstruction, a review of the literature reveals advantages to using postoperative continuous passive motion. The evidence indicates that CPM enhances tendon to bone healing, reduces arthrofibrosis and also reduces the incidence of patellofemoral arthritis after anterior cruciate ligament disruption. The literature indicates that postoperative CPM therapy significantly enhanced tendon-bone healing, as evidenced by increased amount of fibrocartilage, elevated ultimate load to failure levels, and up-regulated gene expressions of Collagen I, alkaline phosphatase, osteopontin, Tenascin C and tenomodulin at the tendon-bone junction. In this case, the ACL reconstruction was performed using the hamstring autograft. As such, tendon to bone healing is likely improved with the use of CPM. CPM contributes to improved knee health by preventing joint stiffness, preserving normal articular tissue with better histologic and biologic properties, and improving range of motion as compared with joint immobilization and intermittent active motion.  In light of the foregoing, the CPM provided was medically necessary for treatment of this enrollee's medical condition. Final Result: The reviewer determined that the device at issue was 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.