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

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for FoundationOne comprehensive cancer genomic panel for evaluation of the enrollees colon cancer. Findings:  2/3 of the physician reviewers found that the physician reviewer found that this patient had recurrent colon cancer. At the time the test was ordered and performed, she had not had treatment for her recurrent, metastatic cancer. The treatment did not depend on the results of FoundationOne testing. The National Comprehensive Cancer Network guidelines recommend routine testing of the primary cancers for mismatch repair and microsatellite instability. There is no pathology report submitted from her original cancer surgery to determine that testing for microsatellite instability and mismatch repair were done at that time. When colon cancer recurs, the guidelines recommend testing for KRAS, NRAS and BRAF, as these relate to treatment options. These tests do not require FoundationOne testing. The guidelines do not recommend other mutation testing. Per the medical evidence, the services at issue were not standard of care. Therefore, FoundationOne comprehensive cancer genomic panel was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox for treatment of the enrollees trigeminal neuralgia.Findings: The physician reviewer found that trigeminal neuralgia (TN) is characterized by recurrent short occurrences of unilateral facial pains, abrupt in onset and termination, in the distribution of one or more divisions of the trigeminal nerve that can be triggered by stimuli involving touching or moving the face. The annual incidence of TN is 4 to 13 per 100,000 people. TN can be caused by compression of the trigeminal nerve root via various mechanism. However, it is not uncommon for the mechanism to remain idiopathic. The medical literature indicates that carbamazepine is the best studied treatment for classic TN and is established as effective in various trials. However, other medications such as phenytoin, valproic acid, pregabalin, clonazepam, and topiramate have also shown benefit. The records appear to indicate that this patients trial of oral medication was limited to carbamazepine and gabapentin. However, there are several other options with positive data for treatment of this patients TN prior to initiating Botox.  Botox therapy data is limited and at best equal to the other available standard oral medications yet to have been tried by the patient. For these reasons noted above, Botox therapy 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services provided. 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. The medical services provided were not necessary for treatment of an emergency medical condition. The medical records submitted for review do not support that the services provided were emergent. The patient presented with squamous cell cancer that required treatment with Mohs surgery. Although the surgery at issue was indicated in a timely fashion, the patients medical condition situation was not emergent. As such, there was no emergent medical situation and the patient did not meet the criteria for emergent services. Thus, 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 dermatology 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 and prospective authorization and coverage for the hematopoietic stem cell transplant provided for treatment of the enrollees multiple sclerosis. Findings:  2/3 of the physician reviewers found that autologous stem cell therapy is still not considered to be within the standard of care for treatment of multiple sclerosis (MS). Overall, there have been no studies comparing stem cell transplant with highly active MS therapies such as Tysabri, Lemtrada, or Ocrevus to establish which therapy is most effective and has the best safety profile. This patient has a stable clinical examination and stable MRI findings after treatment with his first disease modifying therapy. Thus, the hematopoietic stem cell transplant services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the services at issue were not and are 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: Physician reviewer number one is board certified in neurology with sub-specialty certification in neuromuscular 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for remote monitoring services for the already inserted LINQ heart monitor for evaluation of the enrollees paroxysmal atrial fibrillation. Findings:  The physician reviewer found that The physician reviewer found the patient has ongoing documented symptomatic paroxysmal atrial fibrillation despite medication and an ablation procedure. In this circumstance of ongoing documented paroxysmal atrial fibrillation, interrogation of a previously placed implantable loop recorder is not indicated since the diagnosis of paroxysmal atrial fibrillation is already established and the treatment is not likely to significantly change based on the results.  Specifically, a second ablation procedure is apparently already scheduled regardless of results of an implantable loop recorder interrogation. The current guidelines for the evaluation and management of atrial fibrillation also do not consider interrogation of implantable loop recorders indicated in this setting. Therefore, the superior efficacy of remote monitoring services for the already inserted LINQ heart monitor provided from 6/15/17 forward has not been established. Final Result: Two of three reviewers determined that the services at issue were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an upright or standing magnetic resonance imaging (MRI) with contrast. Findings:  The physician reviewer found that as noted in the medical literature, CT imaging is the modality of choice for sinusitis due to excellent depiction of bone anatomy including anatomical variants. While MRI can also show presence and extent of sinusitis, it is not considered to be the first modality in the evaluation of sinusitis. This patient has a history of symptoms such as sinus pressure and frontal headache which suggests possible sinus problem, for which CT would be the appropriate imaging modality. Typically, intravenous contrast is not administered for evaluation of sinusitis. In addition, CT is faster than MRI and coughing would not pose a difficulty during the imaging. According to the American College of Radiology and Radiological Society of North America, the radiation dose in CT sinus is very minimal approximately 0.7 mSv as opposed to CT of the abdomen and pelvis with an effective radiation dose of 10 mSv, or PET/CT with an effective radiation dose of 25 mSv. Given the advantages of CT over MRI in evaluation of sinus, the requested upright or standing MRI with contrast is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy for treatment of the enrollee, who has a history of enlarging uterine fibroids. Findings:  The physician reviewer found that the physician reviewer found The current medical evidence supports the requested services in this clinical setting. The patient is postmenopausal with symptomatic fibroids. A myomectomy is typically reserved for women who desire a fertility sparing procedure. The hormonal medications that are used in reproductive age women are generally not appropriate for postmenopausal women, and generally fibroids naturally decrease in size and symptoms after menopause.  Although the patient has a history of a thickened endometrium, there is no documentation of postmenopausal bleeding. Additionally, she had a negative endometrial biopsy. There is sufficient support for the requested hysterectomy in this patients case. Therefore, the requested hysterectomy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulmonary ablation for treatment of the enrollees metastatic renal cell cancer. Findings:  The physician reviewers found there is sufficient support for the requested services in this clinical setting. Cryoablation is frequently considered in patients with renal cell carcinoma for distant metastases and is less invasive than surgery. Several large studies evaluating cryoablation for the treatment of intrathoracic lesions have revealed that the treatment is an effective and safe option. For this patient, it is less invasive than surgery or radiation, especially given multiple prior lung lesions that have been treated. Therefore, the requested pulmonary ablation is likely to be of greater benefit than other treatment options in this patients case. Final Result: Two of three reviewers determined that the requested services are 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:  Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and actively practicing. The reviewers arte 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 Taltz 80 mg/ml. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. While this patient has tried and failed therapy with topical steroids, the medical records do not indicate that standard biologic agents have been used. The documentation submitted does not support a contraindication to the use of the preferred agents. The records show that this patient does not want to use immunosuppressive treatments. However, Taltz is also considered to be an immunosuppressive injectable biologic agent for the treatment of psoriasis. This patient has not tried and failed treatment with Enbrel or Humira. Therefore, Taltz 80 mg/ml is not medically necessary for the treatment of this patients medical condition as there are other preferred therapies available. 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 dermatology 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 genetic testing for evaluation of the enrollees risk for cancer. Findings:  The physician reviewer found that the records indicate that the patient had her family history interrogated by a genetics counselor who did not recommend genetic testing at this time. Many of the cancers appeared too sporadic since they occurred at older age of onset. Her provider has not recommended genetic testing. Although the patients family history and patient history may be suggestive of Lynch syndrome or a BRCA mutation, several of the cancers occurred in older relatives suggesting sporadic rather than familial predisposition. Thus, the requested genetic testing is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation testing for evaluation of the enrollee, who has a history of high mastoid release syndrome. Findings:  The 3 physician reviewers found that the physician reviewer found MTHFR is an enzyme involved in the metabolism of homocysteine. There is a lack of scientific or medical evidence that the result of genetic testing for MTHFR variants such as 1289c is medically beneficial for the management of medical conditions, including idiopathic mast cell activation syndrome. The American College of Medical Genetics has published a guideline which states there is lack of evidence for the utility of MTHFR polymorphism testing. Thus, MTHFR mutation testing was not likely to be more effective than other methods of evaluating this patient.  Final Result: The 3 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: Physician reviewer number one is board certified in internal 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.Physician reviewer number two is board certified in internal 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.Physician reviewer number three is board certified in internal 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: An enrollee has requested authorization and coverage for Vemlidy for one year for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that the physician reviewer found the current medical evidence supports the requested medication in this clinical setting. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. Therefore, Vemlidy for one year is medically necessary for the treatment of this patient.  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.