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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees shoulder pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The most optimal imaging study to ultimately evaluate shoulder anatomy and pathology is magnetic resonance imaging.  For patients with shoulder pain, the American College of Radiology recommends obtaining plain x-rays as a first line for the evaluation of shoulder pain. However, for patients with persistent significant pain and nonspecific physical examination and history, the next study recommended is MRI.  This patient has severe degenerative change, and, considering the patients age, it is likely that he has rotator cuff pathology.  The only reason to obtain an imaging procedure is whether it will change the therapy. In this patients case, he has already had a trial of physical therapy, and if surgery is a consideration, then an MRI is warranted.  More recent radiographs are not indicated in this case, as the patient has not had any new trauma, and there is no reason why his radiographs will change in the last seven months. It is similarly unreasonable to expect that another course of physical therapy will change the ultimate outcome, considering that the patient has had symptoms for at least 18 months. All told, the requested MRI is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for chromosomal microarray (CMA) FirstStep Dx Plus testing for evaluation the enrollees autism spectrum disorder. Findings:  Three physician reviewers found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for individuals with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), and the Child Neurology Society (CNS). CMA technology has been shown to provide clinically actionable information. In a study, a retrospective chart review of CMA testing was performed on individuals with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies in order to determine the proportion of cases where abnormal CMA results impacted recommendations for clinical action. Among the 1,792 patients that were reviewed, 13.1% had clinically relevant results, either abnormal or variants of possible significance (VPS). When an abnormal result was identified, a recommendation for clinical action was made 54% of the time. Findings in this study demonstrated that CMA results influenced medical care by in the majority of patients by, supporting the use of CMA as a clinically useful diagnostic test. Final Result: The reviewers determined that the requested testing is 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 pediatrics and genetics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for collagen meniscus implant surgery.  Findings:  Three physician reviewers found that there is a lack of scientific evidence to suggest the collagen meniscal cartilage implant and/or bone marrow aspirate are likely to be more beneficial than standard non-surgical treatment or partial meniscectomy. High quality scientific evidence from prospective randomized sham controlled surgical trials have not demonstrated superiority of surgery over non-surgical treatment. There is a lack of high quality comparison trials evaluating standard non-surgical treatment or meniscectomy with collagen meniscal implant and bone marrow aspirate. There is limited short-term evidence of efficacy in patients with persistent pain following partial meniscectomy and there is a paucity of evidence of improved outcomes in this setting of initial surgery for degenerative meniscal tearing. In this patients case, there is no documentation of any non-surgical treatment. All told, the collagen meniscus implant surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service 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: All three physician reviewers 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block for treatment of the enrollee, who has a history of cervicogenic migraine. Findings:  The physician reviewers found that there is sufficient support for the services at issue in this patients case.  Occipital blocks are well accepted as safe and effective for a variety of headache disorders.  The literature shows that they can be valuable for abortive treatment of severe headache, including migraine, cluster, and hemicrania continua. They also have been shown to be valuable as a preventive measure. The patients history supports chronic migraine. Occipital nerve blocks have been shown to be valuable for this condition, and the literature has established their safety. All told, occipital nerve block was likely to have been of greater benefit than other treatment options. Final Result: Two of three reviewers determined that the services at issue were 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 neurology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a lumbar/sacral interlaminar epidural injection for treatment of his low back pain.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has had trials of conservative therapy, including medication trials and chiropractic therapy.  He has evidence of radiculopathy on physical examination as well as positive MRI findings which support the diagnosis. The patient stated that the previous epidural helped him perform his activities of daily living.  Clinical practice guidelines support the performance of an epidural steroid injection for patients with spinal stenosis. The medical evidence supports the requested services in this patients case. All told, the requested lumbar/sacral interlaminar epidural injection 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present, rather than 99% when resistance is absent. Given that NS5A was positive for resistance to Zepatier and Viekira XR, Zepatier monotherapy for 12 weeks is not recommended in this case. For these reasons, although treatment is needed regardless of fibrosis stage, the request Zepatier for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection. 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 and prospective authorization and coverage for intravenous immunoglobulin (IVIG) therapy provided for treatment of the enrollee's inherited thrombophilia. Findings: The physician reviewer found that in the medical literature, IVIG has been proposed as a treatment for the diagnosis of recurrent miscarriage due to immunologic causes. The etiologies for recurrent miscarriage may include chromosomal, uterine structural, ovulatory, immune factors, or a combination of these factors. However, IVIG remains highly controversial for use in this clinical setting. Although a few non-randomized, uncontrolled studies have shown modest benefit in some patients with repeated pregnancy loss, there is a paucity of efficacy shown in the current literature. Moreover, the American Society for Reproductive Medicine states that, several trials and meta-analyses concluded that IVIG is ineffective for primary recurrent pregnancy loss; thus, this treatment is not recommended. Porter and colleagues reviewed IVIG treatment in recurrent miscarriage of autoimmune etiology and also reported a lack of efficacy. All told, the IVIG provided was not and is not medically necessary for treatment of this patients recurrent pregnancy loss.Final Result: The reviewer determined that the medication at issue was not and 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 H.P. Acthar for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. H.P. Acthar is indicated for the treatment of MS relapse. There is a lack of medical literature demonstrating the superiority of H.P. Acthar to high dose oral or high dose intravenous (IV) Solumedrol. H.P. Acthar is typically limited to patients with a moderate to severe clinical MS relapse who do not respond to initial treatment with oral or parenteral steroids, or patients with intolerable side effect issues. In this case, there is mention of agitation, insomnia, and irritability which are typical side effects of steroid therapy. In addition, the records do not support side effects that suggest steroid psychosis. There is no documentation of a recent trial of high dose oral or IV steroids having been provided, and no documentation of significant side effects from IV steroids. There is also no mention of inadequate response to IV steroids for this relapse. Final Result: The reviewers 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: 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg oral tablets.Findings:  The physician reviewer found that according to the most recent 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. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. In addition, these medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable first-line therapy, and neither has been proven safer or more effective than the other in a direct comparison trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repository corticotropin injection (H.P. Acthar Gel). Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. H.P. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for treatment of nephrotic syndrome. In this case, the patient has failed treatment with steroids, cyclosporine, and rituximab. Given the patients preserved renal function and ongoing nephrosis, treatment with H.P. Acthar Gel is clinically indicated. As such, the request for repository corticotropin injection (H.P. Acthar Gel) 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-specialty certification in nephrology 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 reimbursement for emergency services. 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 at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with ear pain and dizziness as well as abdominal pain. She admitted to dysuria. Her urinalysis was positive for leukocytes. Further laboratory testing was indicated to rule out sepsis. The patient received an ultrasound to rule out acute abdominal pathology. Although her ear pain was not acute, the patients abdominal pain required screening tests to rule out an abdominal emergency. Thus, the screening and evaluation to determine if an emergent medical condition was present. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromyogram and autonomic testing performed  for evaluation of the enrollees progressive fatigue, weakness and shortness of breath.  Findings:  Two physician reviewers found that the records indicate that this patient has had fatigability and proximal weakness, as well as postural lightheadedness. The differential of this includes neuropathic and myopathic disorders and autonomic dysfunction. To adequately assess these conditions, it is standard of care to perform electrodiagnostic testing. Autonomic testing has become standard in such conditions where there are clinical features to suggest autonomic dysfunction, as in this patients case.  Final Result: Two reviewers determined that the testing 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 neurology 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.