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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the magnetic esophageal sphincter augmentation (LINX) procedure for treatment of the enrollees gastroesophageal reflux disease (GERD), osteoporosis, and Ehlers-Danlos syndrome. Findings:  Three physician reviewers found that based on the data provided, there is little evidence that the patients symptoms are due to acid reflux. The first 24 hours of the Bravo pH test was borderline positive but Day 2 showed no evidence of acid reflux and this was done off proton pump inhibitor (PPI) and histamine receptor antagonist (H2RA) therapy. Additionally, there was a poor correlation between the patients symptoms and acidification of the esophagus. Final Result: Three reviewers determined that the requested procedure is 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 10-325 oxycodone-acetaminophen tablets to be taken once every six hours as needed for pain for treatment of lupus, chronic neutropenia and myasthenia. Findings:  The physician reviewer found that the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative setting. However, in this case not all non-opioid treatment options have been utilized. The records did not mention the completion of behavior therapy despite much research to support its use. It is also reasonable to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. Moreover, even in the post surgical setting, opioids should be returned back to their preoperative status within a few weeks, and there are issues with opioid prescribing even in the postoperative setting. Also, several requirements for opioid prescribing have not been documented and the need to use them as the primary medication treatment strategy for this patient has not been established. Finally, not all non-opioid medications classes have been optimized or tried. 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 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: A parent of the enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy and 12 hours per month of family treatment for treatment of the enrollee's autism spectrum disorder.Findings: The physician reviewer found that ABA is a medically necessary evidence based intervention for the treatment of autism spectrum disorders. In this case, the patients parents are requesting ABA therapy at the requested frequency of 40 hours per week of direct therapy and 12 hours per month of family treatment to address vocal stereotypies, non-compliance/non-responsiveness, elopement, and self-injury. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Based on the clinical documentation submitted for review and the support in evidence-based guidelines, the request for 40 hours per week of direct ABA therapy and 12 hours per month of family treatment has been established as medically necessary and should be approved. Final Result: The reviewers 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: Physician reviewer number is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 six additional physical therapy sessions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient had undergone sufficient outpatient therapy to have been fully transitioned to an independent modality and exercise program. There were no documented impairments that would have precluded the patient from performing an independent exercise program.  Although she had some ongoing symptoms and reported difficulties with some mobility tasks, a supervised therapeutic exercise and activity program would not have been expected to impart marginally significant benefits on the patients clinical outcomes or clinical course in comparison to a compliantly followed home program. There is a lack of proven benefit of services such as supervised exercise provided on an extended basis following a primary or revision knee arthroplasty. 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 physical medicine and rehabilitation 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: The parent of an enrollee has requested emergency medical services for the dates of service in question (including the services rendered by San Diego Imaging Medical Group, Rady Childrens Hospital, and Sharp Coronado Hospital). 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 services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with a fever and headache. A chest x-ray and laboratory testing to rule out infectious etiology were performed. The chest x-ray was positive for an upper lobe infiltrate. Due to the patients symptoms, and a history of travel outside the country in the past year, there was concern for active pulmonary tuberculosis. This presents a threat to the patients and the publics health.  The patient was transferred to a facility capable of admitting him to an isolation room until active pulmonary tuberculosis could be ruled out. Once his PPD was negative, the patient was discharged. In this case, the patients symptoms were consistent with an emergency medical condition. Therefore, the patient received emergency medical services provided on the dates of service in question (including the services rendered by San Diego Imaging Medical Group, Rady Childrens Hospital, and Sharp Coronado Hospital). 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that childhood apraxia of speech is difficult to evaluate. In this case, the patient only utilizes four to five words, which indicates a more significant delay than shown on testing. Speech therapy is clinically indicated for this patient particularly to work on speech sounds and words. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 proton beam therapy for treatment of the enrollees left breast cancer. Findings: The physician reviewer found that proton therapy has a specific indication in young adult patients in this clinical setting to help reduce cardiac and normal tissue exposure. Young adults are particularly sensitive to secondary malignancy risks. For this patient, there is concern of the contralateral breast, thyroid, and lung, for which proton therapy can provide a clinically meaningful reduction in anticipated risks. Young adults are also particularly sensitive to late cardiac injury, which is another compelling reason to consider proton therapy in this patient. Reviewing the isodose lines in this patients treatment plan supports proton therapy as the target is concave around the chest wall, and there is additional dose being delivered to the retropectoral nodes. Given this support, the requested proton therapy is medically necessary for treatment of this patients left-sided breast cancer.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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for protein testing provided for evaluation of the enrollees lung nodule. Findings: Three physician reviewers found the U.S. Preventative Services Task Force has recommended low dose CT screening for all patients felt to be at high risk of lung cancer, effectively smokers with more than 30 pack years who are either active smokers or quit less than 15 years prior to screening. However, CT scanning results in high rate of incidental nodules found. Often, these nodules are benign and lead to considerable anxiety for patients and occasional morbidity from diagnostic procedures to better elucidate them. These potential complications have resulted in attempts to develop a blood test to better determine the probability that the lesion seen on CT is malignant. In this patients case, his risk factor for lung cancer is strictly his age. He was a never smoker and has no other known risk factors for malignancy.  The Xpresys Lung assay is not validated to be used in this clinical setting. The studies to date were meant to be used in patients who are eligible for lung cancer screening, which this patient does not fit criteria for either. Radiographic follow-up of his nodule would have been appropriate. All told, protein testing provided was not likely to have been more effective than other available methods of evaluating this patient.Final Result: The three 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 physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick for treatment of the enrollee who has a history of coronary artery disease and hyperlipidemia. Findings: The physician reviewer found that the documentation provided supports the medically necessity for the requested medication in this clinical setting. Based on the records, this patient has increased coronary risk, marked hyperlipidemia with documented statin intolerance and up to moderate coronary stenosis on prior coronary CT angiogram. In this circumstance, the patients increased risk and coronary CT angiogram results provide enough evidence, to recommend aggressive lipid reduction with high intensity medication according to standard secondary prevention guidelines. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Based on the CT angiogram results, the patient fits the latter criteria. In this setting, Repatha has been shown to both reduce cholesterol and decrease adverse cardiac outcomes in randomized prospective trials  Zetia may also be considered given favorable outcomes data with this medication but would not be expected to reduce the patients LDL cholesterol to a recommended goal of less than 70 mg/dl according to secondary prevention guidelines. As such, Repatha Sureclick 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne gene test received for the evaluation of the enrollees metastatic low grade mucinous appendiceal adenocarcinomaFindings:  Three physician reviewers found that the patient was diagnosed with a metastatic low grade mucinous appendiceal adenocarcinoma. Per the January 2015 pathology report, multiple abdominal tumors were noted as consistent with a low grade mucinous carcinoma peritonei. Appendectomy was consistent with a low grade mucinous neoplasm. A clinic note reports that the patient presented 10 weeks status post palliative debulking surgery, distal gastrectomy with Billroth II gastrojejunostomy, small bowel resection, total splenectomy, cholecystectomy, appendectomy, complete peritonectomy right hemidiaphragm, and abdominal wall resection with excision of tumor of sigmoid colon.  Appendix cancer is a rare cancer. The prognosis and treatment is closely associated with histologic characteristics. Histologic types include mucinous, intestinal/colonic type, and signet ring. These tumors also have been characterized by their mitotic rate. Signet ring cell types and poorly differentiated/high grade have been associated with poorer prognosis. Prognostic features currently appear to be based on histologic and not specific genomic or proteomic profiles. The role of adjuvant chemotherapy is unknown due to the rarity of the disease. There are currently no standard guidelines, and the use of systemic therapy is extrapolated from colon adenocarcinoma guidelines. Commonly, the types with high-grade features/signet ring will undergo adjuvant fluorouracil based therapy after surgery. From the pathology report, the primary site of disease was the appendix and therefore molecular profiling would not be needed to clarify this. Current therapeutic options are not clearly outlined and therefore it is unclear of what utility the molecular profile would provide in determining treatment options. Final Result: Three reviewers determined that the testing was not likely to have been 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for prostate saturation biopsy for evaluation of the enrollees atypical prostate biopsy results. Findings:  Three physician reviewers found that the biopsy revealed atypical small acinar proliferation (ASAP) at the left lateral apex. There was another follow up biopsy which revealed ASAP at the left apex. At this visit, he presented with elevated prostate specific antigen (PSA), hypogonadism and ASAP. He had a prostate cancer antigen (PCA) 3 test which was normal at 24. His PSA was up to 11.5. He had prostate magnetic resonance imaging (MRI), which was normal. A repeat MRI showed small suspicious areas central zone. However, according to the prostate image reporting and data system (PIRADS), the report indicated a score of 3, which is low suspicion for cancer. He had a normal rectal examination. He is on testosterone replacement therapy. The patient requested authorization and coverage for saturation biopsies to detect prostate cancer. The Health Plan denied the requested services as investigational for the evaluation of this patient. The current evidence suggests that saturation schemes are associated with a higher PCA detection rate compared to standard ones on initial prostate biopsies in men with lower PSA levels or larger prostates. On repeat prostate biopsies, the studies show broad variations throughout the literature. As such, the clinical data must be interpreted with caution. This patient has low risk of having significant prostate cancer based on his history. Therefore, saturation biopsy is not likely to show clinical benefit. If repeat biopsy is considered, it should be with MRI fusion. Therefore, the requested services are not likely to be more beneficial than other alternatives for the evaluation of this patients medical condition. Final Result: The three reviewers determined that the requested services 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: All three physician reviewers are board certified in urology 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 the cell free fetal DNA gene testing for evaluation of the enrollees risk for having a fetus with genetic disorders.Findings:  Three physician reviewers found that there are multiple options for aneuploidy screening including cell-free DNA. The American College of Obstetricians and Gynecologists (ACOG) practice bulletin states that, women should be offered the option of aneuploidy screening or diagnostic testing for fetal genetic disorders, regardless of maternal age. Thus, the use of basic aneuploidy screening is considered within the standard of care. However, there are no recommendations to routine screening for fetal sex chromosome aneuploidies. Final Result: All three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in obstetrics and gynecology 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.