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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the radiofrequency neurolysis. Findings:  Two physician reviewers found that in the documentation available for review, the provider reportedly used steroids while performing the medial branch block. However, the medical literature states that medial branch blocks should be performed using either solely lidocaine or bupivacaine without sedation, and a pain diary should be kept for the day to verify when the local anesthetic wore off. Moreover, it is noted the patient still had relief from the medial branch block done on 9/8/16, almost one month later, thus the block lasted longer than the duration of the local anesthetic. For this reason, it was likely the patient would have obtained the same relief from a steroid injection in the facet joint without also having the increased risk from the radiofrequency neurolysis. Final Result: Two 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 anesthesiology with sub-specialty certification in pain medicine 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 Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions), 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. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks).  In this patients case, NS5A resistance testing results were not provided.  For these reasons, although hepatitis C treatment is needed, Zepatier 50-100 mg, one per day for 12 weeks is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

A parent/guardian of an enrollee has requested reimbursement for residential treatment center (RTC) services.  Findings:  The physician reviewer found that the records provided for review do not demonstrate the RTC services provided specific dates were medically necessary for treatment of this patients behavioral health condition. There was a lack of evidence that the patient had severe and persistent psychiatric symptoms that result in impairment requiring active treatment in a 24-hour supervised setting. There was no evidence of suicidal or homicidal ideations, no evidence of psychosis, and no evidence of physical aggression during this period of time. None of the medication changes made during this period of care required 24-hour supervision and treatment.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed .Findings:  The physician reviewer found that Tomosynthesis is rapidly becoming a standard problem-solving tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as very dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed on the date of dispute has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number 1,2 & 3 are board certified in diagnostic radiology 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: The representative of an enrollee has requested reimbursement the hospital stay provided. Findings:  The physician reviewer found that Based on the clinical documentation submitted for review, the medical necessity for the services at issue have not been established. The patient remained stable during the hospital stay during the dates of dispute and  was no longer requiring parenteral medication. Her blood pressure, pulse and oxygen saturations were stable. The patient was able to take oral nutrition and was voiding without complications. She was ambulatory.  The patient was no longer monitored by daily laboratory studies or receiving imaging studies. The documentation supports that the patient was stable for discharge . Accordingly, the hospital stay provided during the dates of dispute was not medically for treatment of the patients medical condition. Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided for treatment of an emergency medical condition. 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 provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient had run out of a prescription medication for anxiety. He denied suicidal or homicidal ideation. He was not hallucinating. His insight and judgement were good. Although he was anxious, the urgent care evaluation did not meet the criteria for emergency medical services. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services, the patient was experiencing continued foot pain following a twisting injury. Although his symptoms were not acute in onset, his pain was persistent, increasing, and accompanied by swelling and pain with weight bearing. He was found to have a foot fracture requiring immobilization and non-weight bearing. Therefore, the services provided were necessary for treatment of an emergency medical condition.  Final Result: The reviewers determined that the enrollee received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential care for substance abuse treatment. Findings:  The physician reviewer found that the records provided for review document that this patient was having mild withdrawal symptoms on  the date of dispute. However, he was not a danger to himself or others and he was not gravely disabled. He was medically and psychiatrically stable. He was motivated for recovery. The remainder of the patients phenobarbital taper did not require monitoring at a residential level of care. There were no emotional, behavioral, cognitive, or impulsive factors that support treatment at the residential level of care from 1date of dispute forward. He participated in his treatment plan. He could have continued to obtain relapse prevention education and build coping skills on an ambulatory level of care such as intensive outpatient program (IOP) or outpatient with AA support. All told, the residential care for substance abuse treatment from the date of dispute forward was not and is not medically necessary for treatment of this patients medical condition 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 reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 Epclusa with ribavirin for treatment of his hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This recommendation applies regardless of fibrosis stage.  The guidelines recommend that genotype 2 patients who have failed Sovaldi/ribavirin regimens should be treated with Sovaldi/Daklinza with or without ribavirin for 24 weeks. The guidelines also support re-treatment with Epclusa and ribavirin for 12 weeks. This is based on higher cure rates with use of Epclusa and ribavirin rather than Epclusa monotherapy.  Although hepatitis C treatment is needed, the requested medication regimen is not supported as medically necessary over the formulary medications, Sovaldi with Daklinza, for the re-treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Two physician reviewers found that the medical evidence supports the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. Final Result: The reviewers determined that the service 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 overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is 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 digital breast tomosynthesis for evaluation of her status post prior lumpectomies. Findings:  The physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: The reviewers determined that the service 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 overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is 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 Botox injections for treatment of her migraine headaches. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The records support the diagnosis of chronic migraine.  Botox has been shown to be beneficial for preventive treatment of chronic migraine, and is U.S. Food and Drug Administration (FDA) indicated for this purpose.  She has had multiple medication trials, including antidepressant medication, anti-seizure medication, a muscle relaxant, as well as off-label use of Namenda as a headache preventive.  The current medical evidence supports the requested services in this clinical setting.  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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of enrollee, who was breastfeeding.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  This is common when breastfeeding, but if there is a question of an underlying breast abnormality (which could include an abscess), it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor or abscess. Final Result: The reviewers determined that the service 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 overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is 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 digital breast tomosynthesis (three dimensional mammogram) for the evaluation of the enrollee who, presented for a breast examination. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, her breast tissue was described as extremely dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the service at issue was 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 overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers 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: A male enrollee has requested reimbursement for the residential treatment services provided for treatment of the enrollees alcohol use disorder and major depressive disorder. Findings:  The physician reviewer found that the records indicate that this patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential treatment center level of care. He was medically and psychiatrically stable. He was motivated and appeared to be working the program. He was cooperative and participating in his treatment plan. Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting and the patient could have been stepped down to an ambulatory level of care. All told, the residential treatment services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.