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

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of a breast lump requires optimal imaging to avoid a biopsy. Tomosynthesis has been shown to be better in assessing malignant versus benign findings. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, an ultrasonography is often necessary to better confirm the cystic nature of a mass. For the reasons provided, the bilateral breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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: All three physician reviewers 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient stay provided from 3/13/15 through 3/16/15. Findings:  The physician reviewer found that 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 inpatient stay provided from 3/13/15 through 3/16/15 was not necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient presented to the ED with acute abdominal pain and was diagnosed with biliary colic and mild cholecystitis. The patient was stabilized while in the ED and during the surgical consultation. The patient could have been scheduled to undergo an elective cholecystectomy on a later date.  Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested Phentermine 37.50 mg for treatment of the enrollees obesity. Findings: The physician reviewer found that Phentermine 37.50 mg is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested medication for use in this clinical setting. According to Gadde and colleagues The combination of phentermine and topiramate, with office-based lifestyle interventions, might be a valuable treatment for obesity that can be provided by family doctors. In this case, the requested medication is being used along with Topamax (topiramate). In addition, coverage criteria is met if the patient has a current BMI of 35-39 and is treated with medication for hypertension, diabetes, coronary artery disease, dyslipidemia, stroke, osteoarthritis or sleep apnea. In this case, the patient has a BMI of 35.95 and is treated with losartan for treatment of hypertension. All told, Phentermine 37.50 mg has been established as 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 endocrinology, diabetes and metabolism 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 the enrollees breast cancer screening. 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, she has breasts that have been described as being heterogeneously dense.  First, the new mass that was discovered in the lower outer aspect of the left breast was an appropriate indication for breast tomosynthesis. Second, the area of asymmetry is another indication for breast tomosynthesis. Final Result: The reviewers have 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 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 RT300 Functional Electrical Stimulation (FES) Cycle Rehabilitation System for treatment of the enrollees tetraplegia. Findings: Two physician reviewers found that there is a lack of support for the requested device in this clinical setting.  There is a lack of proven significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry.  There have been a number of small papers published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury have not been completed and published.  While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially reverse muscle atrophy in paralyzed muscle, there is a lack of significant health or functional benefit of this achievement in spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide other clinically or functionally relevant benefit.  It does not obviate the need for pressure relief.  To date, the limited data that are available provide mixed results regarding health measures.  There are insufficient data regarding clinically-relevant outcomes related to the use of this device on bone health after spinal cord injury.  Thus, the medical evidence has not established the superior efficacy of the requested RT300 FES Cycle Rehabilitation System for the treatment of this patient.Final Result: Two reviewers determined that the requested device 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 physician reviewers are board certified in physical medicine and rehabilitation 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 DecisionDX-Melanoma Class I investigational for the evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that the patient was diagnosed with a cutaneous melanoma in the skin located in his epigastric region. At that time he was found to have an invasive melanoma, non-ulcerating, Clark Level II, Breslow thickness 0.35, and no mitoses were seen. The provider recommended tissue sampling in an effort to determine the patients prognosis. The patients tissue was sent for DecisionDX- Melanoma Class I assay and testing. The patient requested reimbursement for the testing. The Health Plan has denied reimbursement because the Health Plan deems the services at issue as experimental/investigational for the evaluation of this patient. This denial is the subject of this appeal and determination. The prognosis of cutaneous melanoma has classically been determined by the staging system as documented by the researchers. The mitotic index has also been viewed to add a bit more to the prognostics. DecisionDX-Melanoma is a study of 31 genes in the melanoma cells. It then classifies that melanoma as either high or low risk for recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state that there is interest in these newer genetic profiles, but only in the context of a clinical trial. Currently, medical studies are not clear as to how DecisionDX data compares to the 10 year data of the Balch determinations and whether it is useful in clinical practice for patients with a good prognosis, as is true in this patients case. This assay, was used in an effort to determine this patients prognosis. While this test has some limited support for its use in identifying treatment options for those patients diagnosed with cutaneous melanoma, this assay has not been shown to be superior over other modes of therapy. As such, DecisionDX-Melanoma Class I assay was not likely to be more effective than available standard therapy for the evaluation of this patient. Final Result: The reviewers have 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Effexor XR 75 mg. Findings:  The physician reviewer found that venlafaxine is a dual-acting medication that enhances both noradrenergic and serotonergic tone in the central nervous system. The medication has U.S. Food and Drug Administration (FDA) approval for the treatment of major depressive disorder, generalized anxiety disorder, panic disorder and social anxiety disorder. Considering the biological nature of this life-long, recurrent illness, pharmacotherapy is a primary treatment modality for major depressive disorder. In this case, the patient has been clinically stable for years on an evidence-based antidepressant medication endorsed by current practice guidelines and community standards. The patient previously failed a trial of generic venlafaxine. According to a study, the possibility exists that differences in potency may underlie adverse changes in clinical status, when a brand name medicine is substituted with a generic, or if there is a switch between specific generic manufacturers, which represents a reasonable explanation for this patients experience. Subjecting a euthymic and otherwise stable patient to a medication change to demonstrate clinical failure unnecessarily heightens the risk of morbidity. The patient has been prescribed Effexor, which is a safe and appropriate pharmacotherapy that is consistent with good medical practice and is reasonably expected to maintain her clinical stability and prevent an exacerbation of illness. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided on an emergent basis or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. According to the documentation submitted for review, the patient presented with a non-painful rash in the genital area for five days, without fever, or systemic signs and symptoms. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services.  Findings:  The physician reviewer found that 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 anesthesia services provided were not necessary for treatment of an emergency medical condition. With a laboring patient that is unable to have a vaginal delivery, a cesarean section is indicated. However, an emergency cesarean is reserved for those cases where the cesarean section needs to be performed as soon as possible, such as in the case of a cord prolapse or prolonged deceleration/bradycardia situation. In this case, the cesarean section was not emergent. Although anesthesia is indicated for a cesarean section, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital services provided for treatment of the enrollees acute cervical spinal cord injury. Findings:  The physician reviewer found that the records indicate that patient had a lesion on imaging concerning for a possible inflammatory versus neoplastic process. There was a history of the patient sustaining injury from a fall. After being observed, evaluated and treated in the hospital, the patient was ready for transfer to a rehabilitation facility, but was not reasonably safe for community re-entry given his complex baseline functional impairments, and his history of multiple falls. His newly-acquired deconditioning administrative days were appropriate while attempting to procure a bed for transfer to a skilled nursing facility.  It was appropriate for the facility to have initiated the process for a transfer at the skilled nursing facility level of care given the patients history and deficits. He was appropriately evaluated in a more detailed manner by physical therapy and determined to be a candidate for acute inpatient rehabilitation. This evaluation was necessary to determine his precise functional status, his ability to participate and his prognosis for functional recovery. Coverage of one acute hospital day for the evaluation and making this recommendation was medically appropriate. An additional administrative day was appropriate while attempting to procure a bed for transfer to an acute inpatient rehabilitation facility. As such, the inpatient hospital services provided were medically necessary for the treatment of this patient. However, inpatient hospital stay on their last day there was not medically necessary. Therefore, a portion of the services at issue were medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in physical 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 Accu-Check Smartview test strips for the evaluation the enrollees blood sugar levels. Findings:  The physician reviewer found that the medical literature does not support the medical necessity of the requested test strips in this clinical setting. The patient requested the Accu-Check Smartview strips because she believes they are safer to use around her son. However, the records do not demonstrate that this patient presents with any medical or physical deficits which preclude her from using other meters to test her blood sugar levels. There are other types of glucose meters available to this patient. Precautions can be taken to maintain the safety of the patient and her family. Therefore, the requested Accu-Check Smartview test strips are not medically necessary for the evaluation of this patients blood sugar levels. Final Result: The reviewer determined that the requested supplies are 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 endocrinology and metabolism 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.