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 Zepatier one tablet daily for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer has 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 or 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 (Zeuzem, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewers 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: Physician 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: The parent of the enrollee has requested authorization and coverage for at least six months of 150.5 hours per month of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.Findings: The physician reviewer found that based on the documentation submitted for review, the patient has made progress as evidenced by the behavioral data submitted, but he continues to have problematic behaviors which jeopardize his safety. The patient also demonstrates delays in social skills and communication, lacking the ability to interact or demonstrate social/emotional reciprocity. He had a standard score of 73 on the Adaptive Behavior Composite (ABC), well below the normative mean of 100 which further underscores the patients delays in activities of daily living. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this clinical setting, the request for at least six months of 150.5 hours per month of ABA therapy is medically necessary for treatment of the patients autism. 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 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 laser assisted uvula palatoplasty surgery. Findings: The physician reviewer found that the medical evidence does not support the requested services in this patients case. The records document mild obstructive sleep apnea. He has failed a couple of treatment modalities. The requested procedure, laser assisted uvula palatoplasty, has largely fallen out of favor due to its ineffectiveness in treating obstructive sleep apnea. This procedure was popular in the 1990s and early 2000s, but when long-term results showed poor improvement in snoring, it became unpopular for treating snoring as well. At this point, the laser assisted uvula palatoplasty surgery would not be indicated in treating this patients obstructive sleep apnea. The uvulopalatopharyngoplasty would be more beneficial for this patients condition than the requested services.  All told, the requested laser assisted uvula palatoplasty surgery is not medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number is board certified in otolaryngology 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 gene tests (81211 - BRCA1 and BRCA2; 81213 - BRCA1 and BRCA2; 81479 - BART test) for evaluation of the enrollee, who has a family history of cancer.Findings:  All three reviewers found that there is sufficient support for the services at issue in this patients case.  In women with no personal history of breast cancer, the guidelines support BRCA testing for patients with two or more close relatives with breast cancer, one of whom was diagnosed at the age of 50 or younger.  Thus, the medical evidence supports BRCA testing in this clinical setting.  BART is now included automatically when BRCA testing is done. Final Result: Three reviewers determined that the testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for therapy sessions for treatment to develop a relationship with a family member.Findings:  The physician reviewer found that the patient has requested therapy sessions in order to develop a relationship with a family member. The patient had a telephone intake, and the clinician who completed the intake opined that the patient was not in need of behavioral health services due to a lack of clinical findings or clinical diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, for developmental process underlying mental functioning.   Mental disorders are usually associated with significant distress or disability in social, occupational, for other important activities. According to the material and clinical information presented for this review, the records do not demonstrate a mental disorder.  Psychotherapy involves treatment planning as well as treatment goals that would typically include symptom reduction of some type.  In this case, there is no indication of a symptom that would be the target of a treatment goal. It appears that the patient would like to develop a relationship with a family member, but there is no clinical indication to support any targeted treatment goals.  Final Result: The reviewer determined that the requested treatment was 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 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 urgent care services. Findings: The physician reviewer found that , the patient presented to urgent care with reports of a rash for one week. She denied any fever, chest pain or shortness of breath. The patients vital signs and lung exam were normal. A skin rash was noted. No emergent condition was identified and no emergent treatment was provided. The patient presented to urgent care with reports of a cough and sore throat. Her vital signs were stable. Heart and lung exam were also normal. The patient was discharged with a prescription for an antibiotic. No emergent condition was identified and no emergent treatment was provided. In sum, there is no documentation to support that the patient received emergency medical services on the dates of service at issue. Final Result: The reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral sacral lateral branch block (bipolar radiofrequency ablation for treatment of the enrollees pain. Findings:  Two physician reviewers found that the current medical evidence does not support the requested services in this clinical setting. Radiofrequency ablation of the lateral sacral branches to treat sacroiliac joint pain is not an established treatment in this case because the reported efficacy varies widely as does the technique used.  The American Society of Interventional Pain Physicians clinical practice guidelines found this approach to only have limited evidence in support of the procedure. Similarly, Aydin and colleagues found that while the technique was promising, there is a need for prospective randomized controlled studies. Final Result: Two reviewers determined that the requested treatment 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 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 reimbursement for residential treatment center services. Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. The patient had minimal post-acute withdrawals. He was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, impulsive, psychotic, or manic concerns which would have precluded stepping him down to a lower level of care. He was motivated for treatment. His wife was supportive and his living environment was alcohol free. There was no evidence to suggest that he would deteriorate if treated at a lower level of care. His recovery could have continued at a lower level of care, in conjunction with additional community based Alcoholic Anonymous (AA) meetings, along with help from his sponsor. For the reasons provided, the services at issue 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: Physician reviewer number two 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 Norco. Findings:  The physician reviewer found that based on the presented clinical records, the request for Norco is not medically necessary for treatment of the patients medical condition. In this case, the patient is requesting opioid medication for treatment of his chronic nonmalignant pain. However, there are alternative treatments available for this patient such as non-opioid medications, physical therapy, chiropractic care, acupuncture and interventional care. Also, urine drug screening was consistent with previous cannabis use. The patient has declined subsequent urine drug screening. For these reasons, the request for Norco is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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. 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. 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 or 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; if it is present, Zepatier and ribavirin are needed for 16 weeks. NS5A resistance testing results are not provided, so the medical necessity of Zepatier monotherapy for 12 weeks cannot be established. For these reasons, the request Zepatier for 12 weeks is not supported as 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 Physician 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 authorization and coverage for apremilast (Otezla) for treatment of the enrollees psoriasis vulgaris. Findings:  The physician reviewer found that the patient has tried and failed therapy with topical steroids for extensive plaque psoriasis. However, there is no documented intolerance or contraindication to treatment with ultraviolet light, acitretin or cyclosporine. The medical records indicate that the patient is a recovering alcoholic, but there is no documentation of abnormal liver function tests to indicate a contraindication to methotrexate. As the patient has not been treated with a preferred systemic agent or phototherapy, the requested Otezla is not medically necessary. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breast for evaluation of the enrollee, who has a history of dense breast tissue.Findings:  Two physician reviewers found that MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. In some studies, the specificity of breast MRI has been reported to be as low as 37%. This patient has consistently stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  Per the records, this patient does not meet the criteria for being at high risk for developing breast cancer, which is defined as having a 20 to 25% likelihood of developing the disease.  On the mammogram report, there was no mention of inadequate imaging, and no suspicious abnormalities were seen.  The implants were intact, and there is no reason to expect an implant rupture. Final Result: Two reviewers determined that the requested services 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 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 emergency medical 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 patient presented with ear pain, nasal obstruction and sinus congestion. He denied chest pain, cough, fatigue, shortness of breath, nausea and fever. Given the non-emergent nature of the patients symptoms, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewers 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 otolaryngology 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 magnetic resonance imaging (MRI) of the head for evaluation of the enrollees pain. Findings:  The physician reviewer found that there is a paucity of evidence that supports medical imaging for patients presenting with nonspecific headaches.  The American College of Radiology criteria does not support the requested MRI for this patient with chronic headache, no new features, and normal neurologic examination.  The American College of Radiology notes in adult and pediatric patients with migraine, but without recent change in attack pattern, history of seizures, or other focal neurologic symptoms or signs, the routine use of neuroimaging is usually unwarranted. The American College of Radiology reports that the yield of computed tomography or MRI in patients with headache but normal neurologic examination is low.  In this patients case, he has no localizing signs or symptoms, and he does not have a history of a primary tumor.Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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.