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 Vyvanse 30 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that Vyvanse is a central nervous system stimulant approved by the U.S. Food and Drug Administration for the treatment of ADHD. The compound is a prodrug of dextroamphetamine. After oral administration, lisdexamfetamine is rapidly absorbed and converted to dextroamphetamine, which is responsible for the drugs psychoactive properties. Amphetamines generate a clinical effect by inhibiting norepinephrine and dopamine reuptake into the presynaptic neuron and increasing release of these monoamines into the extraneuronal space of the prefrontal cortex. Stimulant medications, like lisdexamfetamine, are first-line therapies for ADHD. ADHD commonly presents in the primary care setting and is routinely treated with psychostimulants by primary care providers. Thus, the diagnosis and treatment of ADHD falls within the scope of primary care physicians. In this case, the documentation supporting the diagnosis of ADHD lacks an element of comprehensiveness such as a clinical rational or interpretative statement by the diagnosing provider supporting the justification of an initial diagnosis. Considering current practice standards and provisional diagnosis, to maintain patient centricity, continued treatment with Vyvanse 30 mg is medically necessary for a period of three months which would allow the patient opportunity to meet with a psychiatrist for a consultative and comprehensive evaluation.  Final Result: The reviewer determined that the requested medication for a duration of three months is 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser treatment for her varicose veins.  Findings: The physician reviewer found that the request for laser treatment of varicose veins is not medically necessary for treatment of the patients medical condition. Ulceration and hyperpigmentation are recognized complications of sclerotherapy. In general, hyperpigmentation lightens with time and most commonly topical agents are applied. The current data suggests less than a quarter of lesions lighten with laser therapy. Moreover, there are a lack of randomized trials supporting the use of laser treatment for the patients medical condition. As such, the request for laser treatment of varicose veins is not medically necessary. Final Result: The reviewer determined that the requested service is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in vascular surgery 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 emergency medical services provided.Findings: The physician reviewer found that The patient presented with an unspecified traumatic injury to his face, resulting in displacement of tooth number 9, and possibly another tooth and/or teeth. According to the documentation submitted for review, the initial injury occurred and the patient was treated by an oral surgeon, who repositioned the displaced tooth and/or teeth. The patient was seen by an orthodontist. In a letter by the orthodontist states that as a result of the traumatic injury, the patients maxillary left incisor tooth number 9 was malpositioned and in traumatic occlusion with the opposing teeth. The patient was treated with a removable orthodontic appliance to move this tooth back into a normal relationship with the lower teeth, in order to prevent damage to the tooth and supporting structures. The patient has requested reimbursement for medical services provided. 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. The medical services provided were not necessary for treatment of an emergency medical condition. In general, a traumatic injury to a tooth should be treated as soon as possible, as the prognosis is generally better if treated sooner, although this varies depending on the type of injury. In this case, the patient was injured and his tooth was manually repositioned by an oral surgeon. The orthodontic treatment provided was follow-up care, as evidenced by the fact that this treatment was provided 10 days after the injury. There was no emergent medical condition noted in the records submitted for review. In sum, 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 dentistry 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 iron sucrose injections for treatment of the enrollees low ferritin levels. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The medical literature indicates that approximately 70% of patients experience gastrointestinal side effects to oral iron. Intravenous (IV) iron is considered a standard of care for many patients, especially those that cannot tolerate oral iron. There are a number of settings in which the use of IV iron may be preferable to oral iron: patients who cannot (or prefer not to) tolerate the gastrointestinal (GI) side effects of oral iron, patients who prefer to replete iron stores in one or two visits rather than over the course of several months, ongoing blood loss that exceeds the capacity of oral iron to meet needs (e.g., heavy uterine bleeding, or mucosal telangiectasia), anatomic or physiologic condition that interferes with oral iron absorption, or coexisting inflammatory state that interferes with iron homeostasis. This patients records indicate that she meets several of the criteria noted above. She has not been able to tolerate oral iron due to GI side effects and she has heavy uterine bleeding. For these reasons, the use of intravenous iron is reasonable and medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in hematology 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 Botox injection for treatment of the enrollees chronic migraines. Findings:  The 3 physician reviewers found that pooled results of two large, randomized, placebo-controlled trials show that botulinum toxin is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine. Moreover, Botox has been U.S. Food and Drug Administration (FDA) approved for use in this clinical setting. Botox has not been shown to work for the treatment of episodic migraine headaches that occur 14 days or fewer per month, or for other forms of headache. The available medical records provided for review does indicate failure of at least two medications for prophylaxis of migraine. The medical records report this patient is having chronic headaches, migraine type, on an ongoing with headaches lasting four or more hours on 15 days or more per month for at least three months. For these reasons, the Botox injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a schedule 3 drug and Zomig for treatment of the enrollees migraines. Findings:  The physician reviewer found that Zomig is effective in treating acute migraine, but has little role in the management of chronic daily headache.  For the more severe migrainous type headaches, Zomig is a reasonable choice. However, use of this medication should not exceed 10 days per month.  There is no role for narcotic analgesics in the management of chronic headache.  Typically, narcotic use limits the effectiveness of preventive medications. Preventive medications are the best option in this clinical setting.  Furthermore, narcotics can be associated with worsening of headache consistent with medication overuse headache.  Therefore, Zomig is medically necessary for the treatment of this patient.  The medical records fails to demonstrate the medical necessity of a schedule 3 drug. Final Result: The reviewer determined that a portion of the requested medications is 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira for treatment of the enrollees seropositive rheumatoid arthritis. Findings:  The physician reviewer found that the request for Humira is not medically necessary for treatment of the patients medical condition. According to the office visit, the patient is to continue treatment with Enbrel and use Tylenol or Motrin for pain. The addition of Humira to the regimen of Enbrel, Motrin and Tylenol is not supported by evidenced based peer-reviewed guidelines. On the basis of the available medical documentation and the peer-reviewed guidelines, the request for Humira 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 internal medicine with sub-specialty certification in rheumatology 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 Baraclude for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that This patient is currently on brand-name Baraclude (entecavir). Per American Association for the Study of Liver Disease guidelines for treatment of hepatitis B, Baraclude (entecavir) is a recommended medication. Entecavir-mediated viral suppression is a first-line therapy recommended by the guidelines, and has been shown to decrease the risk of decompensation and hepatocellular carcinoma. However, the brand formulation is not recommended over the generic formulation. Additionally, generic medications must demonstrate bioequivalence, with the exact same active ingredient, to be approved for use.  The manufacturer of generic entecavir for sale in the United States did demonstrate equivalence to brand-name Baraclude to the U.S. Food and Drug Administration before approval was granted. There is a lack of medical literature to show that brand-name Baraclude is safer or more effective than generic entecavir.  For these reasons, Baraclude is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. The patient was not in withdrawals.  He reported that his last use was approximately two weeks prior to admission.  He denied cravings. There was no evidence of danger to self or others. He was not psychotic or manic.  The documentation submitted did not note evidence of emotional, behavioral, cognitive, or impulsive symptoms that required supervision in a residential setting. Moreover, his medications did not require management at residential level of care. The patient was medically and psychiatrically stable. He could have been treated at intensive outpatient program or outpatient level of care.  Although initially he may have indicated that he did not feel he required treatment, he did participate in his treatment plan and endorsed motivation.  His parents were supportive and home environment was stable. The medical literature does not support residential treatment center level of care. For these reasons, residential treatment center services were not medically necessary for treatment of this 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 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 Epclusa 400-100 mg tablet for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3. Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as a first-line regimen for non-cirrhotic treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 400-100 mg tablet is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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 positron emission tomography (PET) scan with computed tomography (CT), skull to thigh for evaluation of the enrollee, who has a history of fatigue, palpitations, chest pain, shortness of breath and intermittent pain in the right shin and upper thighs. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested services. In this patients case, the guidelines do not support the efficacy of the PET/CT. In recent years, PET/CT scanning has become increasingly common, primarily as a tool to evaluate the presence or extent of malignancy.  There are non-oncologic indications, such as evaluating fevers of unknown origins and dementias, but these are far less common. For this particular patient, the records do not demonstrate a clear indication for a PET/CT scan. The tiny pulmonary nodules that were noted are too small to be conclusively visualized on PET scans. The residual thymic tissue is not an unusual finding in this clinical setting, and there are no signs or symptoms in the legs that would warrant a PET/CT scan. The American College of Radiology (ACR) Appropriateness Criteria has published over 50 appropriateness criteria for various clinical presentations.  Under the heading of chronic extremity pain, PET/CT scanning is not mentioned as a possible tool. Additionally, there is no clinical information submitted to support the use of a PET/CT scan to evaluate the patients head.  There was some mention of fevers following a dental procedure two years earlier, but dental issues are not routinely evaluated by PET/CT scans. In sum, without a diagnosis of tumor, or without a recognizable abnormality that is likely to be considered a tumor, and for the other non-specific constitutional symptoms, there does not appear to be a clinical indication for PET/CT.  As such, PET/CT skull to thigh is not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services 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 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.