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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper airway stimulation device (outpatient surgery). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. Findings:  Two of the three physician reviewers found the current medical evidence has not established the superior efficacy of the requested services in this clinical setting. This patient has moderate obstructive sleep apnea, as diagnosed from her AHI of 20.6. CPAP is the first-line treatment of obstructive sleep apnea. In this patients case, it is unclear from the records what attempts were made to help her tolerate CPAP. Mandibular advancement devices have been shown to be effective for mild and moderate obstructive sleep apnea. This option could be provided to the patient before pursuing a surgical procedure. In sum, the requested upper airway stimulation device (outpatient surgery) is not likely to be of greater benefit than other available options for the treatment of this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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 assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.Findings:  There is a lack of peer reviewed evidenced base medical literature to support the superior efficacy of the services at issue in this patients case. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages from 0-IV. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class I consistent with a low risk of metastasis or Class II suggestive of a high risk of metastasis. A study noted that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class II. The researchers concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as Class 1 with a low risk of near term (within five years) metastatic disease. While DecisionDx-Melanoma signature may be an independent predictor of metastasis risk, more studies are needed to show its efficacy when compared to standard methods used to guide therapy or predict the risk of cancer. All told, DecisionDx-Melanoma gene assay was not likely to have been more beneficial for the evaluation of this patients medical condition than any available standard therapy. Final Result: All three reviewers determined 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 reviewers are board certified in dermatology and are actively practicing. All three 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 inpatient substance abuse treatment. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition.Findings: The requested services are not medically necessary based on the timeliness of the clinical documentation. Treatment referrals ordinarily progress in a step wise fashion from less to more restrictive settings. However, determining the level of care is a case specific, patient centered process, and the most appropriate entry point for an episode of care may in fact be a residential setting. The records demonstrated that this patient has severe addictive illness.  He has an early onset of use and family history of substance use. The patient has failed outpatient treatments.  The patients work environment, financial struggles, marital discord and depression are significant concerning factors as well.  However, the most recent clinical documentation was months ago.  The patients current clinical status, degree of psychosocial stress, extent of psychiatric and medical comorbidity, and standing in community based treatment and self-help efforts are unknown. Thus, at this time, inpatient substance abuse is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for sensory integration occupational therapy. Findings:  The physician reviewer found that there is significant controversy in the peer-reviewed literature regarding the effectiveness of sensory integration occupational therapy. The authors found that the methodology of the studies was poor. Most of the studies used weak designs, with a tendency for higher quality studies to produce negative results. Based on limited comparative evidence, functional analysis-based interventions for challenging behavior, such as applied behavioral analysis (ABA) therapy, were more effective than sensory integration therapy. Overall, the studies do not provide convincing evidence for the efficacy of sensory integration therapy. Given the lack of support in the peer-reviewed literature, the request for sensory integration occupational therapy has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are 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: One reviewer is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One Reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  All three 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 her current methadone maintenance treatment program (methadone 210 mg daily and take home level). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient has been stable on her methadone maintenance treatment program and is able to function in her activities of daily living. There is no indication of diversion or use of other drugs of abuse. There is no indication of overdose or using other medications that may interact with the methadone. The Centers for Disease Control and Prevention opioid prescribing guidelines specifically state that the new guidelines are not meant for opiate maintenance programs. The effectiveness of methadone to prevent relapse to addiction is well-proven. All told, the patients current methadone maintenance treatment program (methadone 210 mg daily and take home level) is medically necessary for the treatment of this patient. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The records provided for review document that the patient had no significant post-acute withdrawal symptoms, his urine drug screen was negative, and his Clinical Institute Withdrawal Assessment (CIWA) was. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. He was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. His vital signs were stable. He was motivated and had some insight into the impact of his alcohol use. The documentation indicates that the patient could have been safely and effectively treated at a lower level of care and did not require 24-hour supervision at RTC level of care. He did not require the structured setting of a RTC. All told, the RTC services provided were not medically necessary for treatment of the patients behavioral health 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. Guidelines cite data showing reduced survival with delayed treatment. All told, Mavyret is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of autonomic testing. Findings:  The physician reviewer found that although autonomic testing is not required for all patients with diarrhea, it is reasonable for a subset of patients such as this patient. There is a proven association with paraneoplastic processes and antibodies with autonomic dysfunction. This patient had a voltage gated potassium antibody which has specifically been associated with autonomic dysfunction. As part of his work-up it was critical to determine the extent of his symptomatic involvement so that the proper diagnosis could be reached and the proper treatment initiated. Autonomic testing was a reasonable approach to determine what clinical features were associated with his diarrhea and antibody testing. If autonomic abnormalities were detected, this would have also provided insight into his abnormal gastrointestinal findings. Given this support, the autonomic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the autonomic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the autonomic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: A 31-year-old female enrollee has requested authorization and coverage for brand name Strattera 80 mg. Findings:  The physician reviewer found that as noted in the medical literature, pharmacotherapy is considered first-line treatment for ADHD. In 2002, Strattera was approved for the treatment of ADHD from the U.S. Food and Drug Administration (FDA). Strattera is a non-stimulant selective norepinephrine reuptake inhibitor, which distinguishes itself from other standard pharmacologic interventions for ADHD. In 2017, the FDA approved generic versions of atomoxetine. In this case, the brand name Strattera has been well-tolerated and efficacious, appropriately dosed and approved by the FDA for the condition being treated. The therapy is safe, appropriate and consistent with good medical practice while ongoing treatment is reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the requested brand name Strattera 80 mg is medically necessary for treatment of this patients ADHD. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Cosentyx.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees severe hidradenitis suppurativa (HS).There is evidence in the medical literature that supports treatment with Cosentyx may be effective for treatment of HS. According to a study, after 12 weeks of treatment with Cosentyx, the number of lesions reported by one patient within the period of the last four weeks was reduced from 23 to seven. In this case, the patient presents with severely recalcitrant HS, which has been unresponsive to treatment with combination oral antibiotics, topical antibiotics, isotretinoin, Anakinra, and Humira. In addition, the patient was treated with Humira for 10 months and developed neurological side effects requiring discontinuation of the medication. As there are a lack of other alternatives available, the request for Cosentyx has been established as medically necessary for treatment of the patients chronic HS. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage enrollee has requested authorization and coverage for consultation with a plastic surgeon. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested consultation for plastic surgery. According to the records, the patient has generalized skin laxity consistent with the history of massive weight loss. Individuals who undergo massive weight loss will experience some skin laxity. In the absence of clear and compelling documentation of specific signs and symptoms that are clearly related to the excess skin or are health threatening, or cause significant functional disability and have failed to improve despite reasonable attempts at conservative therapy, the requested procedures would not be medically necessary. In this patients case, the submitted records do not include evidence of chronic health problems that have failed reasonable attempts at conservative therapy.  In addition, the records do not include documentation of a series of office notes or photographs. Therefore, plastic surgery consultation for evaluation of the patients medical condition is not medically necessary. With regards to whether or not this patient meets the criteria under the expanded concept of medically necessary reconstructive surgery as defined in California law, the submitted records do not support the patient meets these guidelines. The alleged abnormality does not constitute an abnormal structure of the body. Skin laxity is a normal part of aging and a normal finding in men and women with a history of weight gain and weight loss. Therefore, the requested surgery will not improve function or create a normal appearance to the extent possible. For these reasons, the requested consultation is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret 100-40 mg. Findings: The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg 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 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.