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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for BRAF mutation analysis gene panel testing.Findings:  Two of the three physician reviewers found that the medical evidence has not demonstrated the superior effectiveness of the services at issue. Per the literature, BRAF mutation analysis gene panel testing (Afirma Thyroid FNA Analysis) was not likely to have been superior to cytology interpretation of pathologic thyroid specimens. A study reported that the rate of malignancy in thyroid nodules suspicious by Afirma was 18.3% while the rate of malignancy in nodules suspicious for neoplasm on cytology interpretation was 31.2%, resulting in a false positive rate of 56%. The authors concluded that cytology interpretation has a higher rate of predicting malignancy when compared with the Afirma test, by almost twofold. Sacks and colleagues reported increased incidence of indeterminate fine needle aspiration diagnoses after Afirma became routinely available, whereas the incidence of benign diagnoses significantly decreased. The authors noted that Afirma raised uncertainty of the benefits of molecular testing and may produce unintended collateral effects, increasing the number of indeterminate fine needle aspiration diagnoses while not affecting the institutional thyroidectomy rate or malignancy yield. Thus, BRAF mutation analysis gene panel testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in clinical genetics and genomics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic testing. The Health Plan has denied the testing at issue as investigational. The patient has a medical history that includes seizures that began with myoclonic, absence and tonic clonic types of seizures. The absence seizures began with staring spells and progressed to include myoclonic movements. He has had increased frequency of convulsions in the past months, which occur up to weekly. These have been complicated by multiple shoulder dislocations. On a chance this condition may be related to an immune-system disorder, he was administered intravenous immunoglobulin (IVIG). The patient responded with less fatigue and the convulsions stopped for at least five months.Three physician reviewers found that in this case, the patients seizures have worsened in both frequency and severity despite medical management. Traditional diagnostic modalities have not yielded a specific diagnosis or suggested long-term successful therapy. Updated bioinformatics analyses make a genetic diagnosis via exome sequencing feasible. Further, a specific diagnosis may lead to more targeted and beneficial therapy. Based upon the model coverage policy from the AAN and available literature, genetic testing performed was likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in genetics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has experienced sudden vision loss symptoms of the left eye. The patient was diagnosed with retinal detachment and macular pucker in the left eye. He underwent repair of retina detachment, pars plana vitrectomy, membrane peeling, air fluid exchange and gas to the left eye. At issue, is whether the retina surgery that was provided were emergency services?Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition is manifested by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.In this case, the patient presented to the facility with a detached retina and sudden loss of vision in the left eye. A detached retina is a severe, acute condition. Failure to provide immediate medical attention could result in permanent loss of vision. Therefore, criteria for an emergency medical condition have been met. Because the patient had an emergency medical condition, the services provided were emergency services as defined under California law.Final Result: The reviewer determined the patient did receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology, 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 patient has requested authorization and coverage for Aimovig. Findings:  The physician reviewer found that the current guidance from the American Headache Society (AHS) indicates that prior to the introduction of calcitonin gene-related peptide (CGRP) antibody agents in chronic migraine, established prophylactic therapies should be used. There are a large number of well-established prophylactic therapies for migraine headaches that have substantial support in the medical literature. In this case, the patient has been treated with topiramate and amitriptyline for chronic migraine headaches. While there are concerns about the choice of other prophylactic agents given her comorbid diagnosis of bipolar disorder, there are other level A or B treatments that have greater support in the clinical literature than Aimovig. Given these findings, the requested Aimovig is not supported as medically necessary for treatment of this patients chronic migraines. 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 neurology with subspecialty certification in sleep 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

The patient has requested authorization and coverage for a 24-hour video electroencephalography (EEG) of the brain. In this case, the patient has a history of a significant traumatic brain injury with subsequent episodes that are potentially suggestive of a seizure disorder. Current practice guidelines and literature readily recommend the performance of a routine EEG to evaluate for possible epilepsy. However, prior to consideration of any extended EEG monitoring, a routine EEG should be performed. A routine EEG can be effective in establishing a diagnosis of a seizure disorder and would preclude the need for further testing. The current standards of practice generally involve completion of a routine EEG study prior to consideration and performance of an extended EEG recording (ambulatory or attended, with or without video). Based on the records that were provided for review, there is no documentation that the patient has undergone evaluation with a routine EEG. For these reasons, the requested 24-hour video EEG of the brain is not medically necessary for 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 neurology with subspecialty certification in sleep 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an implantable cardioverter defibrillator (ICD). Findings:  Three physician reviewers found that based on the records provided for review, this patient has apical variant hypertrophic cardiomyopathy. While apical variant hypertrophic cardiomyopathy generally carries a more benign course compared to basal septal hypertrophic cardiomyopathy, this patient has two additional risk factors for sudden cardiac death. Given the presence of at least two risk factors for sudden death, placement of a primary prevention defibrillator is indicated. All told, the requested ICD is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested ICD is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested ICD is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Northera. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Northera is approved for the treatment of neurogenic orthostatic hypotension. The drug improves symptoms of orthostatic dizziness, lightheadedness and near-fainting. Beta hydroxylase deficiency is characterized by both elevated dopamine and low catecholamine. Although the records mentioned the diagnosis of orthostasis, the recorded blood pressures available for review did not demonstrate orthostasis. Autonomic function testing, which is the definitive test, did not show orthostasis. In sum, this patient does not have documented orthostatic hypotension or evidence of cardiovascular autonomic dysfunction. Therefore, Northera 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 cardiovascular disease 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: As reported in the current medical literature, ABA is a medically necessary treatment for patients with autism based on the evidence demonstrating its effectiveness. Findings:  The physician reviewer found that the National Autism Center National Standards Project identified ABA as the most effective, evidence-based treatment available to treat patients with autism spectrum disorders. To determine whether a specific number of ABA hours are medically necessary, the Behavior Analyst Certification Board (BACB) has established guidelines which highlight that treatment dosage is dependent upon goals of treatment, specific client needs, and response to treatment. A study evaluated the dosage of ABA and treatment outcomes of hundreds of children. The authors reported that regression analysis revealed a strong dosage to outcome relationship with children receiving a higher dosage of ABA meeting more treatment goals. While this patient has demonstrated progress, the rate of combined target behaviors is still occurring several times an hour. Of specific concern is the patients elopement, as this behavior poses a safety concern, and was reported to occur multiple times per hour during the previous authorization period. Further, the provider listed several goals that include skill acquisition and behavior reduction, yet require additional time each week to address. The inclusion of the additional five hours of ABA services per week, for a total of 40 hours, is supported by the medical literature. Based on the needs of the patient, the requested 40 hours per week of direct one-on-one ABA therapy are medically necessary.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 psychologist and is a board certified behavior analyst 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 patient is requesting reimbursement and prospective authorization and coverage for residential treatment center services. Findings:  The physician reviewer found that the American Psychiatric Association treatment guidelines recommend inpatient care or residential treatment facility when lower levels of care have been tried and failed. A study evaluated the effectiveness of residential treatment for patients with anorexia nervosa and bulimia nervosa. The authors noted that there were statistically significant improvements in Beck Depression Inventory scores, and a lot of patients completing treatment showed significant improvement at discharge from intensive residential treatment. This patient was experiencing disordered eating behaviors that could not be safely managed in a less restrictive setting. The medical evidence supports the services at issue in this clinical setting. Therefore, residential treatment center services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: The patient has a history of frequent migraine since her teens. Three to four headache-free days per month were noted. She has tried and failed Topamax, Botox propranolol, Imitrex, Relpax, Lexapro, and gabapentin. The patient was provided Aimovig and had dramatic response with a reduction to two to three headache days per month. The patient has requested coverage for Aimovig. The Health Plan denied the request and stated that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Aimovig is medically necessary for treatment of this patients medical condition. Calcitonin gene-related peptide (CGRP) monoclonal antibodies are a new class of migraine prevention agents. The only two classes of medications approved by the U.S. Food and Drug Administration (FDA) for chronic migraine are Botox and CGRP monoclonal antibodies. The CGRP monoclonal antibodies have been shown to be highly effective. Studies concluded that Aimovig is an efficacious and well tolerated preventive treatment in adult patients with episodic and chronic migraine. This patient has chronic migraines, has failed three medications from three classes, and had improvement with Botox but still had greater than 25 headache days per month. She has responded well to Aimovig. Therefore, Aimovig is medically necessary for treatment of this patients chronic migraines.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 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 transcranial magnetic stimulation services. The submitted documentation supports the medical necessity of the requested services. This patients depression is treatment-resistant. Per the records, multiple antidepressants and augmentation strategies have not successfully brought on remission. A researcher reported that transcranial magnetic stimulation had a moderate effect on treatment-resistant depression. Medical literature and studies showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Transcranial magnetic stimulation is an effective treatment which has been approved by the U.S. Food and Drug Administration for patients with treatment-resistant major depressive disorder. Therefore, the requested transcranial magnetic stimulation services are 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 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: The patient has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that a study opined acupuncture provided highly significant and clinically relevant improvements in treating patients with chronic headaches. In addition, the study noted acupuncture could be a valuable non-pharmacological tool for patients with frequent episodic or chronic tension-type headaches. Regarding this patients chronic pain, another study noted that acupuncture is effective for the treatment of chronic pain. In reviewing the records available, it does not appear that the patient has undergone an acupuncture trial. Given the patients continued symptoms, an acupuncture trial is reasonable and supported by the peer-reviewed medical literature. In order to produce pain relief and functional improvement, six treatment sessions should be provided. Additional care should be based on functional improvements obtained with the acupuncture trial. Given this support, acupuncture services are medically necessary for treatment of this patients chronic headaches. 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 oriental 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 reimbursement for psychiatric residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines recommend either inpatient or residential treatment level of care when lower levels of care have been tried and failed. Additionally, comorbid conditions are an important factor to be considered when deciding on a level of care. This patient had ongoing urges to purge and feelings of guilt around mealtimes. Given the severity of the patients illness, evidenced most strikingly by her 15 suicide attempts and her recent violent attempt, residential treatment was medically appropriate. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. The patient has a composite score of 24. This score correlates with residential treatment. Therefore, psychiatric residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychaitry 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.