Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition.Findings:  At issue in this case is whether the enrollee received emergency medical services on the date(s) 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.EMR of large flat polyps is a complex procedure requiring a high level of technical skill and experience.  In fact, performance of over 100 procedures is required before the learning curve begins to flatten.  Without expert performance, perforation, bleeding, and recurrence can occur, especially in polyps larger than 1 cm.  Furthermore, not all endoscopic mucosal resection procedures are the same.  In this case, the patient had a significantly and unusually large polyp (5-7 cm) that would require surgery in most cases; if a complication occurred, due to the rectal location, surgery would result in an ostomy.  The provider who performed the surgery is one of a few experts on the West coast with experience in endoscopic resection of polyps of this size. Accordingly, the documentation provided supports that the EMR was an emergency medical service. Thus, the patient received emergency medical services on the date of service at issue.Final Result: The reviewer has determined that the patient received emergency medical services on the date of service at issue. 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: A patient requested authorization and coverage for esterified estrogens and methyltestosterone (Estratest H.S. tablet 0.625-1.25 mg). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested medication.  There are many options for estrogen only therapy.  There is no current support for the addition of testosterone to hormone replacement for improved symptom management. Therefore, the requested esterified estrogens and methyltestosterone (Estratest H.S. tablet 0.625-1.25 mg) 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee. Menopausal management is a very complex issue. Enrollees have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and/or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the enrollee may be experiencing and kept in context with any other medical issues they may have. Some of these more traditional hormonal and non-hormonal therapies include exercise, weight loss, stress reduction, biofeedback, counseling, and serotonin reuptake drugs, most specifically Paxil. For vaginal symptoms, management can include topical lubricants and moisturizers and topical estrogens. In this enrollees case, the records indicate that the enrollee's menopausal symptoms included occasional hot flashes and vaginal dryness. There are other available options for the treatment of this enrollee. If it is deemed that the enrollee can be given oral estrogens, then it would be reasonable to consider some of the other estrogens with a more traditional progestin. If the risks associated with estrogens and their potential relationship to uterine or other breast/reproductive cancers is driving management, then the use of non-hormonal management, such as Paxil, may be a better option. Duavee has not been found to be safer than other combination options. Therefore, Duavee is not medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Orencia Clickject subcutaneous auto-injector. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients rheumatoid arthritis. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration has approved Orencia for the treatment of patients with moderately to severely active seropositive RA, who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitor. In this case, the patient is noted to have infections with tumor necrosis factor inhibitors. The literature does demonstrate lower rates of infections with Orencia. Given the patients infection history, switching to another agent would be warranted. As such, Orencia Clickject subcutaneous auto-injector is medically necessary for treatment of this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation supports the medical necessity of the requested medication. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. There is evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The researchers noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Therefore, the requested Euflexxa injections are medically necessary for the treatment of this patient.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 orthopedic 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 for a consultation with an orthopedic surgeon. There is sufficient support for the requested services in this patients case. A specialty referral may be appropriate if the provider is uncomfortable with the line of inquiry, with treating a particular cause of delayed recovery, or has difficulty obtaining information or agreement to a treatment plan. Consultants may participate in the patients care by analyzing the diagnostic data, ordering additional studies as needed, and formulating a treatment plan. Current evidence-based literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. This patient presents with a history of chronic right hip pain and limited range of motion. She reports difficulty with prolonged standing, squatting, and running. Right hip x-rays are reportedly negative. She has failed long-term self-directed exercise, activity modification, and over-the-counter medications. Her primary care provider has requested orthopedic referral to order advanced imaging as indicated and formulate a treatment plan. Evidence-based guidelines and peer-reviewed literature support this referral to assist in diagnosis and treatment planning. Therefore, the requested consultation with an orthopedic surgeon is medically necessary for 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 orthopedic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/ml pen injector. In this case, the records document coronary artery disease, hyperlipidemia and intolerance to multiple statin medications, except pravastatin. The patients LDL is significantly above a goal of less than 70 mg/dL while on pravastatin alone.  Zetia was recently added, but there is no follow-up LDL level reported since starting this medication. The addition of Zetia in this setting has been shown to improve outcome.  Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Based on the records, this patient does not meet either of these criteria since her LDL while on the combination of pravastatin and ezetimibe is not reported. Therefore, Repatha SureClick 140 mg/ml pen injector 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus testing (CPT 84999, tumor necrosis factor antagonist test). Findings:  Three physician reviewers found the presence of antibodies alone does not necessarily result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established. Furthermore, studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature reports contradictory outcomes and lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of this testing improves outcome. For these reasons, the superior effectiveness of Prometheus testing (CPT 84999, tumor necrosis factor antagonist test) has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for peripheral nerve block. Findings: The physician reviewer found that The medical evidence does not demonstrate that the expected benefits of the requested services are more likely to be beneficial than any available standard treatment option. Although, there is some literature to suggest the benefits of peripheral nerve block in pain reduction, most studies call for larger randomized controlled trials and longer follow up. It has also been determined that peripheral nerve blocks work best in conjunction with a formal rehabilitation program. In this patients case, the submitted documentation does not reflect that a formal rehabilitation program has been initiated. Complex regional pain syndrome (CRPS) remains a challenging clinical pain condition. Multidisciplinary approaches have been advocated for managing CRPS. Currently, high quality studies are needed to further evaluate the safety, and efficacy for this treatment modality when managing and treating CRPS. The evidence for its efficacy in this clinical setting is somewhat limited. For these reasons, the requested peripheral nerve block is not likely to be superior over the available standard therapies for treating this patients medical condition.  Final Result: Two of the three reviewers determined 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:  All three reviewers are board certified in certified in anesthesiology with sub-specialty certification in pain medicine 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.Nature of Statutory Criteria/Case Summary:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 2b. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 2 patients should be treated with Mavyret for eight weeks. The guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay. Findings:  Three physician reviewers found The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add to these statistics. DecisionDx-Melanoma gene assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis. Studies reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma gene assay classification in patients undergoing sentinel node biopsy. It is not clear how the five-year data from DecisionDx-Melanoma gene assay compares to the ten-year Balch data. Most importantly, it is not clear whether clinical decisions can be made on the basis of DecisionDx-Melanoma gene assay classification. Therefore, the superior efficacy of DecisionDx-Melanoma gene assay has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing and counseling. Findings:  Two of the three physician reviewers found OncotypeDx is a 21 gene analysis of an individuals breast cancer cells. It is particularly useful in predicting prognosis as well as the utility of adjuvant chemotherapy in HER2 negative, estrogen receptor positive, node negative breast cancer. In such patients, it is standard of care for making the decision about adjuvant chemotherapy. Generally, oncologists are using the results of OncotypeDx assay on a case by case basis, particularly if the nodal involvement is minimal, as in this patients case. There is data that the test is useful and reliable in node positive cancer. This patient, with minimal nodal disease, who might otherwise automatically receive chemotherapy, would benefit from OncotypeDx assay. Therefore, genetic testing and counseling was likely to have been more efficacious than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 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.