Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male enrollee has requested authorization and coverage for Genotropin. Findings:  The physician reviewer found that although GH therapy is medically necessary for children with Prader-Willi syndrome, there is no specific brand of GH therapy that has been shown to be more effective or have a lower rate of adverse effects than another. There is no documentation that the patient had an adverse reaction to the Health Plans formulary brand of GH. GH treatment of children with Prader-Willi syndrome has been shown to improve linear growth, promote growth of lean body mass, decrease fat mass by increasing fat oxidation and total body energy expenditure, and improve cardiovascular risk factors. Complications of GH therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, GH therapy is considered safe in this patient population. Given these findings, the requested Genotropin GH therapy is not supported as medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 cognitive processing therapy. The physician reviewer found that submitted documentation supports the medical necessity of the requested services. The patient has a diagnosis of posttraumatic stress disorder. Per the records, the enrollee has not had an evidence-based therapy for the primary psychiatric diagnosis. The patient has expressed a preference for cognitive processing therapy. Although symptomatic, the patient does not have suicidality, aggressiveness, psychosis or active substance use, which is common exclusionary criteria for trauma-focused psychotherapy. The psychology note reported a normal mental status examination and indicated that a stable foundation of skills was needed prior to starting cognitive processing therapy. Of note, the initial sessions of cognitive processing therapy focus on rapport-building, psychoeducation, and the introduction cognitive restructuring, all of which is aimed at establishing a foundational skillset that the therapy builds upon in subsequent sessions. Recent notes stated that the patient denied current suicidal ideation, plans, means, or intent, while mood was euthymic, and the remainder of the mental status examination was reassuringly normal. There was no evidence of substance abuse, violent behavior, psychosis, or a decompensation in baseline functioning. Notwithstanding, although pharmacotherapy is a common intervention, evidence-based, trauma-focused therapies outperform psychotropic medications and represent the first-line treatment for posttraumatic stress disorder, and there is no arbitrary prerequisite medication state needed prior to initiating cognitive processing therapy. Cognitive processing therapy is reasonably expected to improve the patients condition and prevent a more serious episode of illness. The requested services are medically appropriate and consistent with good medical practice. All told, the requested cognitive processing therapy 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 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 Mavyret 100-40 mg (three times daily) for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.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 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg (three times daily) for eight weeks 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing.  Findings:  The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Since this test has not been demonstrated to provide greater benefit than established tests, the genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the genetic testing provided was not 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 dermatology 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: An enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing should not be an impediment to treatment, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed regardless of fibrosis stage, and the request for Zepatier 50-100 mg tablets for 12 weeks 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 reimbursement for residential treatment program from 1/3/18 through 1/9/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.The documentation provided does not support the medical necessity of the services at issue from 1/3/18 through 1/9/18. The patient participated in her treatment and responded well to the psychotherapy, group therapy, medication management and denied any suicidal or homicidal ideations, intent or plan. Based on the records, the patients treatment in the residential facility was clinically indicated until 1/2/18. At which time, the patients symptoms had stabilized, and the need for 24-hour nursing support was no longer medically indicated. She responded well to treatment and developed more insight into her behaviors. The records indicate that her body weight normalized with time. Per the progress report dated 1/3/18, the patients weight was 116 pounds with a BMI of 18.57. In addition, it was noted that she completed meals without hesitation. Per the progress report dated 1/5/18, the patients recorded weight was 118 pounds and on 1/8/18, she weighed 119 pounds. As such, continued residential treatment services from 1/3/18 through 1/9/18 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 with expertise in eating disorders 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: A enrollee has requested reimbursement for gene testing. Findings:  The physician reviewer found that based on the records provided the patient has a family history of hypertrophic cardiomyopathy. In this circumstance, genetic testing would be recommended only if a gene defect could be identified in the proband of the patients mother. If a disease-causing mutation is identified in the proband, then other family members who have no clinical evidence of disease by echocardiography may be tested for that specific mutation. The records provided do not document a specific mutation that has been identified in the proband which could be subsequently tested in family members. As such, the gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the testing at issue was 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: One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 hyaluronic acid injections for treatment of the enrollees osteoarthritis of the left knee. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A meta-analysis conducted found that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The evidence show that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronic acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. For these reasons noted above, the requested hyaluronic acid injections are medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogen breath testing for evaluation of the enrollees chronic diarrhea and weight loss. Findings:  The physician reviewers found that hydrogen breath testing is not likely to be more beneficial for treatment of the patients medical condition than available standard approaches. Symptom induction during a breath test has been found to correlate poorly with the presence of carbohydrate malabsorption. Breath hydrogen tests have limited clinical value in guiding clinical decision for a patient with a functional bowel disorder. In this case, the records noted that the patients symptoms were likely of multifactorial origin and listed a number of differentials to pursue as well as additional trials to consider. As such, hydrogen breath tests are not likely to assess for small intestinal bacterial overgrowth in this clinical setting. Therefore, hydrogen breath testing is not likely to be more effective than other methodologies for evaluating this patients medical condition. Final Result: Two of the three reviewers determined the requested services are 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 internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for eight weeks for treatment of the enrollees hepatitis C virus. 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 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for water-assisted liposuction (WAL) surgery. Findings:  The physician reviewer found that the requested WAL surgery is not medically necessary for treatment of the patients medical condition. In general, the diagnosis of lipedema is based on clinical features. Symmetrical edema in the lower limbs with fatty deposits located to the hips and thighs usually appears at puberty. Main disorders considered for differential diagnosis are lymphedema, obesity, lipo-hypertrophy and phlebedema. Treatment protocols comprise of conservative therapy and surgical approaches. Lipedema is a condition in which excessive adipose tissue is deposited in a symmetrical pattern in the legs. It most commonly affects women, and, unlike almost all other causes of lower leg enlargement, lipedema spares the feet. However, there is limited data in the peer-reviewed literature supporting WAL surgery for the treatment of lipedema. In addition, there is concern for risk of venous thromboembolism given the patients history of DVT, BMI and Factor V Leiden. For the reasons provided, the requested surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: According to the documentation submitted for review, the patient presented to the emergency department with a cough and headache. Her headache had commenced suddenly three days prior and was persistent. The sudden onset of headache that is not characteristic of a patients prior headaches is a red flag for a subarachnoid hemorrhage (SAH). Headaches from SAH are maximally painful at onset, then persist. A non-contrasted head CT is indicated to rule out hemorrhage. If this is normal, then a CT angiogram or lumbar puncture is indicated to rule out aneurysmal bleed, or sentinel hemorrhage. While this patient was determined not to have a hemorrhage, her presentation of acute persistent headache warranted emergent medical services. As such, the services provided were emergency medical services as defined by California lawFinal Result: The reviewer 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 emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.