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 laboratory testing. Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. While 4Kscore testing may add a level of statistical support for a noninvasive estimation of the presence of prostate cancer, its benefit to individual patient care decisions over isolated PSA monitoring has yet to be demonstrated. The medical evidence has not demonstrated the superior efficacy of 4Kscore testing over standard of care for patients with elevated PSA. In sum, laboratory testing was not likely to have been more effective than other available methods of evaluating this patient. 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 urology 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 Botox injections. Findings: Two of the three physician reviewers found that in this case, there is no clear documentation of symptoms typically associated with thoracic outlet syndrome versus other etiologies of arm symptoms. There is no clear documentation in the records of objective evidence on examination or other diagnostic testing of vascular or neurogenic thoracic outlet syndrome, the latter of which is due to brachial plexus compression, predominantly affecting the lower trunk of the brachial plexus. Anterior scalene muscle blocks have been used in the evaluation of suspected neurogenic thoracic outlet syndrome, but these have poor specificity for neurogenic thoracic outlet syndrome and poor confirmatory reliability. There is limited published literature related to the use of botulinum toxin for the treatment of thoracic outlet syndrome. There have been small studies and case series suggesting the possibility of some clinical efficacy of this treatment. However, there is a lack of published high grade studies, such as well-conducted randomized controlled or cohort trials, to establish the efficacy of this intervention.  In this case, the requested services are not likely to be more effective than ongoing empiric therapy, exercises and palliative interventions, such as analgesics and topical modalities. Therefore, the requested Botox injections are not likely to be of greater benefit than other treatment options. 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 enrollee has requested authorization and coverage for Botox injections 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 an implanted hypoglossal nerve stimulator. Hypoglossal nerve stimulation is a new and emerging technology for the treatment of OSA. While initial studies have shown promise, conclusions cannot be drawn from the evidence to date. Ultimately, these summaries reflect that the current evidence does not permit conclusions regarding efficacy or effective health outcomes on hypoglossal nerve stimulation. Moreover, the optimal patient selection criteria for the use of hypoglossal nerve stimulation has not been defined. All told, the current medical literature and guidelines do not support an implanted hypoglossal stimulation system as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that implanted hypoglossal stimulation system is 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 service is 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. One Reviewer is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing.  One Reviewer is board certified in otolaryngology with sub-specialty certification in plastic and reconstructive surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (measurement of antibody to vedolizumab). Findings:  Three physician reviewers found that the current medical evidence does not definitively demonstrate that the services at issue are beneficial for health outcomes in the management of Crohns disease. The published studies including the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions regarding cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-Entyvio antibodies. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with Crohns disease compared with conventional management. For these reasons, laboratory testing (measurement of antibody to vedolizumab) was not likely to have been more effective than other methods of evaluating this patient.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a power scooter. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees chronic pain syndrome. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Studies show that power mobility devices are not recommended if the functional mobility deficit can be sufficiently resolved by the prescription of a cane or walker, or the patient has sufficient upper extremity function to propel a manual wheelchair, or there is a caregiver who is available, willing, and able to provide assistance with a manual wheelchair. Early exercise, mobilization and independence should be encouraged at all steps of the injury recovery process, and if there is any mobility with canes or other assistive devices, a motorized scooter is not essential to care. In this  case, the submitted documentation does not indicate the patient meets criteria for a power scooter based on the cited guidelines. The records indicate he is able to walk 100 feet independently. There is no documentation to justify why he cannot use a manual wheelchair. There is no documentation of a diagnosis which would preclude walking with a cane or a walker. Therefore, the requested power scooter is not medically necessary for the treatment of this patient. 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 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 reimbursement for Helicobacter pylori antibody testing. Findings: Three physician reviewers found that the diagnosis of Helicobacter pylori infection can be achieved in several ways, including endoscopic evaluation, histology, urea breath testing, bacterial culture from biopsy specimens, serology, and stool antigen testing. Each method has its advantages and disadvantages, and several methods are often used to confirm or exclude the diagnosis. Routine screening of asymptomatic patients with serology is not recommended. In this case, the patient had no symptoms to suggest the presence of Helicobacter pylori. Therefore, the services at issue were not indicated based on the records provided. In sum, Helicobacter pylori antibody testing was not likely to have been of greater benefit than other methods of evaluating this patient. 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 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 with primary osteoarthritis of the right knee has tried non-invasive treatment in the past and has benefitted from viscosupplementation of both knees. The enrollee is requesting repeat injections of Euflexxa for recurrent knee pain. The pain is mostly on the medial and posterior aspect and is associated with a positive patellar grind test, and with medial and lateral tenderness. Imaging studies confirm the presence of osteoarthritis. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. A study found that there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa injections in the right knee 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found that this patient underwent expanded BRCA analysis testing, which is considered a standard of care in patients diagnosed with breast cancer before the age of 50, regardless of family history. Her family history also raises the suspicion of an inherited tendency for malignancy. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing is now considered a standard of care. Information regarding whether a patient carries a mutation may guide treatment decision making. Therefore, gene panel testing was likely to have been of greater benefit 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.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A review of the record indicates that the enrollee presented to an urgent care center. The records noted a two-day intermittent fever, night sweats, and right flank pain. The enrollee was evaluated, laboratory evaluations were completed, and she was discharged home with medication therapy including an antibiotic and an anti-inflammatory. The providers assessment was pyelonephritis with tubule-interstitial nephritis.At issue in this case is whether the enrollee received emergency medical services on the date 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. In addition, California law defines an Emergency medical condition as a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placement of the patients health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.Urinary tract infection (UTI)/pyelonephritis can be very well treated as an outpatient if a patient is otherwise well (no septic symptoms such as low blood pressure, low oxygen saturation, or sick appearance) and the patient is tolerating by mouth well. In this case, the patient appeared to be tolerating by mouth well, with no vomiting, and she had no septic signs or symptoms. Under these circumstances, the patient did not present with an emergency medical condition that manifested itself by acute symptoms of sufficient severity such that the absence of immediate medical attention would be expected to result in placement of her health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Accordingly, the services provided were not emergency medical services.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 pediatrics, with subspecialty certification in pediatric nephrology 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 parent of a 17-year-old male enrollee has requested reimbursement for emergency services provided at Janzen and Janzen Chiropractic from 3/13/18 through 5/18/18.  Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the requested custom foot orthotics. The records provided for review document diagnoses of plantar fasciitis of right, left foot with associated heel spur syndrome/infracalcaneal bursitis and gastrocnemius equinus contracture.  The recommendation is for conservative treatment, which consists of over the counter (OTC) inserts, strappings, icing, and stretching exercises, non-steroidal anti-inflammatory drugs (NSAIDs), injection therapy, and rest. Final Result: The reviewer determined that the requested custom foot orthotics are not medically necessary for treatment of this patients medical condition.  Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified chiropractor and with specialization in oriental medicine and 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 coverage of the medication fludrocortisone. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients postural orthostatic tachycardia syndrome (POTS). Physician reviewers found that POTS is a clinical syndrome usually characterized by (1) frequent symptoms that occur with standing, such as light-headedness, palpitations, tremor, generalized weakness, blurred vision, exercise intolerance, and fatigue; (2) an increase in heart rate of 30 beats per minute when moving from a recumbent to a standing position; and (3) the absence of orthostatic hypotension. The characteristic autonomic abnormality in patients with POTS is an exaggerated increase in heart rate on tilt table testing or standing. Nonpharmacologic treatments should be attempted first with all patients. These include withdrawing medications that might worsen POTS, increasing blood volume with enhanced salt and fluid intake, reducing venous pooling with compression garments, and limiting deconditioning. In this patients case, the records do not document nonpharmacological interventions, like enhanced water and salt intake and exercise prior to being prescribed fludrocortisone. There is a lack of support for the requested medication in this clinical setting. Therefore, fludrocortisone is not medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 prescribed Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The submitted documentation supports the medical necessity of the requested medication. This patient has chronic severe widespread plaque psoriasis that requires systemic treatment to prevent further dissemination. Given this support, the requested Otezla is medically necessary for treatment of this patients psoriasis. 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 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.