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

Nature of Statutory Criteria/Case Summary: An requested reimbursement for the Afirma Gene Expressions Classifier (GEC). Findings:  The physician reviewers found that the risk of malignancy is 5-15% in a follicular lesion of unknown significance. The Bethesda System recommends a repeat biopsy for this type of nodule. In this case, the patient had a repeat biopsy. The second biopsy also resulted in FLUS. The American Thyroid Associations guideline suggest that for nodules with FLUS cytology, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this case, the result of the Afirma GEC was suspicious for malignancy. In addition, the BRAF gene mutation analysis was done, with negative results. This information was important to determine the extent of surgery. A benign Afirma test result could have prevented an unnecessary surgery and observation can be safely continued. For these reasons, the Afirma GEC provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer numbers two and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance services provided. Findings:  The physician reviewer found that 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 person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The ambulance services provided on the day of dispute were necessary for treatment of an emergency medical condition. In this case, the patient experienced the sudden onset of hives and shortness of breath. The paramedics documented tachycardia with visible hives on the anterior neck. The paramedics treated the patient with a parenteral antihistamine. Based on the clinical documentation submitted for review, the patients symptoms support an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue.  Final Result: The reviewers 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: Physician reviewer number one 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services provided during a colonoscopy. Findings:  The physician reviewer found that the specific anesthetic procedure was classified as monitored anesthesia care (MAC). According to the American Society of Anesthesiologists, an essential component of MAC anesthesia is the anesthesia assessment and management of a patients actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. In addition, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Furthermore, MAC is a physician service that is distinct from moderate sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure. In this case, the patient has a history of or anticipated intolerance to standard sedative. Thus, the use of MAC services during the colonoscopy was medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prolaris gene test. Findings:  The physician reviewers found that this patient underwent genomic testing to assist in clinical decision making and to determine whether the patient had low or high risk prostate cancer. Molecular and genomic testing can help patients with low risk disease to make decisions regarding observation versus treatment. Drawbacks include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. Considering this patients age and Gleason score, current guidelines place this patient at high risk and additional testing would therefore not be beneficial for either risk stratification or in decision making. Thus, the Prolaris gene test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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: All three physician reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training provided from the date of service in question, forward. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism. In this case, the Health Plan has authorized ABA services for 64 hours per month (approximately 16 hours per week of direct therapy), which is less than what has been provided in the past. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Although the patient has made progress in many areas over the last several years, he continues to demonstrate impairment in several areas including social, cognitive, adaptive and executive functions. He requires substantial support in the areas of non-compliance, along with stereotypic behavior and vocal stereotypy. Based on the support in the peer-reviewed literature and clinical documentation submitted, the request for 20 hours per week of direct ABA therapy, 13 hours per month of supervision and four hours per month of parent training provided from the date of service in question, forward was and is medically necessary for treatment of the patients autism. Final Result: The reviewer determined that 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 male enrollee has requested reimbursement and prospective authorization and coverage for chiropractic treatments, twice a week provided; and chiropractic treatments, once per week for weeks for treatment of the enrollees anxiety disorder and learning disability. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The evidence-based guidelines recommend manual manipulation for back pain and neck pain. However, the guidelines do not recommend chiropractic manipulation for anxiety. In this case, the patient did not present with low back pain and there is a lack of functional deficits that warrant chiropractic manipulation treatments. The chiropractic notes document objective findings of subluxation, but there was no range of motion findings or other physical exam findings noted. As such, the request for chiropractic treatments, twice a week; and chiropractic treatments, once per week for weeks starting on were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in chiropractor 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 male enrollee has requested authorization and coverage for motor cortex stimulation, deep brain stimulator, or spinal peripheral stimulator. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees trigeminal neuralgia. Findings: The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of peer-reviewed studies that show the use of peripheral nerve stimulation results in long-term benefit. A study  performed a retrospective review of the medical records on patients who were trialed and implanted with occipital nerve stimulator (ONS) systems at one institution. These results, although limited by their retrospective nature, suggest that ONS can be effective long-term despite technical challenges. However, the number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Another study noted that larger studies are needed to demonstrate the effectiveness of nerve and brain stimulation for facial pain syndromes. In addition, there are no U.S. Food and Drug Administration (FDA) approved peripheral nerve stimulator devices for trigeminal neuralgia. Given the lack of support in the peer-reviewed literature, the request for motor cortex stimulation, deep brain stimulator, or spinal peripheral stimulator has not been established as medically necessary for treatment of the patients trigeminal neuralgia. 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: Physician reviewer number one is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier (elbasvir grazoprevir tablets 50-100 mg) 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Zepatier for 12 weeks when NS5A resistance is not found.  These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent.  However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks). For these reasons, although hepatitis C treatment is needed, treatment with Zepatier for 12 weeks is not medically necessary for the treatment of this patient due to lack of NS5A resistance testing. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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 authorization and coverage of Harvoni. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks (if there is no NS5A resistance). The guidelines recommend either Harvoni or Zepatier as acceptable therapy. However, there is a need for NS5A resistance testing prior to Zepatier in genotype 1a patients. No medical contraindication to Zepatier is reported in this case. For these reasons, treatment of hepatitis C is needed, but the requested treatment with Harvoni is only supported as medically necessary for the treatment of this patients hepatitis C infection if Zepatier is unavailable. Therefore, Harvoni is not medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) level of care at the AToN Center. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  In this particular case, the patients alcoholism was central to his daily routine and contributed to his significant impairment across multiple domains of functionality.  He had health issues related to his drinking. He had a strained relationship with his significant other.  He had co-occurring depression and rigid personality traits.  He was prescribed antidepressant and anti-craving medication. The documentation provided did not indicate that this patient had consolidated the treatment gains necessary to succeed in the outpatient setting.  Instead, the patient was anxious prior to a family session and described as depressed a few days later.  It was not until the final week that the patient fully accepted his alcoholism. Thereafter, he continued to bolster his motivation for recovery and relapse prevention, and develop aftercare planning, while his anti-craving medication was changed from oral to a long-acting injection.  The services and setting were safe, appropriate and consistent with good practice while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness.  In sum, considering the clinical presentation and relevant peer-reviewed literature, RTC level of care at the AToN Center was medically necessary for treatment of this patients behavioral health condition. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis. Findings:  The physician reviewers found that there is a lack of support for the requested services in this clinical setting.  The progress note does not provide sufficient details regarding the results from prior sacroiliac joint injections, blocks, or the duration of relief from prior radiofrequency ablation procedures. Additionally, no note for a diagnostic block is available for review.  The literature is clear that radiofrequency ablation is done after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage.  This was not provided in the documentation available for review. In addition, the physical examination done in the office was not specific to sacroiliac joint dysfunction. Moreover, it is unclear if the patient obtained significant relief from the prior radiofrequency ablation, why the treating office would change the location of the radiofrequency ablation procedure.  Thus, the requested radiofrequency neurolysis is not likely to be more effective than other treatment options. Final Result: 3 of 3 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain 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.