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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Finding: The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Tomosynthesis is becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the presence of breast implants is not, in itself, an indication for tomosynthesis. However, the patient has breasts that have been described as diffusely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure 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: The three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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 the denosumab (Prolia) injection for treatment of the enrollees osteoporosis. Findings:  Three physician reviewers found that Osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of the patient affected, approximately 80% are women. Fractures are the most dangerous aspect of. A newer medication, Prolia is a fully human monoclonal antibody for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient experienced an adverse reaction to Reclast in the past and is unable to tolerate oral bisphosphonate therapy because of her history of peptic ulcer disease. Given these findings, the Prolia injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the medication at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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: An enrollee has requested residential treatment center services for treatment of the enrollees alcohol use disorder.  Findings: The physician reviewer found that continued residential treatment center services were not medically necessary for treatment of the patients behavioral health condition. Based on the documentation provided for review, the patient did not have significant post-acute withdrawal symptoms. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms. He was motivated, cooperative, and working on his treatment plan. He was medically and psychiatrically stable. His hypertension was controlled on medications. He was on anti-craving medication. In addition, there were no new problems that had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. He did not have a repeated inability to achieve and maintain abstinence and he had support systems in place. The patient no longer met American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care and could have been successfully treated at a lower level of care such as intensive outpatient program (IOP) or outpatient. Thus, the services at issue were not medically necessary for treatment of the 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 sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of implants alone does not constitute a definite indication for tomosynthesis. However, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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 residential mental health and substance for treatment of the enrollees behavior health condition.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The confluence of the patients multiple conditions, and their concerning totality of sequelae and subsequent functional impairment with potential for morbidity, warranted aggressive treatment in a supervised setting. Biologically, the patients seizure disorder, substance use, and treatment with multiple medications, some of which lower the seizure threshold while others fortify the barrier, introduced a particularly challenging element of complexity and risk for complications. Further, it is well-established that alcohol withdrawal is associated with the most serious risk for seizures in patients with epilepsy. Psychologically, it appears that the patient had struggled with developmental task of identity formation, which is not uncommon in context of a chronic medical illness, such as epilepsy, and would only be exaggerated, with the suicide of a parent.  It is more than likely that his history of irritability, and both self-defeating and self-medicating behaviors were steeped in psychodynamic therapy.  Socially, the patient was unable to control his substance use.  His longest period of sobriety had been two weeks. Even though he had not pursued an intermediate level of care for his drug use, such as partial hospitalization, according to the American Psychiatric Association, Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. All told, the submitted documentation demonstrates the medically necessity of the residential mental health and substance use treatment program for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 podiatry consultation with Hermoz Ayvazian, DPM for wart removal for treatment of the enrollees plantar wart.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  The records document warts to the plantar aspect of the left foot.  In his application for independent medical review, the patient reported that the warts are extremely painful and are inhibiting his normal comfortable ambulation.  The patient also reported that he has had these warts in the past.  The current medical evidence supports the requested services in this patients case.  All told, the requested podiatry consultation for wart removal is medically indicated 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 podiatry 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

An enrollee has requested reimbursement for air ambulance services provided. Findings:  The physician reviewer found that the air ambulance services provided was medically necessary for treatment of the patients medical condition. GBS is an acute progressive sensory-motor polyneuropathy. It is an autoimmune condition which if untreated can progress to respiratory failure, and can be fatal. It is standard of care for an acute GBS patient to have access to neurology and critical care expertise. IVIG is standard of care for GBS. In this case, air ambulance services from Arcata to Sacramento is estimated to be less than two hours. In addition, the hospital is an estimated 3-4 hours by ground transport lists two neurologists within a 10 mile radius. Driving 3-4 hours with a worsening GBS patient could have put the patient at further risk of decline, without certainty that a neurologist would have been available upon arrival. Prolonged transport times may be dangerous to a critically ill neurologic patient, and air transport is appropriate to reduce patient risk and improve potential for good therapeutic outcomes. As such, the services at issue were medically necessary for treatment of the patients worsening medical 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that the patient is a female who had digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The patient has requested reimbursement for digital breast tomosynthesis performed.  The Health Plan has denied reimbursement for digital breast tomosynthesis as investigational/experimental for evaluation of this patient. The digital breast tomosynthesis performed was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: 2/3 of the reviewers determined that the service 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 diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 authorization and coverage for mental health services, more frequently (weekly or bi-weekly) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients cases.  In a letter from a treating provider, the notation indicates that the patient is receiving and utilizing CBT and supportive therapy while continuing to assess the patients need for increased sessions. The provider noted that this current plan was discussed with the patients parent. The medical necessity of increasing the sessions to weekly or bi-weekly is not demonstrated by the submitted records.  Instead, the treating provider is suggesting less intervention for treatment of this patient. The provider does not recommend increasing the number of sessions at this time but will assess as needed. There is no clinical evidence to indicate that this patient is not benefitting from her therapy visits at the current rate. As such, the requested mental health services, more frequently (weekly or bi-weekly), are not medically necessary for 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 psychiatry with sub-specialty certification in child and adolescent 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services provided.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates 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 services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with an intradural extramedullary spinal tumor. However, the need for emergency surgical treatment is not supported by the medical records provided for review. The operative note does not describe an emergency medical condition. There was no risk of immediate paralysis or rapid decompensation.  Accordingly, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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.