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 the BRCA gene test that was provided. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees risk of breast cancer.Findings:  Two out of three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guideline recommendation for genetic testing of BRCA genes in the case of a known familial mutation is to test the specific known familial mutation, not the entire BRCA1 gene and BRCA2 gene. The patients mother had BRCA1 positive breast cancer with a known mutation. Thus, a few nucleotide letters needed to be sequenced as opposed to more than one thousand. The BRCA 2 gene did not need to be sequenced, given the known family history of a mutation in the BRCA 1 gene. Thus, the BRCA gene test that was provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One physician reviewer found that the patient was found to be BRCA1 positive with the pathogenic mutation that she inherited from her mother and the BRCA gene test that was provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapyFinal Result: The reviewers determined that the requested testing 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: Physician reviewers 1 and 2 are board certified in medical genetics and genomics, physician reviewer 3 is board certified in clinical biochemical genetics and all 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: At issue is whether the FoundationOne genetic testing that was provided was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. The enrollee had a history of breast cancer treated with radiation therapy and chemotherapy found to have recurrent and metastatic breast cancer. One out of three physician reviewers found that FoundationOne testing provides a rational basis for the choice of available standard therapies or available clinical trials. Studies of genetic testing demonstrate improved clinical outcomes. This patient has already demonstrated significant chemoresistance and progression following first-line chemotherapy choices. Her metastatic recurrence is being treated empirically with combination endocrine therapy of palbociclib/letrozole as an appropriate first-line therapy. The patient will likely need additional therapeutic options after progression on this first-line regimen.  Therefore, the FoundationOne genetic testing that was provided was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. Two out of three physician reviewers found that there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of FoundationOne testing, continues to be the subject of ongoing clinical trials. As such, the FoundationOne genetic testing provided was not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test 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: 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 is requesting reimbursement for Dx-Melanoma gene test performed for evaluation of the patients condition than any available standard therapy.  Findings: The physician reviewer found that the results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, Decision Dx-Melanoma gene test performed was not likely to have been more effective than other methods of evaluating this patient. Two out of three physician reviewers found that this case seems to be an exception, in that his positive node brings up the possibility of adjuvant therapy, which has to be considered very carefully in this patient. Therefore, in this case, Decision Dx-Melanoma gene test that was performed was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test is 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of excision of fat (prolapsed inferior orbital fat). In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Findings:  The physician reviewer found that the requested excision of fat (prolapsed inferior orbital fat) is not supported as medically necessary for treatment of this patients dermatochalasis. The patients symptoms of itching and burning in the eyes is not associated with his condition and not likely to improve with the requested procedure. In addition, the requested excision of prolapsed inferior orbital fat is not indicated to improve this patients vision or other functional deficit. Further, the requested procedure is not reconstructive in nature. The presence of prolapsed inferior orbital fat is either related to the normal anatomy and development of an individual or normal aging. Prolapsed inferior orbital fat is common in society and a common finding with normal changes of aging. In addition, there are no functional issues related to prolapsed inferior orbital fat. The patient reports that the lower eyelid impairs his vision. However, the records do not document a functional deficit related to the patients condition. Furthermore, the requested procedure is not likely to create a more normal appearance or result in a more than minimal improvement in the patients appearance. Based on the records reviewed, the requested excision of fat (prolapsed inferior orbital fat) is not reconstructive in nature and not medically necessary for treatment of this patients medical condition. 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 plastic 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: The patient is diagnosed with a closed fracture of the left proximal tibia, resulting from an accident. The patient was initially treated by splinting and observation for compartment syndrome. An evaluation revealed persistent swelling; therefore, application of a long leg cast was not recommended at that time. A few days later, the patient returned to the emergency department for removal of the leg splint and application of a long leg cast. Physical examination findings indicated good circulation and neurological function. X-rays showed mild displacement and mild angulation at the fracture site. At issue in this case is whether services provided were emergency medical services. Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition 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 placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The patient sustained an acute mildly displaced and angulated fracture of the proximal tibia. Concern for compartment syndrome was noted due to the swelling. A splint was applied and casting was delayed to prevent complications. Three days later, persistent swelling was reported. Six days post trauma, swelling had decreased and the leg splint was removed with application of a long leg cast. In this case, it was unknown if there would be any skin issues, swelling, or pain during the procedure that may have necessitated administration of conscious sedation, or fracture issues on the x-rays that may have necessitated a closed reduction. An evaluation revealed persistent swelling; therefore, application of a long leg cast was not feasible. Thus, the patient returned for removal of the leg splint and application of a long leg cast. The patients medical condition was of sufficient severity such that the absence of medical attention would reasonably have been expected to result in serious dysfunction to the patients leg. Therefore, the services provided were emergency medical services.Final Result: The reviewer determined the patient did receive emergency medical services on the dates of service at issue. 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: The patients parent has requested reimbursement for IOP services that were provided for a month. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether IOP services that were provided for one month were medically necessary for treatment of the patients medical condition. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by providers to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The composite CALOCUS score for this patient is 15, which indicates outpatient services level of care was appropriate for this patient. Therefore, the IOP services provided for one month were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 a subspecialty certificate 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with Graves disease. She reportedly tried and failed methimazole at a low dose and therefore is currently on a methimazole compounded preparation at a dose of 1.25 mg every other day. Laboratory results in September 2018 showed a thyroid stimulating hormone (TSH) level of 2.08, a free T4 level of 1.2, and a free T3 level of 2.3. Laboratory results in December 2018 revealed a TSH level of 2.71, a free T4 level of 1.17, and a free T3 level of 2.2. The patients body mass index is 26.22. The patient has requested coverage for methimazole compound. The Health Plan denied the request and reported the medication is not medically necessary for the treatment of this patient. At issue in this case is whether methimazole compound is medically necessary for the treatment of the patients medical condition. The records provided for review document that this patient was unable to tolerate methimazole at a low dose, and is currently on a methimazole compound at a dose of 1.25 mg every other day. Periodic clinical and biochemical evaluation of thyroid status in patients taking antithyroid drugs (ATDs) is crucial for proper adjustment of mediations. An assessment of serum free T4 and total T3 should be obtained two to six weeks after initiation of therapy, depending on the severity of the thyrotoxicosis, and the dose of medication should be adjusted accordingly. Once euthyroid levels are achieved with the minimal dose of medication, clinical and laboratory evaluation can be undertaken at intervals of two to three months. This patient requires methimazole at much smaller dose than is available in the existing U.S. Food and Drug Administration (FDA) approved tablet forms of 5 mg and 10 mg. At the reduced dose of 1.25 mg every other day, the patient is clinically and biochemically euthyroid. Therefore, the requested methimazole compound is medically necessary for treatment of this patients Graves disease.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 subspecialty certification in diabetes, endocrinology, 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee requested Repatha Sureclick pen injector therapy to further lower his LDL.  This enrollee has a history of coronary artery disease, status post coronary stenting. He has remained stable from a cardiovascular standpoint. He is currently on atorvastatin at a maximal dose. Recent low-density lipoprotein (LDL) cholesterol was 139. He was referred for Repatha therapy to further lower his LDL. The enrollee has established cardiovascular disease, and is not at goal for LDL cholesterol levels despite maximal atorvastatin dosing. According to the most recently published research guidelines, Repatha PCSK-9 therapy is indicated if the LDL cholesterol goal of 70 or less could not be reached on ezetimibe and atorvastatin. This enrollees records do not document that his goal LDL level could not be achieved with an adequate trial of ezetimibe or atorvastatin. Moreover, the records do not document a contraindication or intolerance to ezetimibe or atorvastatin. Therefore, the requested Repatha Sureclick pen injector is not medically necessary for this enrollee.Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology, 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 an enrollee has requested authorization and coverage for Humira 40 mg/0.4 ml injection every other week. Findings:  The physician reviewer found that Humira is indicated for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients who are two years of age and older. Per the 2011 American College of Rheumatology guidelines, the treatment paradigm for arthritis involving five or more joints includes initial use of nonsteroidal anti-inflammatory drugs, followed by the initiation of methotrexate. The guidelines support the use methotrexate for three months in this clinical setting. After that time period, if there is still active arthritis, then a biologic anti-tumor necrosis factor drug may be started. In this case, the patient was prescribed methotrexate, but she did not start this medication. The medical necessity of the requested medication has not been established. Therefore, Humira 40 mg/0.4 ml injection every other week 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 pediatrics with sub-specialty certification in pediatric 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting authroiztaion and coverage of a computed tomography (CT) calcium score, which the provider recommended to assess the patient for statin therapy. Findings:  The physician reviewer found that based on the records provided, the patient has some coronary risk and very atypical chest discomfort. In this circumstance, guidelines for the evaluation and management of cardiac risk and chest discomfort have been established. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing chest pain and coronary risk, including coronary calcium scoring and coronary CT scanning. Treatment change or addition based on the results of screening with specialized tests, including screening coronary CT scanning, has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling, basic lipid analysis and stress testing, when appropriate. Moreover, coronary CT scanning provides only an anatomic evaluation, is less accurate compared to conventional angiography, and does not assess the functional significance of any potential stenosis identified. Based on this, the CT coronary calcium score is not medically necessary for evaluation of this patients medical condition.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 subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a positron emission tomography (PET) scan. Richters transformation, or Richters syndrome, refers to the development of an aggressive lymphoma in patients with CLL. The diagnosis of Richters syndrome requires analysis of tissue, typically from a lymph node or bone marrow biopsy. Richters syndrome appears as an aggregation of cells that are larger than typical CLL cells. Areas of Richters syndrome and CLL can be present in the same biopsy. It is also possible to have Richters syndrome only in some lymph nodes, while others may still show typical CLL. Signs indicating the possibility of Richters syndrome include rapid growth of lymph nodes and high or rapidly rising levels of LDH. According to the National Comprehensive Cancer Network (NCCN), PET imaging is indicated to help identify lymph nodes suspicious for Richters syndrome. This patients records document a rapidly rising white blood cell count and elevated LDH. Thus, the consideration of a Richter transformation was reasonable. In conclusion, the use of PET/CT scanning has become relatively common in the evaluation of worsening CLL. Thus, the PET scan was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the PET scan was likely to have been more beneficial for evaluation of this patients medical condition than any available standard alternative.Final Result: The reviewers determined that the PET scan was likely to have been more beneficial for evaluation of this patients medical condition than any available standard alternative.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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.