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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) for treatment of the enrollees psoriasis vulgaris. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Her history of breast cancer precludes the use of immunosuppressive agents in her treatment, including injectable biologics and cyclosporine.  She lives at too far a distance from the clinic to feasibly undergo in-office phototherapy.  She reports having tried therapy with methotrexate, but developed widespread hyperpigmentation on her skin.  Given the treatments tried and failed, in the context of a breast cancer history rendering some treatments contraindicated, it is medically reasonable to consider therapy with Otezla.  Otezla is an oral, small molecule inhibitor that is U.S. Food and Drug Administration (FDA) approved for treatment of psoriasis and is not considered to be immunosuppressive.  All told, Otezla is medically indicated for the treatment of this patient. 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 physician reviewer is board certified in dermatology 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 magnetic resonance imaging (MRI) of the breasts for evaluation of the enrollee, who has a family history of breast cancer. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  The literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  In some studies, the specificity of breast MRI has been reported to be as low as 37%.  In other words, it is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, and a follow-up MRI is subsequently recommended.  Questionable MRI findings often lead to unnecessary biopsies.  This patient has consistently stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  In this patients case, despite her family history, she does not meet the criteria for being at high-risk for developing breast cancer, which is as defined as having a 20-25% likelihood of developing the disease.  There is insufficient data available to support the use of breast MRI in this clinical setting.  Therefore, the requested MRI of the breasts is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acthar Gel for treatment of the enrollees rapidly progressive glomerulonephritis. Findings:  Two physician reviewers found that there is a lack of data supporting treatment of crescentic glomerulonephritis with Acthar Gel. Overall, Acthar Gel has been primarily used in the treatment of nephrotic syndrome and not crescentic glomerulonephritis. If the patient shows clinically active progression, she may be a candidate for plasma exchange and cyclophosphamide. If her serum creatinine is stable, she should be observed while not on methimazole. Currently, azathioprine, if she does not have deficiency of thiopurine methyltransferase, mycophenolate or methotrexate as maintenance therapy for two years remains the standard of care. Given these findings, the requested Acthar Gel is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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: All three physician reviewers are board certified in nephrology 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for parent child interactive therapy (PCIT) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that typically, parent-child relational problem involves impairment of functioning in behavioral, cognitive, or affective domains, and there is little evidence demonstrating the patient has functional impairment in any of these domains. The records do not show arguments that escalate to threats of physical violence, there is no evidence of avoidance without resolution of problems, hostility or scapegoating, or unwarranted feelings of estrangement. In this clinical setting, standard therapies such as family and group therapies are medically reasonable for this patients issues. Final Result: The reviewer 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: The physician 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: The parent of an enrollee has requested reimbursement for parent child interactive therapy (PCIT) as a psychiatric emergency medical services.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric 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. Based on the documentation submitted for review, the patient did not receive emergency medical services during the dates of service at issue. In this case, the PCIT services were not emergency medical services as the medical records do not show that an emergency existed. There was no evidence that a recommendation to an emergency room, crisis center, or a mobile crisis service was made or occurred due to a potential psychiatric emergency. There is no documentation suggested this patient was out of control, or had impulsivity that was not typical for his age. Moreover, there is no evidence of suicidal or homicidal ideation, and no evidence of any psychosis. There is no evidence that the patient exhibited any self-injurious behavior or harmful behavior towards others.  Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-UM uveal melanoma gene expression profile assay for evaluation of the enrollees uveal melanoma. Findings:  2/3 of the physician reviewers found that DecisionDx assay is a study of 15-31 genes in an individual patients melanoma cells. DecisionDx has been used to classify the melanoma as either a high or low risk of metastasis. While DecisionDx remains controversial for use in cutaneous melanoma, it does appear to be useful in the analysis of uveal melanoma as noted by the American Joint Committee on Cancer (AJCC) and in clinical studies from colleagues. Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis. For use in this clinical setting, the DecisionDx assay has become the standard of care in many ocular cancer centers to determine the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy. For these reasons, the DecisionDx-UM uveal melanoma gene expression profile assay provided 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 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. 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 internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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 and prospective authorization and coverage for speech therapy for treatment of the enrollees autism spectrum disorder and pragmatic language disorder. Findings:  The physician reviewer found that that there is some evidence that social skills groups can improve social competence for some children and adolescents with autism. The patients testing results do not reflect his difficulties with social pragmatic language. In this case, continued speech therapy through the social skills group at Social Thinking was and is medically necessary for treatment of the patients autism spectrum disorder and pragmatic language disorder. Final Result: The reviewer determined that the 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:  Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Epclusa 400100 mg for 12 weeks. Findings:  The physician reviewer found that according to the 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 life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 400 mg  100 mg for 12 weeks is 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 Klonopin 1 mg three times per day for treatment of the enrollees anxiety. Findings:  The physician reviewer found that in the documentation available for review, the patient has seen multiple providers and they all agree that benzodiazepine use is not indicated in this patients medical condition. The patients records document self-medicating as he feels appropriate. Benzodiazepine abuse has clear hazards. The patients providers have recommended treatment without the use of controlled substance medications, consistent with current recommendations. Any future care in regards to any controlled substance medication should only be under the direct guidance of a mental health professional. For these reasons, the requested Klonopin 1 mg three times per day is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera for treatment of the enrollees relapsing remitting multiple sclerosis (RRMS). Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication.  There is a lack of evidence demonstrating that Tecfidera is more effective than the Health Plans available formulary agents. Two of the three Health Plan formulary agents are injectable, and the other is an intravenous therapy. In this case, the patient presents with relapsing remitting MS with active disease as evidenced by increased activity on MRI. Thus, changing to another MS disease-modifying agent is indicated. However, there is a lack of evidence in the peer-reviewed literature supporting the superiority of Tecfidera compared to the Health Plans available disease-modifying agents. 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 physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Northera (droxidopa) for treatment of the enrollee, who has been diagnosed with autonomic failure/neuropathy and orthostatic hypotension. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Multisystem atrophy is a disorder causing failure of normal blood pressure mechanisms, causing frequent low blood pressure when standing.  This disorder places patients at risk for falling, fainting and bodily injury.  In this patients case, the documented absence of blood pressure decreases when standing subsequent to treatment with Northera demonstrates clinical efficacy.  There is sufficient support for the requested medication in this clinical setting.  All told, Northera (droxidopa) is medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance neurography for evaluation of the enrollee, who has been diagnosed with left lumbosacral plexopathy. Findings:  Two physician reviewers found that the medical literature has not demonstrated the superior efficacy of the requested services.  The studies did not involve large numbers and were retrospective.  Additionally, the study was of the ulnar nerve.  There is a lack of large, randomized studies relating to the sciatic nerve or the lumbosacral plexus that have shown the efficacy and utility of this radiographic procedure.  As such, the requested magnetic resonance neurography is not likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in neurological surgery 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 has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lower extremity for evaluation of the enrollees left hip pain. Findings:  Two physician reviewers found that the patient is currently a long distance runner, averaging up to 75 miles per week. As noted in the medical literature, runners experience a myriad of orthopedic problems including simple arthritis, acetabular labral tears, stress fractures, avascular necrosis, bursitis of the iliotibial band, tendinopathy/bursitis, piriformis syndromes, and hernias. The American College of Radiology (ACR) noted that in this clinical setting, a patient should have routine plain x-rays. Since the patients condition has been present for at least 18 months and plain x-rays have not been diagnostic, the second imaging modality recommended for chronic hip pain is an MRI. This is geared to detecting subchondral or stress fractures, osteonecrosis. In an extensive review of the various and likely causes of hip pain in an active individual, a research study concluded that MRI has proven to be a sensitive and efficient modality in the use of fracture imaging. The study found that MRI aids in streamlining patient care, can help guiding towards adequate treatment decision making, as well as detecting different causes of the patient symptoms. Given this support, the requested MRI of the lower extremity is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: All three reviewers 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.