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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two 40mg OxyContin ER (extended release) per day and four 30mg oxycodone IR (immediate release) per day. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medications in this clinical setting. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patients case it is not entirely clear if the work up for the back pain has been finalized. In the documentation available for review, the magnetic resonance imaging has not been performed. Also, drug testing has not been performed under the direct guidance of a medical health professional. The records do not show that all non-opioid medication classes have been optimized or tried. In addition, not all non-opioid treatment options have been utilized. There is no mention of behavior therapy despite much research to support its use. In this patients case, the medications being requested are quite large doses of opioids. The medical evidence shows that continuation of opioid prescribing at higher doses without proper treatment for the substance use disorder sets the patient up for higher morbidity and mortality. In this clinical setting, it is reasonable to consider alternatives to opioids and to have the patient tapered off opioids. Finally, multiple minimal requirements for opioid prescribing have not been performed. The need to use the requested medications as the primary medication treatment strategy for pain has not been established. For all these reasons, two 40 mg OxyContin ER per day and four 30 mg oxycodone IR per day are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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 authorization and coverage for prostate artery embolization. Findings:  The physician reviewers found that the medical evidence does not support the superior efficacy of the requested services in this clinical setting. The first line therapy for management of BPH includes medical therapy. This includes alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medication. The standard of care for management of patients with BPH who are not responding to medical therapy is transurethral resection of the prostate (TURP). In patients with very large glands, as in this patient, holmium laser enucleation of the prostate (HoLEP) and simple prostatectomy are considered the standard of care. Prostate artery embolization is a novel approach for treatment of patients with BPH. The current medical literature is limited to case series and retrospective comparisons. There is a lack of randomized trials that suggest improved efficacy of this modality over TURP, HoLEP or simple prostatectomy. Therefore, based on current medical literature, prostate artery embolization is not likely to be superior over standard treatment options for the treatment of this patient. 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) therapy. Findings:  The physician reviewers found that there is sufficient evidence in the published, peer-reviewed medical literature to support the use of TMS in this clinical setting. TMS is approved by the United States Food and Drug Administration.  Further, the American Psychiatric Association endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  It is a well-tolerated, noninvasive brain stimulating therapy with fewer barriers than electroconvulsive therapy, which the patient has considered but elected not to pursue.  The record reflects that the patient is enduring significant affective impairment consistent with the acute phase of a depressive episode, has pursued evidence-based non-pharmacologic interventions, and has failed at least one antidepressant trial.  Considering the case in its entirety within the context of the current practice guidelines and relevant peer reviewed literature, TMS therapy is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, TMS is likely to be superior to the available standard therapy in the treatment of this patient. Final Result: 2 of 3 reviewers determined that the requested services are 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 psychiatry 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 for the residential treatment services provided. Findings:  The physician reviewer found that the medical records do not support the medical necessity of the RTC services provided for treatment of this patients medical condition. The documentation notes the patient did not have active suicidal ideation or psychosis and she was open in her individual, group, and family therapy sessions throughout her stay. She was noted, on numerous occasions, to be open when discussing sensitive information regarding her mood and behaviors. She did not display any significant or severe behavioral problems. She was noted to be cooperative in therapy and was able to calm down rather quickly after her tantrum type behaviors. While the patient did require treatment to further improve her social functioning, mood, anxiety, family relationships, and behavioral issues, she did not need the restrictiveness of a residential psychiatric treatment facility in order to receive her care. Residential treatment is used for acute stabilization of psychiatric conditions and is the most restrictive form of psychiatric care available. Outpatient treatment and least restrictive options are considered first-lines of care as referenced by The American Academy of Child and Adolescent Psychiatry, which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. In summary, the residential treatment services provided were not medically necessary. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent.  Findings:  The physician reviewer found that based on the records provided, the patient presents with hyperlipidemia.  She is intolerant of two statin medications, and there is no documentation of obstructive coronary disease.  Per the records, her calcium score is only mildly elevated and does not equate to obstructive coronary disease.  Moreover, the documentation does not support the patient has familial homozygous or heterozygous hyperlipidemia.  These diagnoses require not only elevated low-density lipoprotein levels that significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  Praluent is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein levels. This patient does not fit these criteria.  PCSK9 inhibitors have not been studied in other patient populations, such as this patient.  Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications, such as fluvastatin, which have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Therefore, Praluent is not medically indicated 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 physician reviewer is board certified in internal medicine with sub-specialty 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 Afirma Gene Expression Classifier test. Findings:  The physician reviewers found that the initial biopsy report noted a follicular lesion with indeterminate results. The Afirma Gene Expression Classifier showed the lesion was benign. Afirma testing is considered standard protocol on all FNA testing done on thyroid nodules. Further, there is sufficient literature to support the utility of the Afirma testing in this clinical setting. For these reasons, the Afirma Gene Expression Classifier test performed was 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 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An  enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for eight weeks is medically necessary for treatment of the patients hepatitis C infection. 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 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 reimbursement for residential treatment. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the services at issue.  There was no evidence of suicidality or homicidality. She was medically and psychiatrically stable.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She had no history of treatment at a lower level of care.  There was no evidence of a high-degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care.  She was motivated and appeared to be working the program.  She had a stable and sober living environment.  She no longer required the structure of a residential setting and could have continued treatment on an ambulatory level of care, such as intensive outpatient program level of care.  All told, residential treatment provided was not medically indicated for the treatment of this patient. 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy.  Findings:  The physician reviewer found that the use of proton beam radiation therapy is an accepted radiation technology that has proven efficacy and tolerability.  Certain conditions, such as base of skull chordomas and chondrosarcomas and pediatric central nervous system malignancies, are probably best treated with proton beam radiation therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.  In this patient with an anterior temporal lobe recurrence, it is likely that proton beam radiation therapy would better achieve sparing of the optic nerve and orbit.  While a treatment plan comparison was not provided, it is very difficult to spare these structures when treating an anterior temporal lobe region.  This becomes a particular challenge in patients previously irradiated, as these structures are at risk of injury from cumulative doses in excess of 55-60 Gy.  The sharp dose fall off of proton beam radiation therapy is therefore advantageous in this clinical setting.  In this patients case, proton beam radiation therapy was likely to have been superior over other treatment options.  Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1, 2 & 3 are board certified in radiation 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for monitored anesthesia care. Findings:  The physician reviewer found that there is a lack of sufficient support in the medical literature for the services at issue in this clinical setting. The American Gastroenterological Association Institute (AGAI) noted that possible indications for an anesthesia specialist include patients with pregnancy, morbid obesity, neurologic or neuromuscular disorders, a history of alcohol or substance abuse, and patients who are uncooperative or delirious. AGAI also noted endoscopic procedures that may require an anesthesia specialist include endoscopic retrograde cholangiopancreatography (ERCP), stent placement in the upper GI tract, and complex therapeutic procedures. In this case, the patient presented without comorbidities for a standard endoscopic procedure that does would necessitate the use of a monitored anesthesia care. As such, the monitored anesthesia received was 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 physician 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cystectomy and appendectomy 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 cystectomy and appendectomy services provided.were not necessary for treatment of an emergency medical condition. The patient underwent surgical intervention for chronic pelvic pain that had been ongoing for several months. In the operating room, there was an incidental finding on the appendix and an appendectomy was performed. Given that the indication for the initial surgery was elective, the appendectomy was also an elective procedure since it would not have been performed without visualization of the intraoperative findings. In this case, the services in dispute do not constitute emergency services. Therefore, 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 date of service at issue. Final Result: The reviewers determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in colon and rectal 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.