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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for anterior optical coherence tomography (OCT) for evaluation of the enrollee, who has been diagnosed with keratoconus. Findings:  2/3 of the physician reviewers found that Anterior OCT is an imaging technique that provides high resolution cross sectional imaging of the anterior segment of the eye.  It has utility in imaging the iris as well as determining corneal thickness for patients undergoing refractive surgery and phototherapeutic keratectomy.  It is also used as a newer modality for evaluating the tear film and contact lens fit.  In this patients case, the contact lens was not tolerated for more than 30 minutes and was noted to be decentered on clinical examination.  In this clinical setting, the test can provide information with regards to contact lens apposition and fit over the corneal surface and provide beneficial information for refit.  Thus, the anterior OCT provided was likely to have been more beneficial than other available methods of evaluating this patient. Final Result: 2/3 of the reviewers determined that the services at issue were 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 ophthalmology 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 ophthalmology 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 ophthalmology 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 duodenal switch procedure with hiatal hernia repair for treatment of the enrollees obesity. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient is an adult with morbid obesity. The patient underwent the lap vertical sleeve gastrectomy in 2005 but remains morbidly obese with a BMI of 46 kg/m2. Re-operative bariatric surgery is a potential treatment for persistent weight loss and duodenal switch procedure affords durable weight loss of any bariatric procedure. The duodenal switch procedure involves a sleeve gastrectomy and a malabsorptive intestinal bypass. The duodenal switch is performed either is a staged or stand-alone primary procedure. Although the patient is a potential candidate for re-operative bariatric surgery, the medical necessity cannot be considered at this time given that there is no individual dietary evaluation provided for review to ensure that this patient is familiar with and understands the increased risk of micronutrient, fat soluble vitamin and protein deficiency associated with the duodenal switch procedure. Also to ensure that there are no baseline micronutrient deficiencies present currently and to review eating behaviors. There was mention of attendance to a nutrition class, but given the increased risk of protein and vitamin deficiencies associated with duodenal switch procedure, a group class would not be considered sufficient or appropriate to determine the patients understanding, and likelihood of compliance with necessary supplements. Due to lack of an individual dietary evaluation, the requested procedure is not indicated in this clinical setting. Moreover, there is a lack of clinical evidence that hiatal hernia repair which was reported as small on upper gastrointestinal study would warrant primary hiatal hernia repair if not for bariatric surgery. Given this, and that the duodenal switch procedure is not supported at this time due to lack of documentation of completion of a comprehensive multidisciplinary evaluation, the hiatal hernia repair alone would not be supported as medically necessary. Final Result: The reviewer determined that the requested procedure 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza for treatment of the enrollees diabetes. Findings:  The physician reviewer found that the request for Afrezza has been established as medically necessary for treatment of the patients medical condition. According to the guidelines by the American Diabetes Association A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences. In this case, the patient has diabetes mellitus type 1. He has experienced severe glycemic excursions, and severe hypoglycemic reactions with injectable prandial insulin. In addition, his HbA1c remained suboptimal at 7.4%, which indicates that he also has severe hyperglycemic fluctuations. The patient also indicates that his skin is scarred from many years of injectable therapy, which may make the absorption of insulin erratic. The patient has been treated with inhaled insulin, Afrezza and has not had hypoglycemic reactions. With Afrezza the patient has been able to bring his diabetes control to goal. This is consistent with the American Diabetes Association guidelines. Afrezza is the only available inhaled insulin in the market. Studies that led to its approval showed that patients on inhaled insulin improved diabetes control and had fewer hypoglycemic events than with injectable insulin given its very rapid absorption through alveoli. In this case, the patient benefits from taking Afrezza instead of injectable prandial insulin. For the reasons provided, Afrezza is medically necessary for the treatment and management of the patients diabetes type 1. 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 endocrinology, diabetes 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: 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 hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. 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. All told, Harvoni is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 reimbursement for residential treatment at Hoag Neurobehavioral Health for treatment of her behavioral health condition.  Findings: The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria is used to objectively determine if the patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. The patients risk of harm is scored as 3, which is considered to be a moderate risk of harm.  Her functional status is also a 3, moderate impairment.    Medical/addictive/psychiatric comorbidity is scored as a 3, significant comorbidity. The patient has a significant comorbidity of alcohol use disorder and depression. The patient will continue to use substances despite negative consequences. Her recovery environment was a 3, moderately stressful environment. The patient is having serious marital discord due to her alcohol use. The patients level of support is also a 3, limited support in environment. The patient does not feel that her husband is supportive. Her treatment history is a 2 which indicates that she has a significant response to treatment and recovery. The patient has had prior treatment and was sober for 10 years. As to her engagement and recovery status, her score is a 2 which corresponds to a positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations.  According to LOCUS criteria, the patients total score is 19. Based on LOCUS system, the patient would meet criteria for a less restrictive environment such as an intensive outpatient program.  Therefore, the patient could have been treated in a less restrictive environment. Accordingly, the residential treatment at Hoag Neurobehavioral Health was not medically necessary.  Final Result:  The reviewer determined that the services at issue were not medically necessary. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided for treatment of the enrollees interstitial cystitis. Findings:  2/3 of the physician reviewers found that the procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage (10 mA, 1-10 Hz frequency) electrical stimulation that produces sensory and motor responses. Noninvasive PTNS has also been delivered with surface electrodes. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. There is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of PTNS in patients with urinary urgency and frequency as in this case. However, most trials have a small number of patients with short-term follow-up. Moreover, the role of PTNS in patients with interstitial cystitis is largely unknown. Most studies evaluating efficacy of PTNS in interstitial cystitis are small retrospective studies with conflicting results. Overall, the current scientific evidence does not support routine use of PTNS in patients with interstitial cystitis. Thus, the PTNS provided was not and is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the services at issue were not and 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: Physician reviewer number one is board certified in urology 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 urology 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 urology 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: An enrollee has requested reimbursement for emergency medical services.   Findings:  The physician reviewer found that the patient presented to the emergency department with reports of abdominal pain located in the lower abdomen that began suddenly two days prior and had become persistent. Her symptoms commenced after eating pizza. She reported nausea, vomiting and low back pain. The patients past medical history included diabetes and hypercholesterolemia. Her vital signs showed a blood pressure of 122/69, temperature of 98.3 F and pulse of 72. Mild abdominal tenderness was present in all four quadrants with a positive Murphys sign. Laboratory data revealed ketonuria with a glucose of 144, but was unremarkable. An abdominal ultrasound was negative for gallstones or cholecystitis. A computed tomography (CT) scan of the abdomen and pelvis showed signs of gastritis. The patient was medicated with intravenous fluids and antiemetics. She was assessed with abdominal pain and discharged in stable condition.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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with abdominal pain and vomiting. Her symptoms had commenced 36 hours prior, had persisted, and worsened. Due to the patients history of diabetes, she was concerned that she might become dehydrated. Diabetic patients with persistent vomiting are also at risk for diabetic ketoacidosis. Abdominal tenderness with a positive Murphys sign was present, which is a potential indicator of acute cholecystitis. Such patients may not be safely discharged until dehydration with acidosis as well as an acute surgical abdomen have been ruled out. The care provided in the emergency department was for emergency services. As such, the patient received emergency medical services.  Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patient was admitted in active withdrawal with an elevated COWS score, which warranted admission. Although not suicidal, homicidal, or self-harming, she rated depression and anxiety as 10, and isolation as five to six, which also supported admission. The patients self-care was lacking in her disheveled presentation and reported high levels of stress. Thus, RTC was the best treatment option and was medically necessary. Treatment during these dates would afford the patient an opportunity to become more physically comfortable with less intense withdrawals, and increase the chances of compliance with medically assisted treatment with Subutex at a less restrictive level of care. However, RTC services after were not and are not medically necessary. For these reasons, RTC level of care services provided were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and 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 authorization and coverage for Lynparza (olaparib) for treatment of the enrollee who has a history of breast cancer. Findings:  Two of the three physician reviewers found that there is support in the medical literature for the requested medication in this clinical setting. It has been estimated that about 5% of patients with breast cancer carry a germline BRCA mutation. Most carriers will have a family history of breast cancer in younger patients who have triple negative disease. BRCA 1 and 2 are tumor suppressor genes which encode proteins involved in the repair of DNA double-strand breaks via the homologous recombination pathway. Members of the poly (ADP-ribose) polymerase (PARP) family of enzymes are central to the repair of DNA single-strand breaks. It has been demonstrated that cells that lack functional BRCA1 and 2 are susceptible to PARP inhibition. Currently, the PARP inhibitor olaparib is U.S. Food and Drug Administration (FDA) approved for treatment in women with ovarian cancer and who carry a germline BRCA mutation. This patient falls within this patient population. A study evaluated 302 patients that carried a germline BRCA mutation and were HER2 negative who had received more than two previous chemotherapy regimens for metastatic disease.  The median progression free survival was longer in the olaparib arm compared standard of care. The response rate was 59% compared to 28.8%. For patients who carry a germline BRCA mutation, the current recommendation is to consider enrollment in a clinical trial. If trial option is not an option, then a PARP inhibitor could be considered in patients who have demonstrated progression on at least one line of therapy. The use of PARP inhibitors in patients with malignancies secondary to BRCA germline mutations has been encouraging. The OlympiAD study appears to demonstrate similar clinical benefit to that which is seen in ovarian cancer patients secondary to BRCA germline mutations. Based on the currently available data, Lynparza (olaparib) is likely to be more effective than the available standard options for treatment of this patients medical condition. Final Result: The reviewers determined that the requested medication is 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. Final Result: Two of three reviewers determined that the requested medication is 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 reviewers 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.