Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for emergency department services. Findings: The physician reviewer found that the Health Plan has denied this request indicating the enrollee did not receive emergency medical services.  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 emergency department services were not necessary for treatment of an emergency medical condition. In this case, the patient experienced the gradual onset of pain over several days. She was not febrile or toxic-appearing. Her pain was not severe. The patient did not require laboratory testing or intravenous pain medications in the emergency department. The patient was diagnosed with a cellulitis and was treated with oral antibiotics. 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 reviewer 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast exam.  Findings: Three physician reviewers found that Tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. The patient underwent an excisional biopsy and then had follow-up mammography. Considering the prior biopsy and the resultant scarring, a tomosynthesis exam was clinically indicated. In addition, 90 days later she underwent a follow-up mammogram with tomosynthesis. The repeat tomosynthesis was warranted to compare the previous bilateral studies. Therefore, the breast tomosynthesis performed were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedures 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: All three physician 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested breast augmentation for treatment of the enrollees gender dysphoria. The submitted documentation does not support the medical necessity for the requested services in this clinical setting. The patient has been assessed with gender dysphoria. The medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. The surgical concept of breast augmentation in individuals transitioning from the male-to-female gender is well-established and documented within the community of plastic surgeons. However, in this patients case, her examination and photographs depict breast development more consistent with a female than a male. The patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue. The patient has evidence of female breast development. It appears that hormonal therapy has been effective in breast development for this patient. The medical documentation notes a Tanner breast stage of 5, which is consistent with small breasts in an adult female. She has a well-defined inframammary fold and projected breasts. This patient has findings consistent with relatively normal female anatomy and is documented to have had improvement in her gender dysphoria. In this patients case, augmentation mammoplasty would be to enhance the volume and appearance of a relatively normal structure. The surgery would attempt to provide an improvement on a relatively normal female appearance and thus would be consistent with cosmetic surgery. The surgery would not be reconstructive in nature.Findings:The physician reviewer found that the requested services are not medically necessary and are not reconstructive in nature 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc One injections to the left hip for treatment of the enrollees degenerative arthritis of the left hip.  Findings: Three physician reviewers found that although viscosupplementation has been used for many years as non-operative treatment for osteoarthritis of the knees, mixed results have been reported in the literature. With respect to viscosupplementation of the hip joint, the medical literature demonstrates that results have been generally disappointing in hip osteoarthritis. In addition, the American Academy of Orthopedic Surgeons (AAOS) guidelines for treatment of osteoarthritis of the knee does not support the use of viscosupplementation. In sum, there is a lack of medical literature supporting viscosupplementation as effective for osteoarthritis of the hip. As such, the requests for Synvisc One injections to the left hip joint are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three 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 orthopedic 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Epclusa for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver related conditions. The guidelines recommend that genotype 3 patients, who have failed Sovaldi/ribavirin regimens should be treated with Sovaldi/Daklinza and ribavirin for 24 weeks. The AASLD/IDSA guidelines also support re-treatment with Epclusa and ribavirin. This is based on higher cure rates with use of Epclusa and ribavirin rather than Epclusa monotherapy (Pianko, et al). Although hepatitis C treatment is needed, Epclusa is not supported as medically necessary over Sovaldi with Daklinza for the treatment of this patients hepatitis C infection. As such the requested Epclusa treatment is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested Epulsca medication, in lieu of Sovaldi and Daklinza, 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the enrollees cardiac risk.  Findings: Three reviewers found that the patient has hypertension but no diabetes or history of smoking. The patient has no known cardiovascular disease but reported some family history. Her 10 year calculated risk of a cardiovascular event is 1.9% based on American College of Cardiology/American Heart Association (ACC/AHA) cardiovascular risk calculator. This puts her in a low risk category with no recommendation for pharmacologic lipid lowering therapy and only lifestyle and dietary modification as has been done. The patient requested reimbursement for the advanced lipoprotein testing. The Health Plan denied reimbursement for the services at issue as investigational for the evaluation of this patient. Although in situations where there is moderate to intermediate cardiovascular risk but additional clinical risk factors are present, sometimes, a single measurement of these advanced lipid parameters may be useful and indicated in deciding whether to start lifelong statin lipid lowering therapy. However, in this instance, the patient has a low risk for cardiovascular events and the current ACC/AHA guidelines do not recommend starting any pharmacologic therapy (Stone, et al). There is a lack of clear data or published guidelines to suggest that these repeated measurements of advanced lipid profile values provide either prognostic or additional clinical value in low risk patients, as opposed to the current risk factor based guideline recommendations. In this patients case, based on current published ACC/AHA guidelines and published data, repeated advanced lipid profile monitoring does not provide additional actionable clinical information compared to standard profiles and risk assessments. For these reasons, the advanced lipoprotein testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the service at issue is 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 internal medicine with sub-specialty certification in cardiovascular disease 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: The parent of an enrollee has requested Otoscope Panel Genetics testing for evaluation of the enrollees prelingual hearing loss. Findings: Three physician reviewers found that Otoscope Panel Genetics testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Shearer and Smith performed a literature review to evaluate the use of new genetic sequencing techniques for comprehensive genetic testing for hearing loss. An analysis of 20 studies of next generation sequencing in patients with hearing loss found that the overall diagnostic rate was 41%. Some studies had diagnostic rates as high as 83%. The study suggested that comprehensive genetic testing has become the new standard of care for genetic testing for patients with sensorineural hearing loss. Moreover, identifying a specific cause of hearing loss can allow for prediction of associated complications and direct care. This patient likely has a syndromic cause for his hearing loss given the ear malformations. Accordingly, genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested testing 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: All three physician reviewers are board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential therapy treatment services for 12 months for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, residential therapy treatment services are not medically necessary for treatment of the patients medical condition. In this case, the patient presents with anxiety, depression and school problems. According to the therapy notes submitted for review, the patient has responded well to her current treatment plan which includes cognitive behavioral therapy, medication management, anxiety group therapy, family therapy and individual therapy. The patient has developed coping skills and has been able to utilize those skills during her panic attacks. Thus, residential therapy treatment is not clinically indicated for this patient given that she has successfully developed and practiced coping skills. Therefore, the requested services are not medically necessary for treatment of the 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 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 magnetic resonance imaging (MRI) of the left knee for evaluation of the enrollees arthralgia of left lower leg. Findings: The reviewer found that this patients records do not include any documented red flags to indicate immediate imaging of the left knee. Specifically, there is no evidence of trauma, fracture on plain film x-rays or signs of infection. Further, there is no sign of instability. Absent such indications for further imaging, there is no medical indication for immediate MRI of the left knee without a trial of conservative management. Accordingly, the requested MRI of the left knee is not medically necessary.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography (PET) with computed tomography (CT) fusion and single photon emission computed tomography (SPECT) for evaluation of the enrollees confusion and memory decline.  Findings: Two physician reviewers found that the incidence of central nervous system involvement in systemic lupus erythematosus is unusual. The difficulty when one is faced with a patient with severe cognitive decline and tremors is to differentiate cerebral vasculitis associated with an autoimmune disease such as systemic lupus erythematosus versus more common etiologies such as Alzheimers disease and related entities. Traditional imaging such as CT and MRI provide only anatomical information about the brain. The PET/CT and SPECT provides physiologic information not available on conventional imaging. The use of PET allows glucose uptake of infiltrating granulocytes and tissue macrophages to be visualized and quantified to delineate the inflammatory reaction of vasculitis. Thus, the positive findings as seen in this patient with known Lupus are more likely to be associated with Lupus vasculitis rather than other non-inflammatory conditions. This differentiation is crucial for therapy. No other imaging test allows such quantification of inflammatory estimation of disease in the brain than PET/CT and SPECT. For these reasons, the PET with CT fusion and SPECT scan were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedures 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: All three physician reviewers are 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved. That is, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. While in this patient the extra radiation dose is not a factor, as the 2D images were reconstructed from the primary tomosynthesis acquisition, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue 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 reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Amitiza for treatment of the enrollees irritable bowel syndrome with constipation.  Findings: The physician reviewer found that the request for Amitiza is not medically necessary for treatment of the patients medical condition. According to the U.S. Food and Drug Administration (FDA) The safety and efficacy of Amitiza was established in two major studies involving 1,154 patients diagnosed with IBS-C. The majority of the patients studied were women (approximately 8 percent were men). The efficacy of Amitiza in men was not conclusively demonstrated for IBS-C. Amitiza is not approved for use in children and men. In this case, the records do not demonstrate that the patients IBS-C is advanced, nor do the records show that he has maximized treatment with approved step therapy. In sum, Amitiza has not been established as medically necessary for treatment of the patients IBS-C.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 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.