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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Demerol, morphine, or Dilaudid injections for treatment of the enrollees migraine headache pain. Findings: The physician reviewer found that the patient has a history of headaches since childhood, with patterns consistent with migraine. The patient reports that her attacks are relatively infrequent, but can last days at a time. The medical records do not summarize all of her previous treatments. She has used Maxalt as abortive, and injectable opiates as rescue. The patient had a recent emergency room visit and diagnosed with urinary tract infection and migraine. The independent medical review application indicates that she has been given injectable narcotics for home use in the past. The Health Plan has denied her request for Demerol, Dilaudid, or morphine for home injection.  Other treatments such as Toradol, steroids, dihydroergotamine injection were suggested. Valium tablets were also suggested.  She has been prescribed oral opiates including Dilaudid tablets.  Referral for chronic pain management was recommended to her. Instead the patient requests Demerol, morphine, or Dilaudid injections. The Health Plan denied the requested medications as not medically necessary for treatment. This denial is the subject of this appeal and determination.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 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 Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 6.  Findings: The reviewer found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. For treatment-naive patients with genotype 6 hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy (Wong, et al; Kohler, et al). The AASLD guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services for treatment of an emergency medical condition. 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 ED services provided (CPT codes 99283 and 99053) were necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient presented with rapidly progressive throat pain. In this clinical setting, there is potential for the development of acute epiglottitis, parapharyngeal abscesses and infections, allergic laryngeal spasm which are serious, life threatening conditions that may present in this way and be rapidly progressive. It was appropriate to seek immediate medical evaluation for this symptom complex. In addition, treatment with dexamethasone steroid medication indicated that the emergency provider recognized that these symptoms had the possibility for further progression and injury to vital body parts. Therefore, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation, exceeding the clinical standard for treatment duration, for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that Transcranial magnetic stimulation is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course of transcranial magnetic stimulation consists of 30 to 40 sessions spanning four to six weeks.  At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of transcranial magnetic stimulation therapy.  In general, for those who respond to transcranial magnetic stimulation, oral medications remain the primary vehicle for maintenance of remission.  In this case, according to the validated rating scales, the patient achieved remission within typical treatment parameters.  Further, there was no mention of psychotherapy or the specifics regarding prior pharmacological and psychosocial interventions.  The medical records indicate that standard therapies had not been exhausted while the medical evidence does not support a reasonable expectation that additional transcranial magnetic stimulation therapy at the time would have improved the patients condition or prevented a more serious episode of illness.  Thus, 10 sessions of transcranial magnetic stimulation onward were not medically necessary 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested weekly individual speech therapy and weekly group speech and language therapy for treatment of the enrollees pragmatic language disorder.  Findings:  The physician reviewer found that Social (pragmatic) language disorder is a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). It is similar to autism spectrum disorder without the repetitive behaviors (Brukner-Wertman, et al). Social skills groups or group speech therapy is the recommended treatment for pragmatic language disorder. There is sufficient peer-reviewed literature supporting group speech therapy for the diagnosis of pragmatic language disorder. Therefore, in this case individual speech therapy has not been established as medically necessary, however weekly group speech and language therapy is medically necessary for treatment of the patients pragmatic language disorder.Final Result: The reviewer determined that a portion of the requested services are 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollee, who has a history of severe joint laxity and hyperelastic skin. Findings:  2/3 of the physician reviewers found that this patient has a complex medical history (poor oral feeding), structural vertebral anomalies, joint issues, and history of hernia requiring repair.  Based on the medical records, it is likely that the patent has an underlying genetic condition as a cause of his symptoms, and his diagnosis may be a rare connective tissue disorder.  The genetic testing panel requested includes the genes for a number of these rare connective tissue disorders. This is an important diagnosis to make as this patient may require extensive surgery in the future for his joint abnormalities. Some of these conditions also have cardiovascular abnormalities which can present from childhood.  Thus, these are important diagnoses to make.  All told, the requested genetic testing is likely to be more efficacious than other methods of evaluating this patient. Final Result: 2/3 of the reviewers determined that the requested services are 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 pediatrics and clinical genetics 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 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.Physician reviewer number three is board certified in pediatrics and clinical biochemical genetics 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 Natesto for treatment of the enrollees hypogonadism. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The documentation provided for review does not show the patient has a contraindication or inadequate response to treatment with AndroGel. In addition, AndroGel prescribing information provides instructions of how AndroGel should be applied to minimize risk of skin-to-skin contact with another person. All told, Natesto has not been established as medically necessary for treatment of the patients hypogonadism. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient psychiatric treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity of the services at issue.  The patient had a somewhat difficult course after his initial admission.  Despite his changing polypharmacy regimen, he remained actively psychotic, with intrusive and sometimes aggressive behavior.  He lacked either the ability or the desire to attend to hygiene and grooming.  He then developed transaminitis, his medications were held, and he cleared up.  His medications were changed, and he started Invega Sustenna.  He began to show improvement in hygiene, behavior, and psychotic symptoms.  He was not a danger to himself or others, he was no longer acutely psychotic, he was cooperative, and no medication changes had been made for at least two days.  He was awaiting placement at a facility.  He had returned to his baseline level of functioning, and at this point additional inpatient services were not medically necessary.  All told, acute inpatient psychiatric treatment were 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees small intestinal bowel overgrowth (SIBO). Findings:  The physician reviewer found that as noted in the medical literature SIBO is characterized by an increased number of endogenous symbiotic bacteria in the small bowel and can lead to uncomfortable symptoms such as abdominal distention as well as intestinal malabsorption and nutritional deficiencies. A variety of antibiotics have been used in the treatment of SIBO, including metronidazole, either alone or in combination with trimethoprim-sulfamethoxazole. Xifaxan is the antibiotic which has been most frequently studied in placebo-controlled trials for treatment of SIBO in adults, and overall has been shown to be more effective than placebo for normalization of breath hydrogen tests as a marker for SIBO resolution. In the one head-to-head study of Xifaxan versus metronidazole, Xifaxan was more effective and there were also fewer adverse effects and less patient drop-out in the Xifaxan arm. Currently, no direct comparison of Xifaxan versus metronidazole for treatment of SIBO exists in the pediatric population. However, colleagues provided support for the use of Xifaxan in the pediatric population. Further, colleagues noted that while severe side effects of metronidazole are uncommon, they are not always reversible. The more common side effects, which might lead to discontinuation of the medication, would also be very difficult for a young patient with developmental delay and autism spectrum disorder to report. For these reasons, the use of Xifaxan rather than metronidazole for treatment of SIBO in this patient with autism is appropriate as a first-line pharmacologic treatment and is supported as medically necessary. 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 pediatrics with sub-specialty certification in pediatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an Afirma gene expression classifier for evaluation of the enrollees thyroid nodule.  Findings: All three physician reviewers found that the patient was diagnosed with a thyroid nodule found to be indeterminate atypia of indeterminate significance. Per the provider, the genetic testing was to ascertain if the nodule was benign or malignant. The patient is requesting reimbursement for the provided Afirma gene expression classifier. The Health Plan denied reimbursement. Per the Health Plan, the services at issue were investigational for evaluation of the patients medical condition. All three reviewers determined there is sufficient support for the services at issue in this clinical setting. The patients initial biopsy report came back as indeterminate atypia of undetermined significance, but the genetic testing showed that it was a suspicious lesion. This was a major determining factor in delineating further course of action and to see if a possible surgical procedure was warranted. Afirma testing is generally considered standard protocol on all fine needle aspirations performed on thyroid nodules in order to avoid needless surgeries. In this patients case, Afirma test results influenced the course of action for treatment of her thyroid nodule. Therefore, the Afirma gene expression classifier was likely to be more efficacious than other methods of evaluating of this patient.Final Result: Three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewers are 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 bilateral breast reduction surgery for treatment of the enrollee, who has a history of back, neck, and shoulder pain due to her enlarged breasts.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity for the requested services in this clinical setting. The photographs submitted show evidence of significant macromastia with shoulder grooving.  The patients breasts are significantly out of proportion to her body habitus. Anatomic breast measurements are consistent with significant macromastia and breast ptosis. Her symptomatology, examination detail and review of the photographs are supportive of this. The patient has multiple functional deficits supported by typical signs and symptoms associated with macromastia. The patient has neck, back, shoulder and breast pain and well as constant headaches. She has evidence of significant macromastia and shoulder grooving on examination detail and review of the photographs.  Her upper back pain has failed conservative management with trigger point injections.  Her condition of macromastia is causing functional problems, and she would likely benefit significantly from reduction surgery. Breast reduction is a well-known procedure that directly addresses functional compromise. Overall, in this clinical scenario there are well-documented functional deficits. Therefore, the requested bilateral breast reduction surgery is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are 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 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.