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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Onexton gel pump. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees acne. A review of the record indicates that the enrollee has been diagnosed with acne. The medical records indicated the enrollee had acne present on the face, back, and chest. Papules, pustules, cysts, and erythema were noted. The enrollee was using Onexton gel and Retin-A. The enrollees provider has recommended Onexton gel pump for the enrollee.Acne vulgaris is the most common dermatological disorder in adolescence and young adults. In past decades, systemic antibiotics have had the main role in the treatment of acne patients with inflammatory papules and cysts. In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. The morphological characteristics of adult female acne are often distinct from adolescent acne. In adults, inflammatory lesions (particularly papules, pustules and nodules) are generally more prominent on the lower chin, jawline and neck, and comedones are more often-closed comedones (micro cysts). Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. Females with facial acne typically respond more favorably to systemic antibiotic therapies than males. A combination of clindamycin 1% and benzoyl peroxide 5% is indicated for the topical treatment of inflammatory and non-inflammatory lesions of acne vulgaris. Clindamycin/benzoyl peroxide has a rapid onset of action, with acne improvement usually recorded within 24 weeks. Despite widespread use, bacterial resistance is not associated with clindamycin/benzoyl peroxide. This is an effective and well-tolerated option for the management of mild to moderately severe acne. The topical combination of 1% clindamycin and 5% benzoyl peroxide is available in two forms: BenzaClin and Duac. BenzaClin is packaged in a jar and a pump, whereas Duac is packaged in a tube. BenzaClin and Duac show similar propensity to cause moderate irritation. No data is available to suggest that Onexton gel pump may have different efficacy in acne vulgaris than other forms of these agents. Therefore, the requested medication Onexton gel pump is not medically necessary. 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 a wearable cardioverter defibrillator (Zoll LifeVest). Findings:  Two of the three physician reviewers found that there is a lack of support for the device at issue in this clinical setting. There is potential for recovery of left ventricular function over time with medical therapy, and there was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Moreover, more recent retrospective trials in patients with newly diagnosed non-ischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. In sum, the wearable cardioverter defibrillator (Zoll LifeVest) was not and is not likely to be more efficacious than other available treatment options.Final Result: The reviewers determined that the device at issue was not and 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: Physician reviewers 1, 2 and 3 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy (PBRT). Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy, while protons are generated from a cyclotron. The difference between proton and photon irradiation is that there is a Bragg peak with protons, which stop abruptly in the tissue, so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, which has proven efficacy and tolerability in specific clinical settings. However, there is a lack of compelling data to suggest that proton therapy is superior to or more beneficial than standard therapies including intensity modulated radiation therapy (IMRT) for treatment of prostate cancer. Therefore, the PBRT provided to this patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the PBRT provided to this patient was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three 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 reimbursement, authorization and coverage for intensive outpatient program services provided from 8/23/18 forward. The Health Plan denied this request, indicating that the requested service were not and are not medically necessary for treatment of the enrollees behavioral health conditions.The submitted documenation supports the medical necessity of the requested services. The American Psychiatric Association guideline for major depressive disorder notes that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. This patients depression is complicated by his new onset dementia and was not able to be managed as an outpatient, thus necessitating admission to the detoxification/rehabilitation program. Group therapy notes demonstrated a lack of insight into the nature of his difficulties. This, along with the change in his behavior to being easily angered, represent significant departures from his baseline. As it was not resolved in the detoxification/rehabilitation program, step down to the next level of treatment, IOP, is consistent with standards of good medical practice and available evidence. Therefore, the requested services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services were and are medically necessary for treatment of the patients behavioral health condition. Therefore, the Health Plans denial should be overturned.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 for advanced lipoprotein testing. The American College of Cardiology (ACC) guidelines do not support the use of advanced lipid testing. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. Overall, the guidelines have shifted away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator. The benefits of a wearable cardioverter defibrillator have been the subject of intensive study. However, the wearable cardioverter defibrillator has not been proven to be of benefit for patients with newly-diagnosed cardiomyopathy or recent left ventricular dysfunction due to myocardial infarction. Guidelines from the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the wearable cardioverter defibrillator in this clinical setting. Researchers reported that a permanent implantable cardioverter defibrillator is recommended after a waiting period of 40-90 days, but the wearable cardioverter defibrillator has not been proven beneficial. Overall, there is a paucity of randomized controlled trials demonstrating benefit for wearable cardioverter defibrillator over and above that of optimized medical therapy. All told, the wearable cardioverter defibrillator provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the wearable cardioverter defibrillator provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  All three 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 breast reconstruction surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees condition. The submitted documentation supports the medical necessity of the procedure at issue.The patient with evidence of bilateral breast deformity, mild to moderate in severity as the result of previous mastectomy and breast reconstruction for a diagnosis of bilateral breast cancer. She has undergone previous revision with fat injection. She is noted to have an animation deformity, as well as breast deformity and asymmetry as seen on photographic review. Based on the entirety of the documentation provided, the patient does not have a normal appearance of the breasts. There is no functional impairment, but breast reconstruction is aimed at restoring a relatively normal appearance, which the patient does not exhibit. As the patient has described, there is evidence of moderate excess soft tissue of the bilateral inferior poles that creates a moderately abnormal appearance. The patient has evidence of common complications associated with reconstructive breast surgery, namely abnormal appearance. Cosmetic surgery is aimed at improving on relatively normal structures. The patient has evidence of abnormal bilateral breasts because of a previously, severely deforming mastectomy and attempted breast reconstruction that is currently complicated by deformity. This is reconstructive surgery. The American Society of Plastic Surgeons notes that cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Breast reconstruction is done to approximate a normal appearance and this should include complications related to breast reconstruction. By correcting the specific complaint concerning her inferior pole deformity, this would likely provide more than a minimal improvement for this patient. Therefore, the breast reconstruction surgery is medically necessary for treatment of this patients condition.Final Result: The reviewer determined that the requested procedure 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oncotype DX Prostate Cancer Assay. Once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and prostate specific antigen (PSA) level. According to the National Cancer Institutes Physicians Data Query, most clinical variables have not been analyzed in prospective clinical trials. Despite their utility, Gleason score and PSA are imperfect predictors. The Oncotype DX Prostate Cancer Assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association Meeting in 2013 involving 395 patients. The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. Thus, the test aided decision-making for the next treatment step. Given this support, the Oncotype DX Prostate Cancer Assay provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Oncotype DX Prostate Cancer Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine and medical oncology and is actively practicing.  All three 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided from 5/2/18 through 5/24/18. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder.In the case, admission records from 05/02/18 show no evidence of a psychiatric emergency medical condition. Although intoxicated, the admitting history and physical shows that the review of systems was unremarkable for any medical issues, demonstrating that the patient was medically stable. He was psychiatrically stable as well. Per his mental status exam, the patient denied suicidal/homicidal ideation (not a danger to self or others), was cognitively intact and well-groomed. He showed logical thought processes, good insight and judgment, with euthymic mood and full range affect (not gravely disabled). He did not require, nor did he receive, any type of stabilization or evaluation other than what was standardly performed on admission to detoxification/residential level of care. His CIWA's on admission and subsequent to admission showed a minimal-mild level of withdrawal symptoms which could have safely been managed at a lower level of care, especially had he been started on medication assisted treatment. The services at issue were not necessary for diagnosis or treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services from 5/2/18 through 5/24/18.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided as defined in Health and Safety Code section 1317.1, subdivision (a)(2)(A) and subdivision (k)(1) as set forth below. The Health Plan has denied this request indicating that the services at issue were not emergency medical services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder.In this case, the patient was stable, motivated and without any major psychiatric symptoms at the time of admission. He was not an immediate danger to himself or others, nor was he immediately unable to care for himself due to mental health conditions. The services at issue were not necessary for treatment of an emergency psychiatric medical condition. Thus, the patient did not receive emergency psychiatric services. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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.