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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier once daily for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer has found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier for 12 weeks. These guideline recommendations are based on clinical trial results showing a 99% cure rate. The patient has had negative drug testing, and has received education about treatment of hepatitis C with Zepatier. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first line regimen for non-cirrhotic, treatment naive, genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa, one tablet daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 authorization and coverage Otrexup 20 mg/0.4 mL auto injector. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. Per the peer reviewed evidenced based guidelines, Otrexup is indicated for the treatment of severe, active rheumatoid arthritis or patients who have had an insufficient therapeutic response to or are intolerant of an adequate trial of first line therapy. The available medical records indicate that this patient does not have a diagnosis of rheumatoid arthritis, but does have a diagnosis of psoriatic arthritis. Furthermore, the patient has not previously had an adequate response to oral or injectable methotrexate. Based on the peer reviewed guidelines and available medical documentation, the request for Otrexup 20 mg/0.4 mL auto injector is not medically necessary for treatment of this patients medical condition. 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 rheumatology 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 the advanced lipoprotein testing. The Health Plan has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cardiovascular risk. Findings:  Three physician reviewers found that in this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), ApoA-1, C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Final Result: All told, the advanced lipoprotein testing provided to the enrollee was not likely to be more beneficial for evaluation of the enrollee's 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin for treatment of the enrollee, who has been diagnosed with ulcerative colitis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. It is not medically reasonable to treat chronic abdominal pain from ulcerative colitis with chronic opiate therapy.  There are other non-opiate medications and regional blocks that have proven efficacy for chronic abdominal pain. Long and colleagues identified a number of risk factors involved in the use of chronic opiates in inflammatory bowel disease.  The authors concluded that opiates are a poor choice for pain control in these patients.  Similarly, Docherty and colleagues have identified several alternative approaches to managing abdominal pain and noted the risks of chronic opiate use in these patients. In sum, chronic opiate use is a poor choice for pain management in this patients case.  All told, OxyContin is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees hepatitis C virus.Findings: The physician reviewer fount that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/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 all patients should be treated, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier for 12 weeks. These guideline recommendations are based on clinical trial results showing a 99% cure rate. For these reasons, treatment with Zepatier 50/100 mg tablets daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The pulmonary function testing performed was not necessary for treatment of an emergency medical condition. Pulmonary function testing is not supported in the peer-reviewed literature as an emergent or urgent diagnostic test in the management of Raynauds syndrome and scleroderma. In this case, there was no emergent medical condition noted in the records submitted for review. 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 internal medicine with sub-specialty certification in rheumatology 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's representative has requested reimbursement for transcranial magnetic stimulation (TMS) services for treatment of the enrollees major depressive disorder.Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS is approved by the U.S. Food and Drug Administration and is well tolerated with fewer barriers than electroconvulsive therapy. TMS has the endorsement of the American Psychiatric Association (APA) for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In addition, the standard of care does not require multiple medication trials prior to TMS therapy. In this case, the patient had pursued, but not exhausted other standard therapies used to combat depression. However, considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represented a safe and appropriate treatment consistent with good medical practice and was reasonably expected to improve the patients condition at the time of service. As such, the TMS services provided  through was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy for treatment of his high-grade malignant peripheral nerve sheath tumor with heterologous rhabdomyoblastic differentiation.Findings: Three physician reviewers found the provider has recommended intensity modulated technique to deliver adjuvant radiation therapy to the surgical bed. There is clinical data to support the use of IMRT in the treatment of sarcoma. The medical literature has demonstrated decreased bone damage and improved local control when using IMRT compared to standard three-dimensional conformal planning.  A standard three-dimensional conformal plan would be unable to spare the femur and inguinal skin region in this case. Consensus group guidelines support the use of IMRT for this cancer. Based on these reasons, IMRT is likely to be more beneficial for treatment of the patients medical condition than standard therapy.Final Result: Three physician reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein embolization for treatment of the enrollees pelvic congestion syndrome. Findings: All three physician reviewers found that the requested vein embolization is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patients symptoms correlate with the imaging findings that are consistent with pelvic congestion syndrome. Embolization techniques are the standard of care and routinely utilized in the treatment of pelvic congestion syndrome. There is sufficient medical literature to support the request for vein embolization in this clinical setting. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The three physician reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Two physician reviewers are board certified in vascular surgery and are actively practicing. One physician reviewer is board certified in interventional radiology with sub-specialty certification in vascular radiology and is actively practicing.  All three physician 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 Zepatier for 12 weeks for treatment of his hepatitis C virus.Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent (Zeuzem, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.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 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 reimbursement for Amniox Neox grafting. Findings:  Three physician reviewers found that plantar fasciitis is a self-limiting condition and studies show that most cases resolve completely with non-surgical treatment. After non-surgical techniques have been used, procedures that create an acute inflammatory reaction to reinitiate the failed healing process can be utilized. Surgical procedures include Topaz technique, platelet rich plasma injections, and traditional surgical fasciotomies both partial and total. In this case, the surgery performed provided the beginning of a new healing process for the plantar fasciitis. As such, it was not necessary to include another healing process with Amniox grafting at the same time. As such, the Amniox Neox grafting provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All three physician reviewers are board certified in podiatry 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 reimbursement for bone replacement graft for treatment of the enrollees dental condition. Findings: The physician reviewer found that the patient has requested reimbursement for code D7953, bone replacement graft for ridge preservation.  This procedure is typically done for facilitation of a future implant or to preserve the bone ridge in a case where aesthetics may be compromised.  The records show the patient to have a moderate smile line, indicating a graft was not necessary for aesthetics of the smile line. The submitted email correspondence noted that implant placement was not performed. The dental literature indicates that following extraction, the tooth socket will heal and regenerate bone on its own with no additional treatment.  Therefore, a graft would only be necessary if there was a large area of bone loss following extraction which would not be expected to heal. As there was no expectation of a large defect following extraction and there was no implant placed, the dental necessity of the services at issue has not been established. Therefore, bone replacement graft received was not dentally necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry 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.