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 bariatric surgery for treatment of the enrollee, who has a history of morbid obesity and gastroesophageal reflux. Findings: The physician reviewer found that the patients BMI is 37 kg/m2, which is greater than 20 percent weight loss. The patient also has symptoms of GERD. She is status post gastric banding. She has plateaued and is unable to behaviorally manage her weight loss. She also has polycystic ovary syndrome (PCOS), which is aggravated by her obesity. The records also show that this patient has tried other treatment options to address her weight loss. She has demonstrated that the gastric band is not effective in her case. She has not tolerated, but did try, phentermine. The records also demonstrate that she has tried to stay on a restrictive diet. While her BMI may not confirm morbid obesity, she has comorbidities with her diagnoses with GERD and PCOS. As such, this patient has met the guidelines for bariatric surgery. Moreover, this patient also runs the risk of other long-term comorbidities such as hypertension and coronary artery disease. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing (CPT 81479) performed. Findings:  The physician reviewer found that : per the National Comprehensive Cancer Network (NCCN) guidelines, the patient meets criteria for genetic risk evaluation based on her personal diagnosis of early onset breast cancer in her 40's.  Her two additional second degree and third degree relatives with breast cancer along with a sister with a brain tumor enhance her eligibility for testing per the NCCN Guidelines.  If she were to harbor a mutation, she would be eligible for increased screening of breast and other cancers. A negative result changes screening recommendations as well.  Therefore, gene testing (CPT 81479) performed was likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers are all board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the nerve testing (autonomic testing) for evaluation of the enrollees tachycardia. Findings:  All three physician reviewers found that this patient was complaining of palpitations during their office visit which prompted an ECG which did not reveal any ectopy. This was followed by a Holter monitor which is an appropriate cardiac test in the work-up of palpitations. This test revealed rare PVCs. However, it is unclear whether the patients symptoms correlated with these ectopic beats. The office visit note also mentioned shortness of breath and lightheadedness. The patients blood pressure in the office was normal but no orthostatic blood pressure levels were reported. There were no symptoms in the office notes which would support an indication to test the patients autonomic nervous system function. In patients with orthostatic symptoms, autonomic nervous system function is not indicated prior to orthostatic blood pressure testing in the office, at home blood pressure monitoring, a detailed history for possible causes of orthostatic intolerance and treating the patient with a high salt and fluid diet. Autonomic function testing is a specialized test that is reserved for patients after non-pharmacologic measures such as volume repletion and pharmacologic measures such as fludrocortisone have failed to improve symptoms. Final Result: The reviewers determined that the testing 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: Reviewer 1 is board certified in pediatrics with sub-specialty certification in pediatric cardiology and is actively practicing. Reviewers 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services. Findings: The physician reviewer found that the 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 services at issue were not necessary for treatment of an emergency medical condition. This patient presented the day following an ankle injury sustained while running. Although the patient had pain with weight-bearing she was able to ambulate with a steady gait. She denied any neurologic deficits. Tenderness was present without skin discoloration or swelling. The patient was neurovascularly intact. The patient did not receive any pain medication in the urgent care facility and was discharged with an ace bandage. Although it was reasonable for this patient to seek medical attention, there is no documentation to support that the patient received 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested patency capsule for evaluation her history of small bowel obstruction.  Findings:  Two physician reviewers found that in the setting of small bowel Crohns disease with a high concern for obstruction, it is not appropriate to evaluate the patient with capsule endoscopy. Rather, cross-sectional imaging with either computed tomography or magnetic resonance enterography is the appropriate next step. These modalities allow the provider to determine whether obstruction is present due to inflammation or stricturing. Additionally, these tests disclose the overall anatomy such that the number and length of strictures can be identified. The reviewers determined that the requested services are 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400-100 mg for 12 weeks for treatment of her chronic hepatitis C virus genotype 2b. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. In addition, a delay in treatment may result in decreased survival. 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 nrollee has requested authorization and coverage of Harvoni 90-400 mg for eight weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most 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. This applies regardless of fibrosis stage or viral load. Additionally, the guidelines report that patients with certain extrahepatic manifestations of hepatitis C, such as cryoglobulinemia, should be prioritized for treatment.  Per the guidelines, treatment naive, genotype 1 patients should be treated with Harvoni. The guidelines recommend that non-cirrhotic treatment, naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned Decision of Health Plan

Standard Review The parent of a transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees gender dysphoria.  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. Nature of Statutory Criteria/Case Summary: There is sufficient support in the documentation and in the medical literature for the requested services in this clinical setting. The surgical concept of treating female-to-male reassignment surgery is well established and documented within the medical literature. However, each patient must be reviewed on a case-by-case basis to determine medical necessity. In this patients case, medical necessity has been adequately defined in the clinical documentation provided. The patient has identified as a male for an extended time and has been undergoing early steps towards his transition from female to male. He has also been seeing a therapist for 5 years. He has well documented gender dysphoria, and his dysphoria has affected his function. The request is for a surgical consultation and not for the actual surgery. This consultation should be considered medically necessary as the next step in this patient's treatment and consideration for further transition. As such, a plastic surgeon can adequately examine and evaluate the patient to determine the appropriateness of possible surgical treatment. While consideration should be given to all conservative measures for treatment prior to any surgical treatment options, the request for a surgical consultation should be considered medically necessary. For these reasons, an office consultation with a plastic surgeon regarding a bilateral mastectomy is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for buprenorphine for treatment of the enrollee, who has a history of lower back pain. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested buprenorphine in this clinical setting. The records do not mention counseling, despite research and recommendations to support its use in opioid dependency and abuse. Moreover, the notes state he is taking methadone, Percocet, and buprenorphine. There is no clear objective functional goals for the additional buprenorphine being requested. Buprenorphine is only U.S. Food and Drug administration approved and indicated for opioid dependence. However, it is unclear why Suboxone is not sufficient for this patient, given the history, per the provider, of abusing opioids. Per the records, this patient has been on Suboxone for one month. Further, this patient does not acknowledge he has an opioid dependency. The patient does not state he is taking the medication to be free from opioids but rather he is requesting the medication for pain control. Finally, multiple minimal requirements for opioid prescribing have not been performed and the need to use buprenorphine, alongside, other possible opioids for an indefinite basis, as the primary medication treatment strategy for pain or opioid dependency have not been established. 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-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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Anser IFX testing for evaluation of the enrollees Crohns disease. Findings: All three physician reviewers found that in this case, Anser IFX was ordered to determine Remicade level and whether antibodies to Remicade were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to Remicade, nor have clear Remicade levels been established. Studies have found that anti-Remicade antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested 13 hours per week of applied behavioral analysis (ABA) therapy and two hours per week of oversight for treatment of the enrollees autism and global delays.  Findings:  The physician reviewer found that the correlation between treatment outcomes and treatment intensity is well documented. In a recent article on the efficacy of ABA, the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Per the records, the patient appears to have made progress in many areas, but continues to struggle with problematic behaviors which include vocal and physical stereotypy, peer interactions, lack of generalization of skills across environments, transitions and safety awareness and elopement. Failure to improve these behaviors not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. The current medical evidence supports the services at issue in this clinical setting. Final Result: The reviewers determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-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.