Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anterior optical coherence tomography. Findings:  Two of the three physician reviewers found that anterior segment optical coherence tomography is an imaging technique that can be used to examine the structures in the anterior segment. It has been reported to be useful for evaluating the anterior chamber angle. Per the medical evidence, the standard technique for evaluating a patient with narrow angles is gonioscopy. In this case, there is no documentation that a gonioscopy was performed. Studies have not found anterior segment optical coherence tomography to be a replacement for gonioscopy. In sum, anterior optical coherence tomography was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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 authorization and coverage for LINX reflux management system.Findings:  Three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Researchers concluded the long-term safety and efficacy of LINX, both alone and in comparison to current gastroesophageal reflux disease therapies, remains to be determined. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, the requested LINX reflux management system is not likely to be more effective than other treatment modalities.Final Result: The reviewers determined that the requested services are 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX testing.Findings: Two of the three physician reviewers found that the ThyGenX testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment. While a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of deoxyribonucleic acid (DNA) mutations and ribonucleic acid (RNA) translocation fusion markers to assess the risk of malignancy, with good negative and positive predictive value. ThyGenX testing may allow patients to avoid unnecessary surgeries. There is sufficient support for the services at issue in this clinical setting. Therefore, ThyGenX testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment.Final Result: Two of the three reviewers determined that the ThyGenX testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, and all three are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for discography of the lumbar spine. Findings:  Three physician reviewers found that there is a lack of support for the requested services in this clinical setting. The conclusions of recent, high-quality studies on discography have significantly questioned the use of discography results as a preoperative indication for either intradiscal electrothermal annuloplasty or spinal fusion. These studies have suggested that reproduction of the patients specific back complaints on injection of one or more discs is of limited diagnostic value. Provocative discography is not recommended because its diagnostic accuracy remains uncertain, false-positives can occur in patients without low back pain, and its use has not been shown to improve clinical outcomes. In this patients case, the rationale for recommending discography testing is not supported by the available medical literature as being predictive for identifying patients who will respond well to surgical treatment. There is reasonable evidence to indicate this test has the potential to cause harm and result in diminished outcomes. Furthermore, a lumbar fusion procedure would not be recommended for this patient who is being treated for non-specific low back pain with lumbar degenerative disc disease. Therefore, discography of the lumbar spine is not likely to be more effective than other methods of evaluating this patient. Final Result: 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: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bariatric surgeon consultation. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees morbid obesity. A review of the record indicates that the enrollee has been diagnosed with schizoaffective disorder bipolar type; asthma; alcohol use disorder; hypertension; diabetes; and morbid obesity. A progress note dated 7/27/18, reported the enrollee presented for a psychiatric evaluation for gastric bypass procedure. The provider reported the enrollee had tried multiple diets, diet pills (Hydroxycut), and exercises regularly without losing significant weight. The enrollee denied binge eating and purging. The provider reported the enrollee was mentally stable enough to have the procedure and participate in necessary follow up. At issue in this case is whether the requested bariatric surgeon consultation is medically necessary for treatment of the enrollees medical condition. Clinical practice guidelines indicate that adults with a body mass index (BMI) between 30.0 and 34.9 and either uncontrolled diabetes type two or metabolic syndrome may be candidates for this surgery. The following conditions are contraindications to bariatric surgery: untreated major depression or psychosis; uncontrolled eating disorder such as bulimia; current drug and alcohol use; severe cardiac disease with prohibitive anesthetic risk; severe coagulopathy; and inability to comply with post-operative life-long mineral replacement. The patient requests a surgical consultation for bariatric surgery. Based on the clinical practice guidelines, bariatric surgery is justifiable in a patient with a BMI of 35.0 to 39.9 with at least one major complication and a BMI of 40 without major complications. This patient has a BMI of 44.6. Diabetes and mental health issues complicate her obesity. Although this patient has documented schizoaffective disorder and alcohol abuse disorder, both are under control either in treatment or with medication. Bariatric surgery is a consideration for patients who have failed to improve with diet; counseling; exercise; and pharmacologic treatment. The patient is noted to have failed all of these conservative modalities. The patient has met guideline criteria for this surgery and therefore, the request for a bariatric surgeon consultation is medically necessary. Final Result: The reviewer determined that the requested services 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 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 reimbursement for Orthovisc vials purchased for injection and the series of injections that were subsequently administered. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function, a reduction in use of concomitant analgesia, and suggests that there may be a delay in the need for total knee replacement. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for long periods. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the services at issue in this clinical setting. Therefore, the Orthovisc vials purchased for injection and the numerous injections that were subsequently administered were medically necessary for the treatment of this patient.Final Result: The reviewer 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings: Three physician reviewers found that inherited thrombophilia is a genetic tendency to venous thrombosis. The most common inherited thrombophilias are the factor V Leiden mutation and the prothrombin gene mutation. Homozygosity for methylenetetrahydrofolate reductase (MTHFR) polymorphisms is a relatively common cause of mildly elevated plasma homocysteine levels, but these mutations do not appear to increase the risk of venous thromboembolism in pregnant or non-pregnant women. High-quality epidemiologic studies have not found a significant increase in venous thromboembolism risk among individuals homozygous for MTHFR polymorphisms. Routinely screening for inherited thrombophilias in unselected populations is not recommended because of the low frequency of the condition becoming symptomatic and the lack of a safe, long-term method of prophylaxis against thromboembolism. Furthermore, there is a lack of strong evidence on which to base recommendations regarding whom to test or the optimal panel of tests. There is a lack of evidence of a causal association between inherited thrombophilia in women with a history of recurrent or non-recurrent early fetal loss, and a lack of evidence that administration of anticoagulant drugs to such women is effective in improving pregnancy outcomes. Therefore, genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene testing.  Findings: Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) Guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study (trial). Should a patient have high risk results, treatment and surveillance recommendations would unlikely be altered. Therefore, the services at issue were not likely to be more beneficial than any available standard treatments for the patients medical condition.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement for general anesthesia in a hospital operating room setting during dental extraction surgery. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees impacted teeth. A review of the records indicates the enrollee was diagnosed with impacted teeth. In an operative report, the enrollees provider noted that the enrollee had a disturbance of tooth eruption involving the secondary maxillary canines. The maxillary canines were horizontally impacted with crowns facing anteriorly. The roots of the adjacent teeth were close to the impacted teeth. The provider noted the procedure would be carried out in an operating room under general anesthesia due to the enrollees age and significant complexity of the procedure. The enrollee was 12-years-old at the time of the procedure. The enrollees provider recommended general anesthesia during a dental extraction surgery for the enrollee.Per Medi-Cal guidance  cited here as persuasive, non-binding authority  patient selection for conducting dental procedures under general anesthesia utilizes medical history, physical status, and indications for anesthetic management. General anesthesia can be considered only after consideration has been given to behavior modification, local anesthesia and then conscious sedation. Patients with severe asthma should be treated in a hospital setting capable of responding to a serious medical crisis.In this case, there is a well-documented need for general anesthesia. According to the treating physician, hospital-based general anesthesia was necessary because it would not have been safe to sedate this patient in an office setting while performing the complex surgical procedure. Additional documentation indicates the patient required surgical treatment that cannot be rendered under conscious sedation. Per the treating physician, this patient also suffers from severe asthma and thus needed to be treated in a hospital setting equipped to handle an emergency. Per California guidelines, criteria for general anesthesia have been met. Therefore, the general anesthesia provided during dental surgery performed was medically necessary.Final Result: The reviewer determined that the requested service was 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 anesthesiology with subspecialty certification in pediatric anesthesiology, 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Otezla 30mg. The patient has a history of chronic plaque psoriasis in the setting of chronic hepatitis C infection. Records indicate that he has tried and failed treatment with topical steroids. Due to the concurrent hepatitis C infection, use of certain therapies, such as methotrexate or tumor necrosis factor (TNF) inhibitors would be contraindicated. While Otezla has been shown to be less immunosuppressive than other systemic psoriasis treatments, there are no large controlled studies revealing its use in patients with chronic hepatitis C infection. Therefore, the safety of use of Otezla under these circumstances cannot be determined. In this case, Otezla is not clearly superior or safer than the other formulary options. Accordingly, Otezla 30mg is not medically necessary for treatment of the patients medical condition at this time.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One injections. Findings: Two of the three physician reviewers found that there is sufficient support for the requested services in this patients case. This patient has benefitted from prior viscosupplementation. Per the current literature, intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. The authors reported that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, Synvisc-One injections are likely to be more efficacious than other available treatment options. Final Result: The 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: Physician reviewer 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.