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

An enrollee has requested authorization and coverage for whole breast ultrasound.Findings: Two out of three physician reviewers found that the authorization and coverage for whole breast ultrasound is likely to be more beneficial for the enrollee than any available standard therapy.Although ultrasound has a role in screening for breast cancer, most of the literature involves breast ultrasound as an augmentation to routine mammography. When a lump or suspicious abnormality is discovered on a routine mammography, a targeted breast sonogram is the next step prior to biopsy. Breast sonography is the best means to distinguish between cystic and solid lesions. The issue of a whole breast sonography as a screening tool is an entirely different issue. Kaplan states, ABUS [automated breast ultrasonography] is a developing technology that has been recently approved by the U.S. Food and Drug Administration for use in screening for breast cancer as an adjunct to mammography. The issue, in studies supporting the use of ultrasounds, is that automated whole breast sonography was performed as an adjunct to mammography, not as a replacement. Berg and colleagues have shown an increased detection rate of occult breast cancer in a screening population when sonography is added to routine mammography. There are clearly limitations for any type of sonography in evaluating breasts. Specifically, automated whole breast ultrasound (AWBU) cannot diagnose microcalcifications and is marginal in evaluating the deeper portions of the breast. As in this patient, once an abnormality is detected, one will generally resort to an additional hand-held targeted sonogram. Further, when a prior whole breast sonogram is negative, a whole breast ultrasound is not an effective means to screen for breast cancer.For this patient, the screening procedure is apparently only for the sonogram. There is no accompanying mammogram, and there are no reported direct breast symptoms. Whole breast sonography is not a replacement for mammography. Therefore, a whole breast ultrasound is not likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality (galcanezumab). The International Headache Society (IHS) defines chronic migraines as headaches for more than 15 days monthly for longer than three months that are not attributable to another disorder and include at least two of the following characteristics: unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. The criteria also require that the symptoms include one of the following characteristics: nausea, vomiting, photophobia, or phonophobia. Medical literature notes that treatment of chronic migraines with Botox is associated with significant and clinical meaningful reductions in headache impact and improvement in quality of life. Medical literature also notes that galcanezumab, a humanized monoclonal antibody that selectively binds to calcitonin gene-related peptide, appears efficacious, safe, and well tolerated for the preventive treatment of chronic migraine. Medical literature notes that dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A may be an option in the treatment of patients that are resistant to monotherapy. In this case, the patient has chronic migraines and has treatment with tolerated Botox. Given that current medical literature does not note that concurrent calcitonin gene-related peptide inhibitor administration is a contraindication to the use of Botox, and as the patient reports ongoing migraines, the requested medication is medically indicated. Therefore, Emgality (galcanezumab) is medically necessary for the treatment of this patient.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Evrysdi (risdiplam). Findings:  The physician reviewer found that this patients records document that her DNA test results were consistent with SMA. The patients provider has recommended treatment with Evrysdi. SMA is a disease characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem, which results in progressive muscle weakness and atrophy. Evrysdi corrects the splicing deficit of survival motor neuron 2 (SMN2), leading to increased levels of full-length SMN protein. The U.S. Food and Drug Administration (FDA) approved Evrysdi in 2020 for the treatment of SMA in patients two months of age and older. Given this support, the requested Evrysdi (risdiplam) is medically necessary for treatment of this patient. 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 neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Afinitor 2.5 mg tablets and/or Imbruvica 140 mg capsules. Findings:  The physician reviewer found that records provided for review document that this patient presents with stage IV glioblastoma status post subtotal resection. The patients provider has recommended treatment with a combination of Afinitor and Imbruvica. The U.S. Food and Drug Administration (FDA) has not approved Afinitor or Imbruvica for the treatment of patients with glioblastoma. In addition, this medication regimen is not supported by major drug compendia or the National Comprehensive Cancer Network (NCCN) guidelines. Moreover, the requested medication combination is not supported by the medical literature for use in this patients clinical scenario. Given these findings, the requested Afinitor 2.5 mg tablets and/or Imbruvica 140 mg capsules are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication regimen 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 subspecialty certifications in medical oncology and hematology 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 reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that he patients provider noted in a letter that the patient has an elevated lipoprotein A level and a family history of cardiovascular disease and hyperlipidemia. Grundy and colleagues note that the main target of lipid lower therapy is low-density lipoprotein (LDL). While Reiter-Brennan and colleagues note that decisions regarding initiation of statin therapy are based on cardiovascular risk stratification, lipoprotein A testing is not generally part of evaluation. In this clinical setting,  current medical literature does not support the use of the service at issue over standard lipid panel studies. Therefore, the advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the advanced lipoprotein testing was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 and 3 are board certified in internal medicine with sub-specialty certifications in  cardiovascular disease, and clinical cardiac electrophysiology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for diagnostic laparoscopy and bilateral oophorectomy/salpingectomy. Findings:  The physician reviewer found that Laparoscopy with bilateral oophorectomy/salpingectomy is indicated in specific clinical scenarios for ovarian pathology, including malignancy, torsion, and certain ovarian cysts. Chronic pelvic pain with no ovarian pathology on imaging is not a clinical indication for bilateral oophorectomy/salpingectomy. The submitted documentation does not support the medical necessity for  the requested services in this patients case. Therefore, diagnostic laparoscopy and bilateral oophorectomy/salpingectomy are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 implantation of motor cortex stimulator in the brainFindings: Three out of three physician reviewers found that the authorization and coverage for implantation of motor cortex stimulator in the brain is likely to be more beneficial for the enrollee than any available standard therapy.Neuropathic facial pain syndromes are known complications of dental procedures. Although this pain is generally unilateral and in the region of the face and mouth/jaw, it often involves continuous burning pain symptoms. It is well-established that the continuous feature of a chronic pain syndrome is a poor prognostic feature. In the context of an overall poor response to all treatments, conservative treatment with medications is recommended as the first approach. MCS is a technique that has been evaluated for the treatment of chronic pain syndromes. Atypical facial pain is one indication. A small retrospective case study by researchers explored this strategy for patients with chronic pain syndromes, four of whom had chronic atypical facial pain syndromes. Overall, for all patients with chronic pain syndromes, these investigators reported 19 out of 20 patients experienced a positive response, including those with atypical facial pain. A study suggested similar positive results for neuropathic pain syndromes, including atypical facial pain. Further, researchers conclude that MCS may be useful for patients with chronic neuropathic orofacial pain syndromes who do not respond to other treatments.In this case, the patient has facial pain that has been refractory to many of the routine treatment strategies for facial pain syndromes. The patient has tried myriad medications of multiple classes, most of which have yielded no relief. The patient is taking four medications at present, including potent oral narcotics, that provide only minimal relief. Tricyclic antidepressants and anticonvulsants have proven ineffective for this patient. The literature suggests that MCS can be beneficial for this patient. Therefore, implantation of motor cortex stimulator in the brain is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in neurological surgery 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

An enrollee has requested authorization and coverage for Monovisc injection.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of relief from prior injections. Therefore, Monovisc injection is medically necessary to treat the patients 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 the Inspire upper airway stimulation system. In a meta-analysis of five retrospective studies on the outcomes of patients with hypoglossal nerve stimulator implantation versus patients undergoing surgical interventions, including uvulopalatopharyngoplasty, expansion sphincter pharyngoplasty, transoral robotic surgery (lingual tonsillectomy and tongue reduction), and other upper airway surgery, Neruntarat and colleagues concluded that upper airway stimulation provided improved objective and similar subjective outcomes compared to other upper airway surgical procedures. Given the evidence in current medical literature supporting the use of hypoglossal nerve stimulators, in this clinical setting, the requested service is likely to be more beneficial in managing the patients obstructive sleep apnea (OSA) that is refractory to continuous positive airway pressure (CPAP) therapy. Therefore, the Inspire upper airway stimulation system is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Inspire upper airway stimulation system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 reviewers 1 and 3 are board certified in otolaryngology and are actively practicing. Physician reviewer 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine 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: The patient has requested authorization and coverage for Cosentyx 150 mg/mL syringe, two applications subcutaneously once per week for five weeks, quantity 10, with six refills. Chronic plaque psoriasis is a disease that affects not only the skin but a patients quality of life. The U.S. Food and Drug Administration (FDA) approves the use of Cosentyx, a human interleukin-17A antagonist, for the treatment of moderate-to-severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy, adults with active psoriatic arthritis, and adults with active ankylosing spondylitis. Menter and colleagues note that Cosentyx is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. Langley and colleagues report that two phase III trials have established the efficacy of Cosentyx in patients with moderate-to-severe psoriasis, with the percentage of patients who achieved a reduction of 75% or more from baseline in the psoriasis area-and-severity index score (PASI75) at week 12 being higher with secukinumab dosage than with a placebo or with etanercept. In this clinical setting, current medical literature shows that Cosentyx is considered safe, effective and appropriate for the treatment of psoriasis. Therefore, Cosentyx 150 mg/mL syringe, two applications subcutaneously once per week for five weeks, quantity 10, with six refills is medically necessary for the treatment of this patient.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for photorefractive keratectomy (PRK). Findings:  The physician reviewer found that this patients records document a history of lattice corneal dystrophy. The provider has recommended treatment with PRK. Lattice corneal dystrophy leads to deposition of amyloid in the cornea causing blurriness and loss of vision. In this clinical setting, the medical literature supports treatment with excimer laser removal of the corneal opacities and stroma. The requested PRK procedure will remove the corneal opacities that are interfering with the patients vision. Given this support, the requested PRK is medically necessary for treatment of this patient. Moreover, the requested PRK is reconstructive in nature for this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. The presence of lattice corneal dystrophy is an abnormal structure of the body and the PRK is being performed to improve the patients function. For these reasons, the requested PRK is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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: The patient has requested reimbursement for urgent care services. A mental health crisis is an acute disturbance of behavior, thought or mood of a patient which if untreated may lead to harm, either to the patient themself or to others in the environment. Thus, the definition of a psychiatric emergency differs from other medical emergencies in that the danger of harm to the society is weighed in determining the appropriate level of care. Mental health emergencies or crises also can include acute conditions that could quickly deteriorate into dangerousness or inability to care for self, even if those issues do not currently pose a problem. The services rendered during the time period under review do not meet the definition of urgent care services and care as defined by California law. The patient did not require services to prevent the serious deterioration of his health resulting from an unforeseen illness. The patient was under the care of a local provider, who advised the patient to establish care by his school, but this was not reportedly accomplished. In addition, the patients presenting symptoms do not meet the definition of a psychiatric emergency or mental health crisis. Although the patient was experiencing mental health distress as evidenced by his report of increasing depressive symptoms over a four month period, the records do not support that the patient was experiencing a mental health emergency or crisis with acute suicidal ideation with plan or intent that necessitated urgent mental health services before the patient was able to return to the Health Plans service area. For these reasons, the services provided were not urgent care services as defined by California law.Final Result: The reviewer determined that the services at issue were not urgent care services for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent 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.