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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene expression classifier for evaluation of the enrollees indeterminate thyroid nodule. Findings:  Two of three physician reviewers found that While FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma gene expression classifier utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, Afirma gene expression classifier was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 hydrocodone-acetaminophen 10/325 mg one to two tablets every six hours. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested hydrocodone-acetaminophen 10/325 mg one to two tablets every six hours is not medically necessary for treatment of the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, FoundationOne testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of FoundationOne in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the FoundationOne test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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: All three reviewers are 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 are 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided.  Findings:  The physician reviewer found that The records provided for review do not document that this patient has demonstrated post-acute withdrawal symptoms. There is no evidence that she has been a danger to herself or others, and she has not been aggressive or violent. She has been cognitively intact and not gravely disabled. There have been no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the residential treatment center (RTC) level of care.The member been medically and psychiatrically stable to the extent that she does not require the monitoring and supervision of a 24-hour facility to render the remainder of her care. Her medication management could have been performed in an ambulatory setting. There has been no documentation of mania, hallucinations, delusions, or any other significant symptom that would interfere with her care. She has been internally motivated and appears to be working the program. She has been cooperative and participating in all aspects of the treatment plan. She does require further treatment. However, the nature of her polysubstance use disorder has been highly recidivistic in nature, and there has been no evidence to suggest that further residential treatment would change the nature of this. The development and solidification of coping skills and her relapse prevention plan could have been continued at PHP level of care. Her social support was limited, however she showed the ability to reach out to her social support network in the 12 step group. The patient no longer required the structured environment of a RTC setting and could have been stepped down to an ambulatory level of care such as PHP in conjunction with community support and psychotropic medication management. All told, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.Findings: The physician reviewer found that the urgent care services provided were not necessary for treatment of an emergency medical condition. In this case, the patient presented to an urgent care facility with dizziness and palpitations. The patients symptoms were not sudden in onset. The patient had been experiencing symptoms for two months. The patient denied chest pain or shortness of breath. In addition, the patient did not report any acute neurologic deficits. There were no abnormalities identified on physical examination, EKG, or laboratory testing. Based upon the clinical documentation provided for review, the patient did not receive emergency medical services for an emergency medical condition.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis for treatment of the enrollees erectile dysfunction. Findings: The physician reviewer found there is support in the medical literature as well as in the documentation provided for the requested medication in this clinical setting. The patient has erectile dysfunction. Phosphodiesterase inhibitors including Cialis are considered standard first line therapy for management of patients with erectile dysfunction. Accordingly, Cialis would be considered a safe, effective and a standard of care for management of this patients medical condition. The records indicate that treatment with Cialis has been an effective regimen for this patient. Given these findings, Cialis is medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plan's denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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  denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tramadol hcl 50 mg tablets. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested tramadol hcl 50 mg tablets are not medically necessary for treatment of the 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for medical services. 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The medical services provided were not necessary for treatment of an emergency medical condition. The patients parent states the patient was unable to eat properly due to the labial frenum attachment and the mother was developing mastitis from the patients inability to suckle effectively. While some researchers have postulated that the high labial frenum attachment can interfere with the ability to breastfeed, the medical literature does not provide a consensus demonstrating a causal relationship nor improvement after surgical release. Research has shown that there is high variability in the position of attachment of the labial frenum on infants and attachment is quite common. Moreover, there is no clinical documentation supporting a medical condition of failure to thrive. Given the lack of clinical documentation demonstrating an emergent medical condition, the patient did not receive emergency medical services for an emergency medical condition. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for one-on-one speech therapy for 12 weeks at 30 minutes per session for treatment of the enrollees severe language delays. Findings: The physician reviewer found the review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Children with Down syndrome have more complex speech and language disorders. Children with Down syndrome may have frequent cluttering or stuttering. In addition, frequent problems with articulation and more unusual pronunciation problems often occur (Kent and Vorperian). Children diagnosed with childhood apraxia of speech often require daily one-on-one speech therapy (Tierney, et al). In this case, the patient has not been formally diagnosed with apraxia of speech, however he does have many signs of this disorder. He has made progress with treatment that is directed toward childhood apraxia of speech. Moreover, the school district provides group speech therapy which is not appropriate for this patient. Speech therapy in the group setting cannot address more complex oral motor problems such as childhood apraxia of speech or severe articulation problems from Down syndrome. Based on the clinical documentation provided for review, one-on-one speech therapy is clinically indicated for this patient. For the reasons stated, one-on-one speech therapy for 12 weeks at 30 minutes per session is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for Concerta and modafinil for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that Concerta is a methylphenidate-based product that was approved by the U.S. Food and Drug Administration (FDA) for the treatment of attention deficit hyperactivity disorder (ADHD) in 2000. Concerta is a central nervous system psychostimulant that is thought to exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day. Modafinil is not a stimulant, but rather a novel wake-promoting agent that selectively increases neuronal activity in the hypothalamus, particularly in the wakefulness center of the tuberomammillary nucleus. Modafinil is approved by the FDA for excessive sleepiness associated with narcolepsy, obstructive sleep apnea, and shift-work sleep disorder. Although modafinil has demonstrated promising results in the treatment of ADHD, the FDA has not approved the agent for this indication in the absence of rigorous scientific trials demonstrating the long-term safety and efficacy of the medication. This patient does not have narcolepsy, obstructive sleep apnea, or shift-work sleep disorder. The medical record also noted that the patient did not meet the diagnostic criteria for ADHD. Although psychostimulants have shown promise as an adjunctive treatment for refractory depression, Concerta and modafinil are not considered evidence-based monotherapies for major depressive disorder or chronic fatigue for that matter. Thus, based on the documentation provided, the requested Concerta and modafinil are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage laparoscopic anti-reflux surgery utilizing LINX Reflux Management System (CPT 43284) for the enrollees gastroesophageal reflux disease (GERD). Findings:  The 3 physician reviewers found that according to the documentation submitted for review, the patient has GERD based on pH recording. However, it appears the patient has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in this clinical setting must be approached with caution given the patients lack of endoscopically-advanced esophageal inflammation. LINX implantation, with its inherent surgical risks and post-operative complications is not likely to be more beneficial than conventional medical therapy in combination with lifestyle modification aimed at reducing GERD symptoms and manifestations. All told, the request for laparoscopic anti-reflux surgery utilizing LINX Reflux Management System (CPT 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.