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 computed tomography (CT) scan of the heart for evaluation of the enrollees hypertension and hyperlipidemia.Findings:  Two physician reviewers found that this patients records note that he exercises regularly and vigorously without any provoked cardiovascular based symptoms such as chest pain, dyspnea or palpitations. Further, the patients provider recommended stress testing, which was not reportedly completed. In the setting of dyslipidemia, the patients treatment would be the same since the patient was asymptomatic and would include lipid lowering therapy. Thus, stress testing and the deployment of a statin represents the standard of care. Based on the current peer-reviewed medical literature, there is a lack of significant supporting data that the patients health outcome would have been positively impacted by the use of calcium scoring testing. Final Result: Two reviewers determined that the diagnostic procedure 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Prometheus Anser IFX (measurement of serum infliximab and the antibodies to infliximab) for testing evaluation of the enrollees Crohns disease.  Findings: Two reviewers found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al) As such, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Moreover, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Accordingly, the Prometheus Anser IFX testing was not likely to be more beneficial for evaluation of the patients Crohns disease than therapeutic adjustment based on clinical observation in lieu of Anser testing.Final Result: Two 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 physician reviewers 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 the iStent trabecular micro-bypass procedure for treatment of the enrollees primary open angle glaucoma. Findings:  The physician reviewers found that The iStent is a minimally invasive device that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glaucoma in patients who are undergoing cataract surgery. The iStent device has been found to be effective in patients with mild-to-moderate glaucoma who are undergoing cataract surgery at the same time. The overall effect of the iStent on the intraocular pressure is modest and its use is not appropriate for patients who have advanced glaucoma and an intraocular pressure that is uncontrolled with medication. Since the patient meets these criteria, the use of iStent trabecular micro-bypass procedure was likely to be more beneficial than standard therapy. Final Result: All three reviewers determined that the service at issue was 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 number one, two, and three are board certified in ophthalmology and 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 bilateral knee injections with Synvisc for treatment of the enrollees osteoarthritis of the knees.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this patients case, clinical examination findings are consistent with x-ray evidence of bone-on-bone osteoarthritis of both knees.  She has undergone two prior viscosupplementation series, with documented long-term pain reduction and improvement in walking tolerance.  She has failed to respond adequately to other conservative treatment, including anti-inflammatory medications. Therefore, bilateral knee injections with Synvisc are medically indicated for the treatment of this patient.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for inpatient mental health services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that inpatient mental health services were not medically necessary for treatment of the patients behavioral health conditions. The patient was paranoid, labile and bizarre with thought blocking. However, the following day he dismissed the behavior and he was noted to be calm, appropriate and communicative. He was not paranoid. He was sleeping and eating well. He had a good visit with his parents and had plans to discharge to their home before moving to an apartment. The psychiatrist noted that the patient was taking and tolerating his medications. There were no medication changes as he continued lithium, bupropion, eszopiclone, propranolol and buspirone. He was neither violent nor aggressive on the unit. He was coherent, logical and goal directed. He was anxious and depressed, but he was not suicidal, paranoid or delusional. He was sleeping well at night. He had a supportive family. Although ongoing care is indicated, there was no evidence of an acute psychiatric syndrome and the patient had a safe plan for aftercare. As such, the services at issue were not medically necessary.Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Nucala for treatment of the enrollees hypereosinophilic syndrome. Findings: Three physician reviewers found that Hypereosinophilic syndrome is a form of myeloproliferative disorder characterized by a vigorous proliferation of eosinophils that cause end organ damage through infiltration and chemokine/cytokine mediated mechanisms (Tefferi and Vardiman). Interleukin-5 (IL-5) is the main cytokine responsible for eosinophil proliferation. IL-5 is secreted by T cells. Thus, hypereosinophilic syndrome may be driven by expanded T cells, especially those of the Th2 phenotype as in atopic disorders (Zaheri, et al). Alternatively, hypereosinophilic syndrome may be caused by the cell intrinsic expansion of eosinophils through platelet derived growth factor receptor alpha (PDGFRA) and platelet derived growth factor receptor beta (PDGFRB) rearrangements (Gotlib and Cools). Hypereosinophilic syndrome may be amenable to Gleevac, which inhibits PDGF receptors or by interferon (Butterfield). Since this patient has progressed through common therapies including treatment with Gleevac, her provider has recommended treatment with Nucala, which is a monoclonal antibody against IL-5. Thus, Nucala is a reasonable therapeutic option for this patient whose disease has progressed on standard treatments and it is supported by the medical literature (Rothenberg, et al). All told, the peer-reviewed medical literature supports the requested Nucala as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested medication 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: All three physician 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 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 for Daklinza 60 mg, Sovaldi 400 mg and ribavirin 200 mg for treatment of the enrollees hepatitis C virus. The Health Plan indicates that the preferred regiment for genotype 3 treatment naive patients with compensated cirrhosis is Epclusa for 12 weeks.  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. Per the guidelines, treatment-naive genotype 3 patients should be treated with Sovaldi and Daklinza for 12 weeks, or Epclusa for 12 weeks. This is based on the ALLY-3 trial for Sovaldi and Daklinza, and the ASTRAL-3 trial for Epclusa (Nelson, et al; Foster, et al). Per the guidelines, treatment with Sovaldi and Daklinza with ribavirin regimen is not recommended. Furthermore, there is no medical contraindication to Epclusa noted in the records provided for review. Although hepatitis C treatment is indicated, Sovaldi 400 mg and Daklinza 60 mg with ribavirin 200 mg has not been established as medically necessary for the treatment of this patients hepatitis C virus.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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Ambien (zolpidem tartrate) 10 mg for treatment of the enrollees insomnia. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The U.S. Food and Drug Administration (FDA) has approved the use of Ambien for short-term treatment of insomnia with difficulty of sleep onset.  Ambien is not approved for the long-term treatment of insomnia.   When treating insomnia, patients should receive therapy for any medical condition, psychiatric illness, or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy (CBT) is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered.  In this case, the documentation does not support that the patient has received optimal therapy for medical and psychiatric conditions or that non-pharmacologic treatment for insomnia has failed.  There is a lack of support for the requested medication in this clinical setting.  Therefore, the requested medication is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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 Orthovisc injections for treatment of the enrollees osteoarthritis. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with advanced osteoarthritis of the both knees.  Clinical examination findings are consistent with this diagnosis.  He has undergone two prior viscosupplementation series, with long-term pain reduction documented and improvement in ability to perform activities of daily living. He has failed to respond adequately to other conservative treatment, including anti-inflammatory medications and regular exercise. Therefore, the requested series of Orthovisc injections are medically indicated for the treatment of this patient.  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 physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for the anesthesia service performed during an endoscopy/colonoscopy for evaluation of the enrollees Crohns disease. Findings:  The physician reviewer found that the records provided for review demonstrate that this patient is an American Society of Anesthesiologists (ASA) II with only moderate systemic disease. He has no medical history of the cardiac or pulmonary systems and he does not have a documented history of difficulty or problems with anesthesia. Severe Crohns disease does not render the patient at increased risk for endoscopy or colonoscopy and does not require MAC services for the procedure. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested percutaneous ventricular assist device (PVAD) for treatment of the enrollees cardiogenic shock.  Findings: Three physician reviewers found that this patient presented with an acute myocardial infarction treated with urgent coronary artery bypass surgery.  This was followed by documented cardiogenic shock despite volume resuscitation and pressor therapy.  In this circumstance, temporary additional hemodynamic support using the Impella device was appropriate in an attempt to lessen cardiogenic shock while waiting for ventricular function to improve after coronary revascularization.  Seyfarth and colleagues performed a study of patients with cardiogenic shock after myocardial infarction randomly assigned to an Impella device or intra-aortic balloon pump, and the authors noted improved hemodynamic parameters with the Impella device.  All told, the device at issue was likely to have been of greater benefit than other treatment options in this clinical setting.Final Result: Three reviewers determined that the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services.  Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a rapidly progressive symptom complex with sore throat, severe right ear pain, and bloody drainage from the ear canal.  A prudent layperson would have considered this an acute emergency for several reasons. First, the intense pain rating of 10/10 is often associated with severe middle ear infections. Second, the patient experienced bloody drainage from the right ear. Third, the loss of hearing associated with purulent otitis media and tympanic membrane rupture would be very concerning to the prudent layperson for permanent hearing loss. In this clinical setting, the patients ear function was at risk for further deterioration, and had the potential for more damage if the infection was not treated in a timely manner.  Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the emergency department services at issue met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.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.