Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acthar for treatment of her relapsing multiple sclerosis (MS).  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with mild loss of vision of 20/60, no pain with eye movements which is characteristic of optic neuritis, and no optic nerve enhancement, or imaging evidence of active disease. In this case, the provider recommends treatment with Acthar due to reports of previous intolerance with oral and IV steroids, however the medical records do not document intolerance or adverse side effects. Given the lack of documentation demonstrating intolerance with steroids, Acthar is not medically necessary for treatment of the patients medical condition. Final Results: 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 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: An enrollee has requested authorization and coverage for an office visit with a hematologist for his evaluation of thrombocytopenia, unspecified.  Findings: The physician reviewer found that thrombocytopenia is defined as a platelet count below 150,000. The degree of thrombocytopenia can be further subdivided into mild with a platelet count of 100,000 to 150,000, moderate of 50,000 to 99,000, and severe with less than 50,000. The risk of bleeding is proportional to degree of thrombocytopenia. There are certain medical conditions that warrant immediate evaluation by a hematologist, such as urgent need for invasive procedure, pregnancy with low platelets, suspected heparin induced thrombocytopenia, suspected thrombocytopenic purpura, hemolytic uremic syndrome or drug induced, or suspected malignancy. Prompt evaluation is recommended in order to institute the appropriate intervention. In this case, the patient presents with newly diagnosed thrombocytopenia with platelet count of 82,000 which warrants hematologic evaluation. For the reasons provided, the request for an office visit with a hematologist is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Foundation One testing provided for evaluation of the enrollees stage IV colon cancer. Findings: The three physician reviewers found that the utility of Foundation One testing has not been definitely proven in the current peer-reviewed medical literature. To demonstrate clinical utility of panel genetic testing such as Foundation One assay, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. No such trials have currently been published. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. However, the National Comprehensive Cancer Network (NCCN) has endorsed KRAS and NRAS testing to help determine appropriate therapy. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is not routinely recommended and the utility of the KRAS and NRAS portions of the Foundation One assay are supported as beneficial in this clinical setting. Accordingly, the KRAS and NRAS portions of the Foundation One testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Foundation One test was not likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier test. Findings:  Three physician reviewers found that there is sufficient support for the Afirma gene classifier testing performed in this clinical setting. The patients biopsy revealed atypia of undetermined significance, and genetic testing showed benign results. The Afirma test was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. Therefore, the Afirma GEC test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in intenal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 authorization and coverage for eteplirsen (Exondys 51) for treatment of the enrollees Duchenne muscular dystrophy. Findings:  The physician reviewers found that Duchenne muscular dystrophy is a neuromuscular disorder that is characterized by progressive muscular deterioration. It is caused by loss-of-function mutations in the gene coding for dystrophin, a cytoskeletal protein that stabilizes the plasma membrane of muscle fibers. Dystrophin is important to maintain the muscle fibers cell membrane.  Typically, muscle loss occurs first in the upper legs and pelvis followed by those of the upper arms.  The disorder is X-linked recessive, and genetic testing can often make the diagnosis at birth.  Eteplirsen modulates splicing to treat Duchenne muscular dystrophy patients, and received accelerated approval by U.S. Food and Drug Administration (FDA).  Eteplirsen is beneficial for patients with amenable Duchenne muscular dystrophy mutations, comprising approximately 14% of the Duchenne muscular dystrophy patient population. This medication is recommended for patients with amenable mutations, and this patient was having significant side effects while on steroids. There is sufficient support for the requested medication in this clinical setting. Therefore, eteplirsen (Exondys 51) is likely to be of greater benefit than other treatment options. Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in pediatrics 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 reimbursement for the brand name drug, Asacol HD, for treatment of the enrollees ulcerative colitis. Findings:  The physician reviewer found that te submitted documentation supports the medical necessity of the medication at issue.  Asacol has proven to be effective for the treatment of ulcerative colitis. Although several 5-aminosalicylate medications and mesalamine formulations are available for the treatment of ulcerative colitis, each formulation results in release at distinct times and locations in the gastrointestinal tract. Specifically, Asacol has proven to be different from Apriso, Salofalk, Mezavant XL, and Pentasa, with release later and at a higher pH. The result of changing therapy can be inadequate control by a different formulation which directs the drug to a different part of the gastrointestinal tract. Additionally, ulcerative colitis flares can be induced by salicylate medications, and changing therapy can expose the patient to this risk. In this case, the change to generic mesalamine could have resulted in a different formulation with inability to control disease. Therefore, Asacol HD, was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication at issue 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 internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for Synvisc injections in both knees for treatment of the enrollees osteoarthritis in both knees. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use 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 allows for delay of total knee replacement. Additionally, the literature indicates that viscosupplementation injections are more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of both knees. He reported a history of knee pain and functional impairment in mobility that had failed to respond adequately to other conservative treatment, including steroid injections. Significant prior pain reduction and functional benefit was documented with viscosupplementation (in the form of Supartz). All told, Synvisc injections in both knees are medically necessary for the treatment of this 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 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 the Oncotype Dx prostate cancer assay provided for evaluation of the enrollees prostate cancer. Findings: Three physician reviewers found that the Oncotype Dx prostate cancer assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score is suggestive of a more favorable biology and less aggressive disease. This test may be utilized to counsel patients regarding the best course of therapy in newly diagnosed low or low-intermediate prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state that, retrospective case cohort studies have shown that these assays provide prognostic information independent of NCCN risk groups. However, the NCCN cautions that there is a lack of randomized controlled trials to confirm the utility of these tests and comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of men with prostate cancer. A guideline from the American Society for Clinical Oncology (ASCO) similarly found that prospective validation of these tests is needed to assess their impact on patient outcomes such as survival. Overall, there is limited data on clinical outcomes to currently support routine use of Oncotype Dx in this clinical setting. Thus, the Oncotype Dx prostate cancer assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician 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 urology 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 has requested authorization and coverage for Otezla (apremilast) for treatment of the enrollees psoriatic arthritis. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The records demonstrate the patients joint disease is active and is peripheral. Treatment recommendations for peripheral arthritis include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, disease-modifying antirheumatic drugs (DMARDs) and [tumor necrosis factor] TNF inhibitors (Ritchlin, et al). Anti-TNF agents have been proven effective for psoriatic arthritis and are disease modifying agents. Anti-TNF agents prevent progression of disease, erosions and disability and are the preferred agent for psoriatic arthritis (Gossec, et al). Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis but it is not currently known to be disease modifying. As such, it is not a preferred agent for the treatment of psoriatic arthritis (Gossec, et al) In this case, the patient has failed one anti-TNF agent and the medical records fail to demonstrate that the patient has a contraindication to a trial of a second preferred anti-TNF agent. As such, the request for Otezla has not been established as 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 internal medicine with sub-specialty certification in rheumatology 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 urgent care services provided.Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.The services at issue were not necessary for treatment of an emergency medical condition. No emergent condition was identified and no emergent treatment was provided. In this case, the patient presented to urgent care on during the dates in dispute with reports of abdominal pain for three months. He had previously undergone extensive testing and his symptoms were improving while taking an H2 blocker. This patients symptoms had not suddenly worsened. No associated symptoms were present such as fever, vomiting, or abnormal vital signs, to suggest an acute abdominal emergency. The services provided to this patient on do not meet criteria for emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for continued adaptive living skills program services. Findings:  The physician reviewer found that a study investigated the extent to which life skills training was offered to middle and high school students with autism and life skills training needs after high school. A secondary analysis in this study found that the majority of the middle and high school students with autism had received life skills training in school or the community. The request for adaptive life skills program are educational in nature and as such not medically necessary. ABA therapy as authorized by the Health Plan is medically appropriate for treatment of the patients autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the skilled nursing facility (SNF) services provided treatment of the enrollees sepsis, pneumonia, non-ST elevation myocardial infarction (STEMI), and other abnormalities of gait and mobility.Findings: The physician reviewer found that the documentation does not reveal that the patient has needs for SNF services. The patient does not have intravenous (IV) antibiotics, complex wound care needs and does not require daily inpatient SNF services to prevent a deterioration in his condition or establish an effective home program. The documentation does not report that the patient requires inpatient skilled therapy services on a daily basis or skilled nursing services on a daily basis. The records indicate that the patient has plateaued in therapy and therefore would not be expected to make measurable gains in a reasonable and predictable time or require daily inpatient skilled therapy to prevent a deterioration with mobility, ADLs, or to establish an effective maintenance program. The patients needs can safely and adequately addressed with physical therapy with home health services. The patient does not require continued services on an inpatient treatment and physical therapy at a SNF level of care. Given these findings, the SNF services provided (including physical therapy) were not and are not medically necessary for treatment of this patients medical condition.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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.