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 Depend brand adult diapers. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. There are several types of urinary incontinence, and there is significant overlap in the conditions that cause urinary leakage. The risks for urinary incontinence increase with age, female gender, decrease in estrogen levels at menopause, obesity, smoking, chronic constipation, neurologic disorders and diabetes mellitus.  The diagnosis is mainly based on history and examination. The treatment depends on the etiology of the incontinence. Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. Patients often use incontinence pads when leaking is not controlled by medications or surgical treatments.  In this case, the patient is requesting a specific brand of adult briefs or incontinence pads. However, there is no medical documentation to support that she has had a significant adverse reaction to the pads that are provided by her Health Plan. Therefore, the requested Depend brand adult diapers are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: A 40-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint arthrodesis. In the peer-reviewed medical literature, researchers noted that pain related to SI joint dysfunction is difficult to diagnose. The authors reported that that evidence demonstrating improved outcomes is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up. More outcomes studies are needed to show safety and efficacy. With regard to this patient, there is no documented SI joint instability, fracture, or tumor. Thus, the requested SI joint arthrodesis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested SI joint arthrodesis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries including reduction of forehead, contouring and setback of anterior frontal sinus; brow reduction. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. Research notes that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. The study aggregates opinions from multiple organizations including the American Medical Association, American Association of Family Physicians, Endocrine Society, American Psychiatric Association, American Psychological Association, American College of Obstetricians and Gynecologists, and the American Public Health Association. The authors note that the medical procedures attendant to sex reassignment are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A publication notes that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. A study concludes that Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery] or both) are associated with improved mental health-related quality of life  Further a study notes that this surgery does not aim to rejuvenate the face but rather it helps transgender women in passing as a female and integrating into everyday society. In conclusion, the submitted documentation demonstrates the patient experiences significant anxiety and distress secondary to her male facial features. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, the requested services are 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 psychiatry with expertise in treatment of gender dysphoria 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 parent of a patient has requested authorization and coverage for Nutropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients idiopathic short stature. The submitted documentation supports the medical necessity of the requested medication. The patients height is more than standard deviations below the mean the patients for age and gender, insulin-like growth factors -1 level is low, growth velocity is poor, and adult predicted height is less than 63 inches. Although the patient had normal results on provocative GH testing, the patient meets generally accepted criteria established by the Pediatric Endocrinology Society and the U.S. Food and Drug Administration for treatment of idiopathic short stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature; who pass GH stimulation tests, but who meet several of the following criteria; height is more than 2.25 standard deviations below the mean for age, or more than two standard deviations below the mid-parental height percentile; or growth velocity of less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factors-1 and/or insulin-like growth factor-binding protein 3; and/or other clinical features suggestive of GH deficiency. This patient does meet several of the above criteria. Therefore, Nutropin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 etanercept 50 mg/ml cartridge (Enbrel). The submitted documentation supports the medical necessity of the requested medication. This patient has tried and failed therapy with topical steroids and methotrexate. The medical records indicate that the patient has been treated with methotrexate but did not tolerate the medication due to nausea. Enbrel is a U.S. Food and Drug Administration (FDA) approved injectable biologic used in the treatment of plaque psoriasis. The use of Enbrel after failing methotrexate due to intolerance of side effects is medically appropriate. Per the records, this patient has tried and failed the preferred first-line therapy methotrexate. Thus, etanercept 50 mg/ml cartridge (Enbrel) 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: A enrollee has requested authorization and coverage for a computed tomography (CT) scan of the abdomen and pelvis. Findings:  The physician reviewer found that in the medical literature reported that non-contrasted CT is a sensitive imaging modality for the detection of urinary tract calculi and obstruction. Studies concluded that the majority of the patients evaluated required no further imaging to determine the need for urological intervention. Thus, the literature supports the use of ultrasound for the detection of hydronephrosis, and CT has been documented to be effective for the detection of ureteral stone. Thus, further evaluation with non-contrast CT of this patients left renal collecting system dilatation seen on ultrasound is appropriate. Given this support, the requested CT scan of the abdomen and pelvis is medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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 diagnostic radiology 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: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 2. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent 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 limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine 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 authorization and coverage for weekly therapy sessions that accompany the enrollees electroconvulsive therapy (ECT) treatment. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document major depressive disorder, generalized anxiety disorder, borderline personality disorder and posttraumatic stress disorder. Per the submitted documentation, this patient is receiving three ECT treatments per week. The Health Plan noted that the patient will be accepted into intensive outpatient program treatment while he receives ECT. In this patients case, intensive outpatient program services are medically appropriate while the patient is receiving ECT. As intensive outpatient program services are available, the medical necessity of the requested weekly therapy sessions is not established. Therefore, the requested weekly therapy sessions that accompany his ECT treatment are not medically necessary for the treatment of this patient. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Eucrisa 2% ointment for treatment of the enrollees eczema.  Findings:  The physician reviewer found that the Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients eczema. The submitted documentation does not support the medical necessity of the requested medication. Eucrisa is an inhibitor of phosphodiesterase 4, a novel non-steroidal treatment for children over the age of two years. It can be applied to any part of the body. without concern for side effects.  It is intended for treatment of mild to moderate eczema. Per the Health Plan, coverage for Eucrisa 2.0% ointment requires failure of other topical immunosuppressive agents for mild to moderate atopic dermatitis in a non-immunocompromised patient. Coverage also requires documentation that corticosteroids are inadvisable due to location or inadequate response. The other possible immunosuppressive agents includes Elidel, and tacrolimus. In this patients case, there is no documentation of use/failure of other immunosuppressant topical medications. The degree of eczema was also not documented. The medical necessity of the requested medication has not been established. Therefore, Eucrisa 2% ointment is not medically necessary 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 reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing. Findings:  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which would guide the provider as to which chemotherapeutic agent would be useful. At this time, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Also, finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. Therefore, FoundationOne testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two of the three physician reviewers found that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. The Health Plan has denied this request indicating the enrollee was not experiencing an emergency medical condition on the date of service at issue.Findings: At issue in this case is whether the enrollee received emergency medical services on the date(s) 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. The patient did not receive emergency services and care provided as defined by the California Health and Safety Code  1317.1 (a)(1).  The records demonstrate that this patient presented for a scheduled sleep study evaluation. His vital signs were documented as normal and he was asymptomatic at the time of his arrival. Sleep studies to assess for sleep apnea are routinely scheduled on an outpatient basis. There were no indications for an emergency sleep study evaluation. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test. Findings:  Two of the three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic agent would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized study did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. All told, the superior efficacy of FoundationOne gene test has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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.