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

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for leukocyte histamine release test (CPT 86343) for evaluation of the enrollee who has a history of asthma and eosinophilic esophagitis. Findings:  The physician reviewers found that there is a lack of support for the superior efficacy of the services at issue in this clinical setting. This patient has a history of asthma, allergic rhinitis, dermatographism and EoE.  In this patients case, there is no diagnosis of chronic uncontrolled urticaria, only dermatographism which is a physical urticaria. Laboratory evaluation has failed to confirm an autoimmune process.  The services at issue is a leukocyte histamine release assay.  At this time, the clinical utility of this test is not well established and there are currently no national allergy and  immunology or dermatology guidelines recommending routine use of this test. At this time, this test is not needed to make a diagnosis of chronic urticaria, guide therapy or follow for clinical disease course. The current guidelines recommend against screening. The records do not show that this patient has tried and failed standard therapy. For these reasons noted above, leukocyte histamine release test (CPT 86343) was not likely to have been of greater benefit than other standard treatment methods for the evaluation of this patients medical condition. Final Result: All three 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 number one, two, and three are board certified in allergy and immunology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the single photon emission computed tomography (SPECT) scans of the brain for evaluation of the enrollees atypical depression, brain fog and cloudy thinking. Findings:  The physician reviewers found that single photon emission computed tomography (SPECT) is a sophisticated nuclear medicine study that examines blood flow in the brain with the assistance of a radioactive tracer that is introduced to the patients body. Advances in neuroimaging techniques such as SPECT represent an exciting, and potentially useful, expansion of the collective knowledge base. However, the available data has not demonstrated a meaningful correlation between clinical diagnoses and specific brain activity patterns. This patient had not exhausted standard treatments available to treat her condition including serotonin-norepinephrine reuptake inhibitors or monoamine oxidase inhibitors, which represent classes of medications commonly used to treat atypical depression. Further, her antidepressants had not been augmented with agents such as buspirone, lithium, aripiprazole, quetiapine or thyroid hormone. Finally, there was no evidence that the patient had failed evidence-based non-pharmacologic interventions, such as cognitive behavioral therapy, psychodynamic psychotherapy or interpersonal therapy. In sum, considering the relevant peer-reviewed literature and current practice standards, the SPECT scans of the brain provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three reviewers determined that the diagnostic procedures 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 reviewer numbers one, two, and three are board certified in psychiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for more than 40 hours per week of applied behavioral analysis (ABA) services for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the request for more than 40 hours per week of ABA services provided was not and is not medically necessary for the treatment of the patients medical condition. The records show that the patient has been documented as making progress of his reported problematic behaviors. In addition, he does not have severe behaviors such as aggression or significant self-injury that need to be targeted by more than 40 hours per week of direct ABA therapy. The gains made toward developmental norms and behavioral goals can be maintained at the ABA hours authorized by the Health Plan. All told, the services at issue were not and are not medically necessary for treatment of the 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 pediatrics and neurology with special qualification in child 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided at the Alta Bates in Berkeley, during the course of the delivery of her baby. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided during the course of the delivery of her baby were not necessary for treatment of an emergency medical condition. Women with late-term pregnancies are at risk of oligohydramnios. If oligohydramnios is detected at term or beyond, delivery usually is indicated. In this case, although induction of labor was indicated due to the oligohydramnios, the timing of this induction was not emergent. There was no indication of fetal distress requiring emergency delivery since the patient labored for days prior to her vaginal delivery. Therefore, the medical services provided during the course of the delivery of her baby were not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal 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: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) with Gammagard 45 grams intravenous (IV) every three weeks. Findings:  The physician reviewer found that patients with IgG subclass deficiency require more extensive diagnostic evaluation including the demonstration of a poor antibody response to vaccine challenge to support a diagnosis of a clinically significant IgG subclass deficiency. Subclass deficiencies need to be carefully interpreted taking into account the clinical status of the patient as well as the patients ability to produce specific antibodies in response to vaccines. A patient is considered to have a selective IgG subclass deficiency if blood levels of one or more of the IgG subclasses are below the normal range based on age, and the levels of other immunoglobulins (total IgG, IgA, and IgM) are normal or near normal. An additional subset of patients have normal levels of immunoglobulin and normal IgG subclasses, yet fail to develop protective antibody levels in response to infections with streptococcus pneumoniae or vaccines against the bacteria. Overall, this patients medical records do not support a diagnosis of specific antibody deficiency. The patient has tried and failed multiple antibiotics but there is a lack of documentation of an adequate vaccine challenge. There is insufficient medical documentation by the provider indicating the date of the Pneumovax vaccine and proper timing of pre- and post-vaccination titers following vaccine administration. There were two dates for pneumococcal antibody titers which were one year apart but there were no repeat antibody titers three to four weeks following vaccine. All told, the requested IVIG with Gammagard 45 grams IV every three weeks is not supported as medically necessary for treatment of this 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 allergy and immunology 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 an enrollee has requested authorization and coverage for Nutropin AQ Nuspin for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that The request for Nutropin AQ Nuspin is not medically necessary for treatment of the patients medical condition. The records support a diagnosis of idiopathic short stature, given the patients growth pattern and the normal growth factors. In October 2016, at the patients chronological age of six years and two months, the patients bone age was consistent with that of a five-year-old. The patients ongoing height velocity is consistent with children with short stature on the basis of constitution delay. The available laboratory data does not support a diagnosis of growth deficiency. As such, the patients growth pattern does not support GH therapy for this patient. Therefore, the requested medication 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox 200 unit injections, 155 units every three months for treatment of the enrollee, who has a history of chronic headaches. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The records indicate the patient has migraines and chronic daily headaches. However, the records do not describe in detail the features that would confirm the diagnosis of migraine, such as sensitivity to light and noise, or untreated headache duration of four hours or longer. Thus, chronic migraine cannot be confirmed in this patients case. Botox has been proven to be effective for chronic migraine, but is not supported for other headache types. Therefore, the requested Botox 200 unit injections, 155 units every three months 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Assay for evaluation of the enrollees melanoma. Findings:  The physician reviewer found there is a lack of support for the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, DecisionDx-Melanoma Assay was not likely to have been of greater benefit than other available modalities for evaluating this patient. Final Result: Three 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 reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block for treatment of the enrollees migraine. Findings:  2/3 of the physician reviewers found that occipital nerve block is one treatment option for a number of headache disorders. There have been some studies that are small that show benefit, especially for acute migraine treatment, and less data for treating chronic migraine. There is currently a paucity of data supporting occipital nerve blocks for chronic tension type headache. There is also a lack of clinical trials comparing the use of occipital nerve black against other standard therapies such as oral medications or Botox. In this patients case, there is inadequate documentation of the patients headache disorder to determine the type of headache disorder, which previous medications have been attempted, and the patients response to those medications. In addition, the procedure report states that nerve blocks were indicated due to significant pain in palpated muscles. Tenderness to palpation is seen in nearly all headache disorders, and is not an indication for any specific treatment. Further, the records do not document that the patient has previously used other preventive therapies such as tricyclic antidepressants, beta blockers, or Botox. Thus, the occipital nerve block was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service at issue was 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 neurology with a 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.Physician reviewer number two 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.Physician reviewer number three 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 whole exome sequencing for evaluation of the enrollees developmental delay. Findings:  The physician reviewer found that whole exome sequencing has been established as medically necessary for evaluation of the patients medical condition. Whole exome sequencing is clinically indicated for this patient given his complex neurologic phenotype and epilepsy. These multi-system findings increase the likelihood of an underlying single gene disorder which can be identified by whole exome sequencing. Whole exome sequencing is the most efficient way to identify such a genetic etiology given the large number of potential conditions which can cause developmental delay, autism spectrum disorders, and epilepsy. Moreover, the identification of a specific diagnosis in this patient may provide guidance for management in the future. A unifying diagnosis may also provide insight into helpful treatments for seizures in this patient. All told, the request for whole exome sequencing is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested testing 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 pediatrics and clinical genetics 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 vacuum assisted wound therapy for treatment of the enrollees foot ulcers. Findings:  2/3 of the physician reviewers found that negative wound pressure treatment (NWPT) is appropriate for this patients diabetic foot infection. There have been multiple peer reviewed studies supporting the effectiveness of NWPT for treatment of diabetic foot ulcers. A study by colleagues concluded, With emergent evacuation of abscess, early vascular intervention and appropriate debridement, NPWT can be a useful adjunct to the management of limb-threatening diabetic foot infections.  Another study by colleagues noted, NPWT appears to be as safe as and more efficacious than advanced moist wound therapy for the treatment of diabetic foot ulcers. As such, there has been consistent evidence of the superior benefits of this modality when compared to conventional treatments for foot ulcers. All told, the vacuum assisted wound therapy was likely to have been more efficacious than other methods for treating this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were 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 is board certified in plastic 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.Physician reviewer number two is board certified in plastic 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.Physician reviewer number three is board certified in plastic 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.