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 oxycodone 15 mg five tablets per day for treatment of the enrollees neck and back pain. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication and several requirements for opioid prescribing have not been documented to be done. Thus, the need to use them as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient was recently taking 112.5 MME per day. However, there is a lack of medical evidence based rationale for this high of MME per day. Also, the records suggest that tolerance has taken place since the patient was started on narcotics and there is also the possibility of opioid induced hyperalgesia. All told, the requested authorization and coverage for oxycodone 15 mg five tablets per day, is not 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier tablet for 12 weeks for treatment of the enrollees chronic hepatitis C virus. Findings: The physician reviewer found that 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 non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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 the medication Xeljanz for treatment of the enrollees rheumatoid arthritis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested medication.  Per evidenced-based, peer-reviewed medical guidelines, Xeljanz may be recommended as a second line treatment for rheumatoid arthritis. While the records indicate this patient has tried and failed treatment with Humira, the records do not document an adequate trial and failure with Enbrel. The Health Plans requirement that the patient try Enbrel prior to treatment with Xeljanz is medically appropriate. On the basis of the available medical documentation and peer reviewed guidelines, the medication Xeljanz is not 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Trulicity Pen injections for treatment of the enrollees diabetes mellitus. Findings:  The physician reviewer found that Trulicity is a member of the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss and low incidence of hypoglycemia. While Trulicity, and other members of this class of medications, may be an effective treatment option, metformin is considered a proven first-line treatment for type 2 diabetes. The patient states that she does not want to take metformin because of her history of primary biliary cirrhosis. However, following a thorough literature review, there was a lack of evidence that metformin is associated with worsening liver function in patients with primary biliary cirrhosis. Since the patient has not demonstrated an adequate trial of formulary alternative metformin, the requested Trulicity Pen injections are not supported as medically necessary. 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility level of care after completion of chemotherapy for treatment of the enrollees malignant neoplasm of the breast. Findings:  The physician reviewer found that the patient had nausea and extreme vertigo. She remained at risk for secondary complications of immobility such as pressure ulcers and contractures. She was participating in the treatments being provided and continued to require hands on assistance when ambulating and was not consistently ambulating household distances. The patient had previously been able to function independently. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care requested. As such, continued SNF level care was and is medically necessary for treatment of the patients medical condition. The reviewer determined that the services at issue were and 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An male enrollee has requested reimbursement for the genetic tests on two dates of service. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, researchers noted genetic testing of APOE may be considered in cases where there is concern for inheritance and risk of Alzheimers among children. Studies reported that genetic testing may be considered for determination of future risk assessment of children but does not provide treatment outcome guidance for the carrier. This patients records do not indicate concern for inheritance or that children are concerned of genetic risk of Alzheimers disease. As no risk of inheritance is noted, the genetic tests performed on the two dates of service were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. Physician reviewers number two and number three are board certified in neurology and are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Rasuvo for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The America College of Rheumatologys 2015 guidelines for the treatment of rheumatoid arthritis (RA) state The panel also voted that methotrexate (MTX) should be the preferred initial disease-modifying antirheumatic drugs (DMARD) for most early RA patients. For patients with established RA, the American College of Rheumatology continues to recommend methotrexate for all disease activity levels in combination with other biologic agents. In this case, the patient has flaring rheumatoid arthritis which has responded partially to Rasuvo and Xeljanz.  She has failed multiple other DMARDs.  The appeal letter states that the patient has had side effects to methotrexate and Otrexup.  However, the medical records fail to document a trial of either medication or elaborate on what issues/side effects she was having with these medications.  The medical records fail to demonstrate an adequate trial of oral methotrexate and injectable methotrexate with failure of therapy, intolerance or contraindication. As such, the requested medication Rasuvo 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services provided for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The determination of level of care required for adequate treatment of persistent eating disorders cannot be made on the basis of weight alone, and rapid weight gain is also not a positive prognostic indicator. Per the records, this patient continued to have high levels of significant comorbidity, intrusive misperceptions, and preoccupations which presented a risk of relapse absent the intensive treatment of partial hospitalization. She continued to receive multiple psychotropic medications, including two atypical antipsychotic medications. Thus, there was an increased risk of adverse side effects from these medications. The current medical evidence supports partial hospitalization program level of care in this clinical setting. All told, partial hospitalization program services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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 LINX procedure for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: Three physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment  surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Given these findings, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for laser hair removal. Findings:  The physician reviewer found that the requested services are medically necessary in this clinical setting. The providers have documented that this patient has folliculitis as well as gender dysphoria.  Folliculitis is a condition that typically affects the male gender with curly hair and who shave too closely to the skin. For this condition, electrolysis/laser hair removal are an effective treatment option. Moreover, the medical literature supports hair removal lasers for treatment and management of folliculitis. In this patients case, laser hair removal is medically necessary for treatment of this patients recalcitrant folliculitis. With regard to whether the requested services are considered reconstructive in nature, recalcitrant folliculitis in a female is an abnormal body structure. Recalcitrant folliculitis is a condition that is congenital and generally occurs in people with curly hair. The highly curved hairs grow back into the skin and causes inflammation. The documentation from the treating providers note that this patient suffers from this condition. As such, the requested laser hair removal can provide more than a minimal improvement in the appearance of this patient and create as normal an appearance as possible. For these reasons, laser hair removal in this patients case is reconstructive in nature and not cosmetic. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services received. 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. The medical services provided were not necessary for treatment of an emergency medical condition. The patient was discharged in stable condition from the hospital prior to the dates in question. For the dates of service in question, the patient received laboratory work-up, repeat CT, complete vaccinations for hepatitis A and B, shoulder x-rays, upper endoscopy and multiple office visits. There was no emergent medical condition noted in the records submitted for review during the dates in dispute. Based on the clinical documentation submitted for review, the services provided between the dates of service in question were not 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 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.