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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (gene expression profiling), Decision Dx-UM for evaluation of his uveal melanoma.  Findings:  Three physician reviewers found that The gene test (gene expression profiling), Decision Dx-UM performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cytogenetic testing of choroidal melanoma is an established method of laboratory evaluation of melanomas. The medical literature supports the routine use of this test for patients with uveal melanoma. The testing at issue allows for adjustment of the patients monitoring and surveillance based on the genetic profile of the tumor. In addition, the counseling and eligibility for clinical treatment trials is based heavily on the tumor genetic profile. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  All three 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: Three physician reviewers are board certified in ophthalmology and is 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 lorazepam once daily for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Progress notes  indicate good results and efficacy with lorazepam.  The patient was tried on Lunesta, which did not have a lasting benefit for his insomnia. He reports having been on lorazepam 1 mg for 20 years. Given its ongoing efficacy, undergoing trials with formulary medications is not indicated. The current medical evidence supports the requested medication in this clinical setting.  All told, lorazepam once daily 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 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: An enrollee has requested reimbursement for residential treatment center services provided for treatment of his behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patients post-acute withdrawal symptoms were noted to be anxiety and agitation.  There was no evidence of danger to self or others.  There was no evidence of emotional, behavioral, cognitive, or impulsive symptoms that would impede recovery.  He was not manic or psychotic. He was anxious, but not on any psychotropic medications.  He was stable on Naltrexone and tolerating it well.  He was psychiatrically stable, and his hypertension did not require a residential setting.  He was motivated and completing his assignments. He was meeting with his chosen sponsor. His home environment was stable and supportive.  Based on the records, this patient no longer required 24 hour per day, seven day per week residential setting and could have stepped down to an ambulatory level of care. All told, residential treatment center services provided were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for the inpatient mental health services for treatment of the enrollee's behavioral health issues. Findings: The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on the CALOCUS, the patient remained at significant risk of harm (score 3) with a recent suicide attempt by overdosing on 500 mg of melatonin, but the notes stated that the patient denied any suicidal ideation during treatment. The patients functional status demonstrated moderate impairment (score 3) given the patients conflictual relationships with her parents and peers. The patient had moderate co-morbidity with OCD, trichotillomania, and depression (score 3). The patients recovery environment was moderately stressful (score 3) with transitioning to high school and limited peer support, and her parents were noted to be supportive (score 2). The patient had equivocal resiliency and response to treatment (score 3) considering the patients practice of non-suicidal self-injury behavior such as cutting to deal with stressors. The patients acceptance and engagement in treatment was constructive (score 2) since the patient was described as cooperative and compliant with treatment recommendations from her providers. This gives the patient a composite score of 19, which indicates the patient continued to require treatment for her OCD and trichotillomania, but she could be treated in a less restrictive environment such as an intensive outpatient program (IOP) or partial hospitalization program (PHP). However, although the patient could have been treated in a lower level of care, it is not standard of care to discharge a patient that requires IOP or PHP services without follow-up in place. Discharging the patient on a Sunday after admission on a Friday would not be proper care. Arranging outpatient follow-up during the weekend is not standard care as most PHP and IOP facilities are closed. Therefore, without proper follow-up in place, it would not have been safe to discharge the patient, and it was medically necessary to keep the patient at which time IOP or PHP could be arranged. Thus, the inpatient mental health services provided were medically necessary for treatment of this patients behavioral health issues but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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 genetic testing performed for evaluation of the enrollees behavior condition. Findings: The physician reviewer found that medication and psychotherapy have strong evidence based support for their use in this clinical setting. Conversely, it is unclear if genetic testing has been used in an evidence based manner. As such, the evidence based literature does not support the use of pharmacogenomic testing in cases like this one. Kirchheiner and colleagues note the following, there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice. Moreover, the documentation provided does not indicate specific medication doses used, length of medication trials or combinations of medications tried and failed.  Additionally, the records do not indicate whether or not this patient has had cognitive behavioral therapy (CBT) for her generalized anxiety disorder diagnosis. CBT has proven efficacy and is considered first line therapy for treatment of this patients medical condition.  Accordingly, the genetic testing performed was not likely to have been more effective than the standard methods of evaluating this patients medical condition.Final Result: All three physician 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: All three physician reviewers are board certified in psychiatry and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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 services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with abdominal pain. Although his abdominal pain was not acute in onset, he also reported numerous episodes of vomiting and diarrhea for the past three to four days. His vital signs showed a borderline tachycardia, prompting laboratory testing which revealed a mild acidosis, consistent with his clinical symptoms. The patients EKG was also abnormal, prompting cardiac biomarker testing to rule out acute coronary syndrome, which may also present as epigastric pain with nausea and vomiting. Based on the clinical documentation submitted for review, the patient received emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that based on the documentation submitted for review, the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. During the dates in dispute, the patient was no longer at risk for withdrawals, she was status post detoxification and treated with Naltrexone.  She was medically and psychiatrically stable, and she was highly motivated and participating in all factors of her treatment plan. In individual therapy she was dealing with issues such as self-esteem, improving boundaries, and guilt. In family sessions, she and her husband were working towards improving communication. These concerns could have been addressed at a lower level of care such as outpatient treatment. The patient no longer required the structure of the residential setting and could have been stepped down to a lower level of care. Thus, the services at issue were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: An enrollee has requested authorization and coverage for blood test for free testosterone for evaluation of his history of decreased libido.Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. While measurement of a total morning testosterone level is a rather sensitive and specific test for evaluating hypogonadism, a free testosterone level tends to be less reliable. Most guidelines recommend serum total testosterone measurement as the initial test to evaluate male hypogonadism, and reserving free testosterone assessment for men with suspected sex hormone binding globulin abnormalities or total testosterone near the lower limit of normal. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dl.  While this patient is experiencing symptoms, which he attributes to hypogonadism, his symptoms are rather nonspecific and may be multifactorial in nature. The patients total testosterone level is within normal limits. As such, the measurement of free testosterone level will have limited utility and may in fact be misleading. In sum, the requested blood test for free testosterone is not medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test performed for evaluation of her pregnancy at advanced maternal age.  Findings:  Three physician reviewers found that the American College of Obstetrics and Gynecology (ACOG) recommends patients undergo non-invasive prenatal testing, especially in the high risk setting. ACOG endorses the discussion and use of non-invasive prenatal testing in this patient population. In this case, the gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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 reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX Melanoma gene assay provided for evaluation of her melanoma.  Findings: Three physician reviewers found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on the Decision DX Melanoma gene assay has not made it part of routine analysis after sentinel lymph node biopsy.  There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, Decision DX Melanoma gene assay provided was not likely to have been more beneficial than other available methods of 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: Three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services from Hoag Neurobehavioral Health, LLC for treatment of her alcohol use disorder.Findings: The physician reviewer found that The residential treatment center (RTC) services provided by Hoag Neurobehavioral Health, LLC were not medically necessary for treatment of this patients behavioral health condition. There was no evidence of post-acute withdrawal symptoms, nor was there any evidence of danger to self or others. The patients alcohol related medical conditions could have been monitored on an outpatient basis and she was psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. She was motivated and appeared to be working the program. She demonstrated insight and motivation and she had a stable, sober support network. The issues she was working on in individual psychotherapy could have continued in an ambulatory based treatment. Relapse prevention could have continued at a lower level of care with the combination of a 12-step program, counseling, and maintaining contact with her sponsor. Thus, the services at issue were not medically necessary.Final Review: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 Epclusa once daily for 12 weeks for treatment for his hepatitis C virus.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America all patients with chronic Hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies to all patients, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 4 patients, based on the ASTRAL-1 trial, which showed 100% cure rate. For these reasons, Epclusa once daily for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.  Final Results:  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.