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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for a Humira Pen Injection kit. Current medical literature supports the use of Humira for the treatment of psoriasis and psoriatic arthritis (PsA). Anti-TNF (anti-tumor necrosis factor) agents have been proven very effective for PsA and are disease modifying agents. They prevent progression of disease, erosions and disability and are thus the preferred agent for PsA. In regards to treatment of psoriatic arthritis and TNF inhibitor (TNFi), there are multiple studies and international guidelines recommending their use. The recent recommendations involved a systematic literature review of 25 papers and 12 abstracts, and this review confirmed the efficacy of TNFi in PsA. In this case, given the patients age, sex and desire for pregnancy, methotrexate and leflunomide would be contraindicated. Both of these agents are pregnancy category X per FDA labeling. The guidelines and medical literature support Humira use for the treatment of psoriasis and psoriatic arthritis. Accordingly, the request for Humira Pen Injection kit is medically necessary for treatment of the patients medical condition.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 allergy and immunology and internal medicine, with subspecialty 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 a consultation with a podiatrist. The submitted documentation does not support that the requested service is medically necessary. According to Fields and colleagues, foot pain is commonly reported in adult patients. A correct diagnosis is made through the patient history, physical examination of the foot and ankle, as well as imaging studies. The history of the patients pain, in this case, is not well documented. There is no documentation of an initial history of the presenting complaint or of any physical examination documenting the location of pain. There is no documentation of any acute red flag findings. There is no documentation of a response to a trial of conservative care (e.g. non-steroidal anti-inflammatory drugs, heel support, and a home exercise program). Under these circumstances, the requested consultation with a podiatrist is not medically necessary for the treatment of the patient's medical condition.Final Result: The reviewer determined that the requested service 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 family 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 authorization and coverage for the gammaCore vagus nerve stimulator. In the peer-reviewed medical literature, Straube and colleagues noted that treatment of chronic migraine by vagal nerve stimulator at 1 Hz was safe and effective. In this randomized monocentric clinical trial, the authors found that the mean reduction of headache days after 12 weeks of treatment exceeded that reported for other nerve stimulating procedures. However, the treatment was not compared for efficacy to standard medical therapies for chronic headache prophylaxis. The available data lacks large controlled placebo controlled studies demonstrating superior efficacy when compared to the current standard of care for chronic migraine headaches. Accordingly, the requested gammaCore vagus nerve stimulator is not likely to be more beneficial for treatment of this patients medical condition than standard available therapies. One reviewer found that the requested gammaCore vagus nerve stimulator is likely to be more beneficial for treatment of this patients medical condition than standard available therapies.Final Result: Two of the three reviewers determined that the requested services are 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 overturned.Credentials/Qualifications:  One reviewer is board certified in neurology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 40-year-old male enrollee has requested reimbursement for the bilateral radiofrequency ablation (RFA) of the thoracic spine (nerve block). Findings:  The physician reviewer found that there  is limited evidence in the literature supporting an indication for thoracic RFA in well selected patients. However, in the documentation available for review, the provider did not document a pain diary or include a procedure note for the medial branch block. The literature indicates that a diagnostic medial branch block should be performed prior to RFA with use of a pain diary for the day to verify when the local anesthetic wore off. In addition, the medial branch block should be performed using either lidocaine or bupivacaine, and no sedation. This patient reportedly obtained pain relief for longer period of time than is expected with local anesthetic. Moreover, there are no physical examination findings supporting facet joint pain at the requested levels. All told, the bilateral RFA of the thoracic spine (nerve block) provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the bilateral RFA of the thoracic spine (nerve block) provided was not 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 services at issue were 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:  One reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  One Reviewer is board certified in anesthesiology with subspecialty certification in pain management 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. This patient has a reported history of hyperlipidemia but no other risk factors for cardiovascular disease. She is being treated with atorvastatin 20 mg and is well below goal low density lipoprotein (LDL) cholesterol. In addition, she has a good high density lipoprotein (HDL). Moreover, the current guidelines do not suggest that advanced lipid profile monitoring, including LDL particle number or size, would provide substantially better cardiovascular risk prediction than standard risk profiling. Overall, the consensus remains that advanced lipid testing results should not alter a patients treatment in this clinical setting. For these reasons, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for extracorporeal shock wave therapy.Findings:  Three physician reviewers found that the current medical evidence has not established the superior effectiveness of the services at issue. There is some evidence that low intensity shock wave therapy to the penis may be helpful for patients with erectile dysfunction. The theory behind this treatment is that it may increase vascular flow to the penis by stimulating vascular growth. At this time, there is a lack of randomized studies showing that this treatment option is superior to conventional therapy. Furthermore, the records do not document that this patient was evaluated for vasculogenic erectile dysfunction. Thus, extracorporeal shock wave therapy was not likely to have been of greater benefit than other available treatment modalities. Final Result: The reviewers determined that the services at issue were not likely to have been 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 reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy. There is a paucity of medical literature demonstrating that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer (Allen, et al). Further, there is a paucity of data showing that treatment with proton techniques improve sparing of the skin, heart, and/or lungs compared to standard photon techniques. Consensus group guidelines, including those from the National Comprehensive Cancer Network (NCCN), do not support the use of proton therapy in this setting. In the majority of cases, intensity modulated radiation or three-dimensional conformal techniques with photons are able to achieve an acceptable cardiac and lung dosing in left-sided breast cancer. For these reasons, proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than standard therapy. Findings:  Three physician reviewers found proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than standard therapy.Final Result: The reviewers determined that proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for orthodontic treatment. The submitted documentation supports that the requested services are dentally necessary. The Handicapping Labio-Lingual Deviation (HLD) Index is one of four commonly used American and European orthodontic treatment need indices. These indices were devised to minimize the subjectivity associated with the diagnosis, referral and complexity assessment of malocclusion. The HLD Index, as with other indices, has a score component to determine orthodontic need as well as conditions that automatically qualify for dental necessity. One automatic qualifier is an overjet greater than 9mm. When using the HLD Index, if one of the automatic qualifiers is present, the examiner is to stop scoring. In this case, the submitted records show that an overjet of 11mm is present, which automatically qualifies treatment as dentally necessary. The records also show a retrognathic mandible with the lower anterior teeth positioned palatally to the upper incisors, which would be at risk for impinging on the palatal tissue. The orthodontic narrative describes the bite as presenting with lower incisors contacting the upper palatal tissue, which would be an automatic qualifier for dental necessity as well, but photographs neither confirm nor refute this. With one condition of excessive overjet confirmed as present, and a second qualifier of occlusion into the palatal tissues described, the submitted documentation supports that the requested services are dentally necessary. Accordingly, the requested orthodontic treatment is dentally necessary.Final Result: The reviewer determined that the requested services are dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in general dentistry 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 Synvisc injections. Findings:  The physician reviewer found that According to the current practice guidelines for knee arthritis from the American Academy of Orthopaedic Surgeons (AAOS), hyaluronic acid is no longer a recommended treatment for knee arthritis (Brown, G.). The current large studies have not shown a clinical benefit for this intervention. While there are some smaller studies with conflicting evidence, when the current medical evidence is pooled together, there is no proven efficacy for the requested intervention. The current medical literature indicates that viscosupplementation is no more effective than a placebo in large studies. Under these circumstances, the requested Synvisc injections are not medically necessary to treat the patients medical condition.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 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: Urgent Care
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for hospital services. The Health Plan has denied this request indicating that the requested services were not emergent/urgent and were not authorized. Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. In this case, the patient presented with symptoms that were not acute in onset but had been present for 10 days. The patient's symptoms were not sudden, acute, or severe. She denied any severe symptoms such as fever or shortness of breath. The patients treatment plan included over-the-counter medication. A lack of immediate medical attention would not have placed her health in serious jeopardy, nor was she at risk for serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The patient did not have an emergency medical condition as defined by California law. Therefore, the patient did not receive emergency medical services on the said date. Final Result: The reviewer determined that the services at issue were not emergent or urgent for treatment of the patients medical condition. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decipher test.Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. Therefore, Decipher test was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is requesting authorization and coverage for direct applied behavior analysis (ABA) 1:1 10 hours per week, two hours supervision/month, six hours treatment planning/month and two hours parent training/month. The patient is diagnosed with autism spectrum disorder, mild intellectual disability and an unspecified communication disorder. While the patient has made progress and has had a history of receiving ABA services previously, to draw the conclusion that the gains were due to outpatient therapy are purely correlational. There is no evidence base for individuals benefiting from outpatient therapy with a diagnosis of autism with comorbid intellectual disability, while there is an abundance of research on the effectiveness of ABA therapy for these same individuals. The psychologist who reaffirmed the patients autism diagnosis, recommended ABA therapy but did not recommend traditional outpatient therapy. While the patient was receiving outpatient therapy, they were also receiving ABA therapy, thus progress on any goals are likely attributed to ABA therapy. In this case, 10 hours of ABA per week are considered focused intervention, with an emphasis on treating specific areas for an individual versus a broad treatment, attempting to ameliorate most, if not all, autism symptoms simultaneously. The providers request is well within the BACB guidelines, as assessment and treatment methods are clearly outlined. ABA is the most evidence-based treatment for the patient on the autism spectrum. Therefore, these services are medically necessary, and the Health Plans decision should be overturned.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 psychology 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.