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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing performed for evaluation of the enrollee who has a history of breast cancer.Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  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 inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are a variety of nonrandomized studies exploring the value of molecular profiling but none of which have been convincing as to the efficacy of these analyses. While Doroshow and colleagues noted these ongoing studies, they also reported serious limitations of such studies. This viewpoint was also expressed in an editorial by West in 2016. Moreover, a randomized trial by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus the oncologists clinical judgment. Finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. Accordingly, the FoundationOne testing performed was not likely to have been superior over the standard options of evaluating this patients medical condition. 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: All three physician 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 authorization and coverage for Epclusa for treatment of the enrollees hepatitis C. 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 Zepatier (with ribavirin when NS5A resistance is found) and Epclusa. However, although the U.S. Food and Drug Administration approved prescribing information for Zepatier reports that liver enzymes may rise with Zepatier, this is typically asymptomatic and resolves with ongoing or completion of therapy, and discontinuation could be considered if ALT levels remain persistently greater than 10 times the upper limit of normal or there are concurrent signs or symptoms of liver inflammation or increasing conjugated bilirubin, alkaline phosphatase, or international normalized ratio. This patient has an elevation in ALT, but these criteria are not met.  Therefore, there is no medical contraindication to Zepatier in this case. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, although treatment of hepatitis C is medically necessary in this case, Epclusa is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing performed on 2/1/17 for evaluation of the enrollee, who has a history of elevated blood pressure and cholesterol.Findings:  Two physician reviewers found that in this circumstance, guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2 (Lp-PLA2), myeloperoxidase, sub-classifications of low density lipoprotein, high density lipoprotein, subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results are lacking. Final Result: Two reviewers determined that the testing 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are an 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the special wound product called xenograft that was used for surgery performed for treatment of the enrollees burns to her upper right arm.Findings: The three physician reviewers found that xenografting in the use of burn wound care is not investigational. The available literature concludes that xenografting provides rapid wound closure and quicker healing time. Xenograft has been used as a wound dressing as far back as 1973. A review by Banyard and colleagues note that Evidence indicates that skin replacement requires a dermal layer or structural components that facilitate the generation of a dermal layer to optimize healing and reduce scarring and contraction. As a result, a number of synthetic, natural, cellular, and acellular products have been developed for various uses, including the treatment of diabetic, chronic, and burn wounds.  Moreover, the evidence also shows that the addition of this wound dressing not only results in quicker healing time but can serve to prevent the need for emergency surgery. Xenografting is an effective tool in the standard of care treatment of partial thickness and full thickness burns. There is ample support in the medical literature for the use of porcine xenografts as temporary coverage of wounds. In summary, the special wound product called xenograft that was used on the surgery performed on was likely to be more beneficial to this patient with respect to her burn treatment than other treatment options.Final Result: All three physician 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: All three physician reviewers are board certified in plastic surgery 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: An enrollee has requested authorization and coverage for bilateral Orthovisc injections for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the current evidence-based medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis who have failed conservative treatment.  Per the medical evidence, there is no maximum amount of injections established by high quality scientific evidence. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. He has undergone multiple prior series of viscosupplementation series with positive results documented in terms of significant pain reduction and improved function for at least six months. He is currently reporting progressive worsening of his knee pain and difficulty in ambulation. Viscosupplementation has been requested based on significant prior benefit and to delay total knee replacement. There is sufficient support for the requested services in this clinical setting.  All told, the requested bilateral Orthovisc injections are medically necessary for the treatment of this patient. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees osteoarthritis of the right knee. Findings: The physician reviewer found that the evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. A meta-analysis conducted by Bannuru and colleagues found that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Moreover, a study performed by Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54 month follow up period. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this patients case, the clinical examination findings were consistent with imaging evidence of right knee medial compartment osteoarthritis. The record indicates that prior corticosteroid injections have not provided relief of symptoms. However, it was noted that prior viscosupplementation injections have provided significant pain relief for up to one year. The provider had recommended Orthovisc injections to delay total knee replacement. Therefore, Orthovisc injections for treatment of this patients medical condition is medically necessary.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a manual wheelchair for treatment of the enrollee, who has a history of severely short stature. Findings:  The physician reviewer found that the records forwarded for review do not support the medical necessity for the requested equipment. The patient has multiple impairments precluding functional ambulation and functional propulsion of a manual wheelchair, including short limbs and brachydactyly. The patient uses a power wheelchair for independent mobility. A formal mobility assessment, which is an appropriate evaluation in this situation, verified this mobility status.  A manual wheelchair that the patient is not able to self-propel is not medically necessary, even if used as a backup.  She would be dependent on others for mobility.  The standard of care would be to arrange transportation that is capable of transporting her in her usual mobility device so that she can be independent after she arrives at her destination.  If her power wheelchair is inoperable, her mobility device vendor should supply her with an appropriate backup wheelchair for maintaining her independent mobility (i.e., a replacement power wheelchair) while her wheelchair is being serviced.  A plan and training of caregiver(s) should be in place to effectuate egress from the home in the event of an emergency should the power wheelchairs power functions be inoperable. Therefore, the requested manual wheelchair is not medically necessary for 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 physical medicine and rehabilitation 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 a computed tomography (CT) scan for evaluation of the enrollees chest discomfort. Findings:  The 3 physician reviewers found that based on the records provided the patient is female with some coronary risk, atypical chest discomfort, a normal cardiovascular physical exam, a normal electrocardiogram and a normal troponin valve. In this circumstance if additional cardiac evaluation is indicated, a form of stress testing would be most appropriate and considered the standard of care. A coronary CT scan provides an assessment of coronary anatomy without any evaluation of the functional significance of any potential stenosis identified, thus not evaluating for a cardiac cause of the patients atypical chest pain. Also, the proposed CT scan does not assess for other potential mechanisms of coronary ischemia such as vasospasm or small vessel coronary disease, both of which could be assessed with stress testing. Coronary CT scanning is not recommended in this clinical setting. Moreover, guidelines for the management of cardiac risk do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning for calcium scoring. As such, the request for a CT scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested service is 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 cardiovascular disease 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 cardiovascular disease 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 cardiovascular disease 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 once daily for 12 weeks for treatment of her hepatitis C virus.Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication. 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 applies regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed PEG-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on the C-EDGE TE clinical trial results showing a 94% cure rate when NS5A resistance is absent (Kwo, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier 50/100 mg, once daily, 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: 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 has 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 the sudden onset of severe abdominal pain with a fever and nausea. On arrival, she was found to be febrile and tachycardic. This prompted assessment for sepsis, evaluation for urinary tract infection, a search for acute surgical abdominal pathology, and treatment for systemic inflammatory response syndrome with intravenous fluids. Once an acute surgical emergency was ruled out and the patients vital signs had normalized, she was discharged. Based on the clinical documentation submitted for review, the patient received emergency medical services. 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.