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 magnetic resonance imaging (MRI) of the chest for evaluation of the enrollees chest pain. Findings: The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. According to the medical literature, a recent chest x-ray and a nuclear medicine bone scan are necessary tests to perform prior to evaluation with chest MRI in the evaluation of chest wall pain. The medical records indicate a chest x-ray was performed in January 2016 and that a bone scan has not been performed. For the reasons provided, the requested MRI of the chest is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewers determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number two is board certified in diagnostic radiology 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 Yasmin for treatment of the enrollee, who reports a history of menstrual pain.Findings:  The physician reviewer found that there is no documentation that this patient has failed a trial of generic oral contraceptive pills that are specifically of the same formulation as Yasmin. Failing other oral contraceptive pills or generics of other pill formulations is not comparable.  There are many different formulations of oral contraceptive pills, each with a varying combination of estrogen and progestin. Specifically, Yasmin is drospirenone/ethinyl estradiol. In this case, the Health Plan has offered the patient several different alternatives to Yasmin which in and of themselves are appropriate equivalents. All oral contraceptive pills are acceptable to help treat patients presenting with the medical condition of dysmenorrhea. Oral contraceptive pills are typically used in conjunction with other management options, such as nonsteroidal anti-inflammatory medications, and can be very effective in controlling menses and the associated pain symptoms some women experience. Generic oral contraceptive pills approved by the U.S. Food and Drug Administration have been shown to be bioequivalent and pharmaceutically equivalent to the branded product and are interchangeable. In this patients case, the submitted records do not document that the patient has had a trial of a similar estrogen/progestin combination as a generic. The Health Plans list of alternative oral contraceptive pills are appropriate options. 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 obstetrics and gynecology 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 consultation for bariatric surgery (gastric sleeve) for treatment of the enrollees obesity. Findings:  The physician reviewer found that the submitted documentation and medical literature demonstrate the medical necessity of the requested consultation. This patient is morbidly obese and may benefit from a bariatric procedure. The patient has made effort at non-surgical weight loss with her provider in the past. In addition, the patient previously obtained a bariatric consultation in 2016, and an updated consultation would be appropriate. Final Result: The reviewer determined that the requested consultation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay for evaluation of the enrollees cutaneous melanoma.Findings:  Three physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a thin melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its use. Final Result: The 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: All three reviewers are board certified in dermatology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wheelchair power seat elevation installation and repair for treatment of the enrollee, who has been diagnosed with multiple sclerosis.Findings:  The physician reviewer found that this patient has a history of multiple sclerosis.  The records submitted for review, however, do not include any physical examinations or functional evaluations by a physician, physical therapist, occupational therapist or equivalent objective professional (i.e., not affiliated with the product vendor) documenting the relevant neuromusculoskeletal examination and functional ability findings. These assessments should be included for the proper prescription of durable medical equipment, and to establish the eligibility of this equipment, or accessories thereof. The available records in this case do not objectively establish that the requested power seat elevation device is necessary for independent transfers.  There are no indications that the patient could not independently transfer to a bed, chair, toilet or other surface without the equipment in question, including when using implements such as a sliding board after appropriate training. 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 physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Vemlidy for treatment of the enrollees hepatitis B virus.Findings:  The physician reviewer found that the guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. Entecavir has failed due to resistance. In comparison with tenofovir disoproxil fumarate, Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. Final Result: The reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollees homozygous 9p21. Findings:  Two physician reviewers found that the patient had dyslipidemia and reported homozygous for 9p21 associated with increased cardiovascular risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia 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), sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), myeloperoxidase, high sensitivity CRP, 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. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are no controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: Two physician 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Orap 1 mg, once daily for treatment delusions of parasitosis and prurigo nodularis. Findings:  The physician reviewer found that treatment with Orap is well established in the medical literature for treatment in this clinical setting. Orap is the standard of care first-line treatment for delusions of parasitosis. The patient tried treatment with generic pimozide and had poor control of symptoms and side effects. Thus, the continued use of Orap is clinically indicated for this patient to control disease and improve function. 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 physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for jaw joint device for treatment of the enrollees bilateral temporomandibular joint disorder (TMJ). Findings:  The physician reviewer found that there is sufficient support for the requested oral appliance in this clinical setting. The use of oral appliance, also referred to as splint therapy, has been shown to be effective in relieving signs and symptoms of TMJ disorders. Additionally, there is evidence in the literature showing that this oral appliance reduces the excessive loading on the joint and relaxes the masticatory muscles. It also supports the adaptation of the articular structures and regenerative processes in the joint. Final Result: The reviewer determined that the requested device 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 oral facial and maxillary 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 reimbursement for the substance abuse residential treatment services she received. Findings:  The physician reviewer found that the requirements for inpatient treatment for alcohol withdrawal and continuing substance abuse treatment rely on indications of severe withdrawal symptoms, comorbidities, and the presence of environmental instabilities, the duration of alcohol abuse, and the history of severe withdrawal symptoms such as delirium tremens or hallucinosis. The records provided for review document that this patient had a long history of alcohol abuse, but also had a successful extended period of abstinence, with evidence of good response to previous outpatient treatment. She was not suicidal, homicidal, or displaying severe withdrawal symptoms. She was a candidate for treatment in a less restrictive treatment setting and did not meet the criteria for residential detoxification and treatment. She was being actively treated for comorbidities and there is no indication that she was deteriorating. Medications prescribed for her bipolar disorder and PTSD could have been adequately and safely managed on an outpatient basis. All told, the substance abuse residential treatment services provided were not medically necessary for treatment of this patients behavioral health 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 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 ambulance transportation services and emergency department services he received. 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The ambulance transportation services and emergency department services received were not necessary for treatment of an emergency medical condition. Patients with potentially life-threatening causes of abdominal pain should be referred to the emergency department. Indications include unstable vital signs, signs of peritonitis on abdominal exam, and concern that the abdominal pain is from a life-threatening condition. In this case, the patient did not have acute distress, his vital signs were normal, there were no signs of peritonitis, and there was no concern for life-threatening condition. The patients symptoms resolved without therapeutic intervention. In sum, there is insufficient documentation in the medical record to support the presence of an emergency condition and necessity for emergent services. Given that the patients symptoms were not acute, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care she received. Findings:  The physician reviewer found that for this patient, there is no documentation of clinical findings that would have required monitored anesthesia care during her colonoscopy procedure. The patient had an American Society of Anesthesiology (ASA) preoperative physical status classification score of 2, which is deemed as a low risk. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research. Given a low preoperative physical status classification score, this patient did not require monitored anesthesia care. All told, the monitored anesthesia care received was not medically necessary for treatment of the patient during her colonoscopy. Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary for the treatment of this patient.  Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 peripheral bone density scan she received. Findings:  Two physician reviewers found that it is recommended that patients with anorexia nervosa should be assessed for bone density by dual-energy x-ray absorptiometry (DEXA) at diagnosis and at periodic intervals thereafter. Whereas both trabecular and cortical bone sites are affected in anorexia nervosa, the data overall suggest that in females, trabecular bone (such as the lumbar spine) are affected more severely than sites of predominantly cortical bone (such as the hip and whole body). This has been attributed to the profound estrogen deficiency that typically accompanies this disorder in addition to other hormonal and nutritional deficiencies. Therefore, the measurement of the lumbar spine is the most important. The bone density of the hip reflects the density of cortical bone. Medical management is based on the measurement of these two sites, which is the standard test, and not of the peripheral study that is done at the distal radius of the forearm. Thus, the peripheral bone density scan performed was not likely to be more effective than other modalities for evaluating this patient. Final Result: Two 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 reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin growth hormone (GH) therapy. Findings:  The physician reviewer found that there is insufficient information to support the medical necessity of GH in this patients case. Although the patients height prior to treatment was more than two SDs below the mean for age and gender, there is no record of her bone age, adult height prediction, or that all other causes of short stature have been ruled out. Thus, a diagnosis of idiopathic short stature with poor adult height prediction cannot be confirmed based on the information provided. Given these findings, the requested Nutropin GH therapy 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 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.