Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services. 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 provided were necessary for treatment of an emergency medical condition. In this case, the patient experienced the sudden onset of headache and dizziness while driving. He was driving erratically, of which he was unaware, when he was pulled over by the highway patrol. The highway patrol called 911. The paramedics found the patient to be tachycardic. He was administered an antiemetic and an EKG was obtained. In the emergency department, the patient was evaluated for a brain hemorrhage as well as acute coronary syndrome. Final Result: The reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Strattera with a dosage of 40 mg 2 x daily for treatment of her attention and concentration deficit following cerebral infarction. Findings:  The physician reviewer found that the patient presents with poor concentration and inattention following cerebral infarction is more consistent with the diagnosis of major or mild vascular neurocognitive disorder. The patient has a symptom burden similar to attention deficit hyperactivity disorder (ADHD). Strattera is a selective norepinephrine reuptake inhibitor used to treat ADHD. Pharmacotherapy is the first-line treatment for ADHD. The patient has no evidence of arrhythmia or elevated blood pressure. The medication has been conservatively dosed, well-tolerated and reportedly efficacious with no adverse drug response. Thus, continued treatment with Strattera is safe, appropriate and consistent with good medical practice. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested automated nerve conduction testing for evaluation of her history of spinal stenosis, spondylolisthesis, sciatica, osteoarthritis and intervertebral disc degeneration.  Findings:  Three physician reviewers found that the patient had undergone spine surgery. During the surgery, the surgeon requested automated nerve conduction testing. The records indicate that the patient underwent spine surgery with monitoring of nerve root function to insure that the integrity of nerve function was maintained.  Peer reviewed literature shows support of this monitoring in spine surgery. Researchers have noted that intraoperative neurophysiological monitoring and mapping represent an effective method of identifying and monitoring, in real time, the functional integrity of both the spinal cord and the nerve roots. Moreover, there was noted consensus by medical groups that this method of monitoring improved safety of the surgical procedure and reduced complication rates. 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: Reviewers 1, 2 and 3 are board certified in neurology 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 one pair diabetic mellitus shoes and two insoles for treatment of the enrollee who has a history of diabetes and high blood pressure. Findings: The physician reviewer found that the requested diabetic shoes and insoles are medically necessary in this clinical setting. The submitted records document that this patient has retinopathy, status post retinal detachment and blindness in one eye. The patient reported that he walks a lot making him a high risk for developing ulcers. Foot ulcers can be prevented with the proper shoes. The importance for diabetic shoes in the prevention of foot ulcers is well documented in the medical literature. A good foot examination, including neurologic examination of the foot, is part of the diabetes evaluation and physical examination.  Visual impairment is an indication for diabetic shoes per guidelines of the American Diabetes Association. Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of her invasive ductal carcinoma. Findings:  The physician reviewer found that there is currently a lack of medical literature to support treatment with proton beam radiation over conventional radiation therapy techniques for breast cancer. Inadequate data is available to suggest that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated radiation therapy (IMRT) with photon techniques. In addition, consensus group guidelines from the National Comprehensive Cancer Network (NCCN) do not support the use of proton therapy in this clinical setting. In the majority of cases, IMRT or three-dimensional (3D) conformal techniques with photons is able to achieve an acceptable cardiac and lung doses in patients with left-sided breast cancer. 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 radiation oncology 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 Victoza for treatment of her diabetes mellitus and polycystic ovarian syndrome (PCOS). Findings:  The physician reviewer found that Victoza is a member of  the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors for patients with diabetes. In 2014, the U.S. Food and Drug Administration (FDA) approved liraglutide as the first GLP-1 analogue for use as a weight loss aid in obese adults and overweight adults with at least one weight related co-morbidity. In addition, recent interventions have demonstrated significant improvement of weight-related measures in obese women with PCOS. The records provided for review document that this patient has responded well to Victoza in the past with regard to weight loss, glycemic control, and symptoms from her PCOS, including acne and hirsutism. 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided.  Findings:  The physician reviewer found that according to the American Psychiatric Association Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, the patients alcoholism was central to the daily routine and contributed to significant impairment across multiple domains of functionality. The patient had a history of abuse and co-occurring anxiety and depressive symptoms and had problematic family dynamics and co-dependent personality traits that fueled recurrent poor relationships. The patient had not consolidated the treatment gains necessary to succeed in the outpatient setting.  The patient was irritable, depressed, dysphoric and has urges to consume alcohol and negative side effects from an anti-craving medication, naltrexone. The patient has remained actively engaged in treatment. The services at issue were and are safe, appropriate and consistent with good medical practice. Additionally, the services at issue were and are reasonably expected to improve her condition and prevent a more serious episode of illness. Final Result: The reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  the reviewer is board certified in 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 authorization and coverage for atovaquone 750 mg/5 mL oral suspension. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting atovaquone in this clinical setting. The patient presents for treatment of Babesia duncani infection. However, this patient has no evidence for Babesia infection. Babesia infection is an acute illness with fever, anemia, and fatigue, and is not a chronic infection. The primary organism is Babesia microti and duncani. Moreover, there is no evidence for Rocky Mountain spotted fever. The treatment for Babesia duncani is clindamycin and quinidine. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the reviewer is board certified in internal medicine 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 Mekinist (trametinib) dimethyl sulfoxide tablet 0.5 mg (base equivalent), oral. Findings:  The physician reviewer found that the medical literature indicates that radiation therapy may cause an increased risk of secondary malignant neoplasms. Given this patients genetic predisposition for additional cancers, radiation therapy is not recommended for this three-year-old patient. Furthermore, radiation therapy would risk significant neuropsychiatric and educational abilities. The medical records show that this patient has already received the standard therapy for optic glioma and this was not effective. There is no standard of care for progression of optic glioma tumors. The records note that treatment through a clinical trial is currently unavailable. As such, his treatment options are very limited. The patient has a intolerance to standard chemotherapy. 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 pediatrics with sub-specialty certification in pediatric hematology and oncology 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 breast removal surgery for treatment of her breast pain and discomfort.  Findings:  The physician reviewer found that The request for breast removal surgery is not medically necessary for treatment of the patients medical condition. In this case, the patient does not have evidence of cancer in the reconstructed breast within the TRAM flap. Further, there is a lack of medical literature supporting the removal of TRAM flap reconstruction for chronic pain following the initial surgery. The pain that the patient experiences in the right chest appears to be neuropathic in nature. As noted by multiple providers, the requested breast removal procedure is not likely to alleviate the patients pain. Therefore, in this setting of chronic pain without locally recurrent malignancy, the request for removal of the TRAM flap is not medically necessary. In addition, the patient tested BRCA negative and has a history of unilateral breast cancer so the request for contralateral prophylactic mastectomy is also not medically necessary.In regards to the reconstructive surgery criteria, the requested surgery is not considered reconstructive in nature for treatment of the patients medical condition. The patient presents with stage IV breast cancer status post mastectomy and TRAM flap reconstruction. Based upon the documentation provided, the patients condition does not constitute an abnormal structure of the body. The initial TRAM flap reconstruction resulted in a normal appearance following mastectomy. The proposed breast removal would create an abnormal appearance. For the reasons provided, the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy for treatment of her pleomorphic liposarcoma.  Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this patients case.  This patients provider has recommended intensity modulated technique to deliver radiation therapy.  There is clinical data to support the use of intensity modulated radiation in the treatment of sarcoma.  A recent retrospective review found decreased recurrence rates in patients who received intensity modulated technique compared to standard three-dimensional conformal techniques. National guidelines state that intensity modulated radiation therapy can be utilized in the treatment of sarcoma. Furthermore, the provider has submitted a plan comparison using intensity modulated radiation therapy technique versus standard three-dimensional technique. The plan comparison shows a clinically significant reduction in radiation dose to the long bones and external genitals with the use of intensity modulated radiation therapy. Final Result: The reviewers determined that the requested services are 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: Reviewer 1, 2, and 3 are board certified in radiation oncology 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 Harvoni 90-400 mg, one tablet daily for 12 weeks for treatment of her chronic hepatitis C virus (HCV) genotype 1b. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic Hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An 18-year-old female enrollee has requested authorization and coverage for septoplasty (CPT code 30520), inferior turbinate reduction (CPT code 30140), and open nasal reconstruction (CPT code 30410). Findings:  The physician reviewer found that According to the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF), indications for septoplasty and turbinate reduction surgery include nasal obstruction secondary to septal deviation, refractory to medical management or for surgical access. Although this patients records include documentation of septal deviation, turbinate hypertrophy and nasal obstruction, there is no record that adequate medical management has failed to improve this patients symptoms. Thus, the requested surgery is not supported as medically necessary for treatment of this patients medical condition. This patient has a remote history of nasal trauma and previous surgery to correct the nasal fracture. While the bony dorsum was described as deviated to the left, there were no descriptions of the nasal bones or any other anatomical structures beside the septum and turbinates to demonstrate the presence of an abnormal condition. There were no photographs to document the deformity. Further, the records do not demonstrate that the requested rhinoplasty is functional in nature. The patient reported she did not like the appearance and it was noted that the surgery was to address cosmetic issues. For these reasons, the requested surgery is not reconstructive in nature. Final Result: The reviewer determined that the requested surgery is not reconstructive in nature or 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 otolaryngology 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.