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

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an inpatient hospital stay. The Health Plan denied the inpatient hospital stay as not medically necessary for the patients medical condition. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested inpatient hospital stay on the date in question. In this case, the patient was admitted in stable condition for a scheduled surgery.  He improved clinically without any complications. By the date in question, the patients vital signs were stable, physical exam unremarkable, and his pain was noted as being well-controlled.  He had a Foley catheter for voiding; was ambulating and could have been treated at a lower level of care. The additional medical documentation includes the admitting history and physical, operative report, discharge instructions, and progress notes. On the date in question, the patient was still having pain and passing flatus without a rating on VAS (visual analogue scale), but with stable vital signs and lab studies. A physical examination was unremarkable. Ambulation and oral analgesics as needed continued. Therefore, the inpatient hospital stay for this date was not medically necessary for the patient.Final Result: The reviewer determined that the inpatient hospital stay for the date in question was not medically necessary for the patient and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a male who has requested reimbursement for skilled nursing facility (SNF) level of care services. The Health Plan has denied this request, indicating that the services at issue were not medically necessary for treatment of the patients medical condition. In June 2018, the patient was transferred from a long-term acute care facility to an SNF. As of July 2018, the patient had plateaued with respect to his functionality. There were no ongoing skilled rehabilitation; no nursing or medical needs that required care at the skilled nursing facility level. In this case, the patient has severe heart failure with an ejection fraction of 15 percent. He had poor exercise tolerance. End-stage chronic heart failure with a reduced ejection fraction is a condition with very poor outcomes in general. The best and only true cure for this condition is cardiac transplantation. The patient was at a long-term acute care hospital from September 2017 to June 2018, receiving therapies. In mid-June 2018, he was transferred to an SNF, where he made minimal to no progress with therapy services, compared to his functional status in May 2018 at the long-term acute care facility. The patients progress was limited to the degree that the heart transplant clinic had recommended a neurological evaluation for further evaluation of his deconditioned state. There is no documentation of this evaluation, or indication that there is a treatable or reversible condition of his leg weakness or generalized weakness, neurological in nature or otherwise. As of July 2018, the patient had plateaued with respect to his functionality. There were no ongoing skilled rehabilitation, nursing or medical needs documented to demonstrate the patient required further care at the skilled nursing facility level. He could have returned to the community with his social supports, custodial level assistance and outpatient therapy services for basic restorative strengthening and endurance exercises, as well as for cardiac rehabilitation. Therefore, the SNF level of care services were not medically necessary.Final Result: The reviewer determined that the requested services 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ambien 5 mg oral tablets. The U.S. Food and Drug Administration (FDA) has approved the use of Ambien for the short-term treatment of insomnia. Ambien is not approved for the long-term treatment of insomnia. When treating insomnia, patients should receive therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia. For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy (CBT) is the initial therapy that is recommended. If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered. If the patient is still having symptoms, an evaluation in a sleep disorder center may be indicated prior to the institution of long-term medications.  In this case, the documentation does not support that the patient has received optimal therapy for medical and psychiatric conditions or that non-pharmacologic treatment for insomnia has failed. Furthermore, the patient was noted to have been taking approximately 85 mg of Ambien per day, which exceeds the recommended maximum daily dosage. Therefore, Ambien 5 mg oral tablets are not medically necessary for the treatment of this patient. 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: The patient has requested authorization and coverage for Repatha Sureclick 140 mg/mL. Based on the records provided for review, this patient presents with hyperlipidemia and coronary artery disease status post myocardial infarction. She has a documented intolerance to Praluent and Zetia. The patients LDL cholesterol was 102 mg/dL while on maximum tolerated Crestor at 10 mg per day. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. Repatha has been demonstrated to be effective for patients with heterozygous familial hypercholesterolemia or documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this clinical setting, Repatha has been shown to be safe, effective at significantly lowering LDL cholesterol and is associated with improved cardiovascular outcomes. All told, the Repatha Sureclick 140 mg/mL is medically necessary for treatment of this patients hyperlipidemia and coronary artery disease. 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 subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous transcatheter closure of congenital interatrial communication (patent foramen ovale). Findings:  The physician reviewer found that the medical evidence supports the requested services in this clinical setting. Based upon recent clinical trials, patent foramen ovale closure has been shown to significantly reduce recurrence from ischemic strokes compared with medical therapy. This patient had a neurologic event approximately 10 years ago consisting of sudden loss of hearing and dizziness. She was subsequently found to have a patent foramen ovale on echocardiography. The use of aspirin for greater than 12 months is associated with significant bleeding risk. Patent foramen ovale closure has been demonstrated to be safe and effective. Thus, the requested percutaneous transcatheter closure of congenital interatrial communication (patent foramen ovale) is likely to be of greater benefit than other treatment options. Final Result: Two of the three physician reviewers foundthat 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 speech therapy services. Findings:  The physician reviewer found that The submitted documentation supports that the requested services are medically necessary. Maiano and colleagues estimate that 44 percent of children with autism are bullied at school. This is frequently due to their difficulty interacting appropriately with others. Helland and colleague recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism and that further development of therapy plans and interventions targeting pragmatics is strongly needed. Loukusa and colleagues discuss methods of exploring deficits in the pragmatic language in children with autism using the Pragma test, the Social Interaction Deviance Composite (SIDC) of Children's Communication Checklist-2 (CCC-2), and the Theory of Mind subtest of the Developmental Neuropsychological Assessment, Second edition (NEPSY-II). The results of their research showed that children with autism differed from typically developing children in questions demanding context utilization. In this case, the patient has been diagnosed with autism spectrum disorder, and he is noted to be the target of bullying at school because of his impairments in the appropriate social use of pragmatic language. Under these circumstances, the requested speech therapy services are medically necessary to treat the patients medical condition.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 pediatrics and neurology, with special qualification in child neurology, 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: The patient is requesting reimbursement for the partial hospitalization program (PHP) services provided for 21 days, and the intensive outpatient program (IOP) services provided for 15 days. The Health Plan denied the partial hospitalization program services for all days and the intensive outpatient program for all days as not medically necessary for the patients behavioral health condition. Findings:  The physician reviewer found that on admission to PHP, the patient did not require monitoring for post-acute withdrawals. Methamphetamine does not require detoxification and his last use of marijuana was 10 days prior to admission. The patient was medically stable and did not require five days per week of medical observation.  There were no barriers to recovery on an outpatient basis.  He had a sober and supportive recovery environment.  The patient denied psychiatric issues on admission.  He was not a danger to himself or others.  The patient had no functional impairments in activities of daily living, and he had no psychiatric issues requiring monitoring at the PHP level of care. During the dates of IOP services, the patient was not a danger to himself or others. His environment was conducive to recovery and his spouse was sober and supportive. The patient was medically stable and had no emotional or impulsive conditions requiring acute management beyond the outpatient setting.  He had no functional impairments in activities of daily living.  There were no barriers to recovery at an outpatient level of care.  There were no acute stressors or crisis situations preventing him from continuing treatment at an outpatient level of care.  The patient was already sober and participating in 12-step meetings, and did not require enhanced sobriety education beyond the outpatient setting.Final Result: The reviewer determined the patient had no functional impairments in activities of daily living, and he had no psychiatric issues requiring monitoring at the PHP level of care. Therefore, the PHP services were not medically necessary and the Health Plans denial should be upheld. The patient was already sober and participating in 12-step meetings, and did not require enhanced sobriety education beyond the outpatient setting. Therefore, the IOP level of care was not medically necessary and the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary The patient has requested reimbursement for residential treatment center (RTC) services.  The Health Plan has denied this request, indicating that the requested services were not medically necessary for treatment of the patients behavioral health condition. The submitted documentation supports the medical necessity of the requested RTC services. The patient was experiencing a disturbance in mood (comorbid condition), and disordered eating, which manifested in many ways as described, but included worsening suicidal ideation. This could not be safely managed in a less restrictive setting. Her isolation, recent breakup, and feeling that she is a burden to others put her at risk for not being able to seek help from others. All of the RTC services provided were medically necessary and in accordance with generally accepted standards of medical practice. Final Result: The reviewer determined that the requested RTC services were all clinically appropriate for the patients behavioral health condition and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a biopsy on the right breast mass. Based on the documentation provided for review, this patients imaging has not revealed any suspicious masses that are concerning for malignancy. However, the patient has consistently complained of a painful mass in her breast. In addition, this mass has been documented by the provider to be palpable and the patient is obese. Therefore, the palpable mass is not likely to correspond to the 0.4 or 0.5 cm findings on the ultrasound or mammogram. With discordant findings on imaging and physical examination, if the mass cannot radiographically be identified, either serial examinations of the breast, or excision of the palpable area should be performed. Breast cancer can be radiographically occult. This patients prior imaging has not demonstrated breast cancer, yet the palpable mass has not been thoroughly evaluated. As a problem solving tool, the requested breast biopsy is indicated in a clinical setting. Thus, consistent with current guidelines, the requested biopsy on the right breast mass is supported as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar gel. Medical literature shows that the available data on IgM nephropathy is based on clinical observations. Medical literature cautioned that mechanistic studies of IgM nephropathy are lacking. Moreover, there is a lack of support in the available clinical guidelines reporting that Acthar gel is safe and effective for treatment of IgM nephropathy. There is data demonstrating that rituximab can lead to remission in IgM nephropathy. Researchers concluded that rituximab is likely a valuable novel therapeutic drug for the treatment of patients with IgM nephropathy. This patients records do not document an adequate treatment course with rituximab. All told, the requested Acthar gel is not 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 internal medicine with subspecialty certification in nephrology 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: The patient has requested authorization and coverage for Mavyret, three times daily for eight weeks. Currently, the general position of experts in hepatology is that all patients chronically infected with hepatitis C should be treated. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) state that data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus eradication. Moreover, the guidelines noted that the panel continues to recommend treatment for all patients with chronic hepatitis C virus infection, except those with a short life expectancy that cannot be remediated by hepatitis C virus treatment, liver transplantation, or another directed therapy. Furthermore, treatment for nearly all with chronic hepatitis C is also the recommendation of the California Department of Health Care Services. All told, the requested Mavyret, three times daily for eight weeks, is medically necessary for treatment of this 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 internal medicine with subspecialty certification in infectious 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lenalidomide (Revlimid). Findings:  Two physician reviewers found that cutaneous involvement in systemic lupus erythematosus (SLE) is common and characterized by a chronic relapsing course. Although most patients respond to the standard first-line therapy of topical steroids and anti-malarials, approximately 30-40% of patients will be refractory to these regimens. For this significant minority, there is no consensus algorithm on treatment. One agent, thalidomide, is a potent immunomodulatory medication that has multiple effects on the immune system. Thalidomide has shown marked efficacy in several case series of refractory cutaneous SLE. Revlimid, a thalidomide analogue, has shown greater potency and a more favorable side effect profile when compared to thalidomide. As Revlimid is more potent than thalidomide, it achieves responses at lower doses. This patient has been treated with and failed first-line therapies. However, the patients condition improved while on thalidomide, which was discontinued due to side effects, and then with Revlimid without untoward events. Given these findings, the requested Revlimid is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. One reviewer found that Revlimid is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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 dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology 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.