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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nusinersen (Spinraza). Spinraza has U.S. Food and Drug Administration (FDA) approval for treatment of patients with SMA. Additionally, the medical literature reports positive health outcomes with use of Spinraza in this patient population. Data from researchers state that the sham controlled phase 3 clinical study ENDEAR was terminated early based on significantly favorable results in interim analysis. The authors reported that given the positive preliminary results, all patients were transitioned to receive Spinraza in an ongoing open-label, phase 3 study, SHINE, which will evaluate the long-term efficacy, safety and tolerability of the medication. All told, Spinraza is considered the standard of care for the treatment of SMA. Thus, the requested Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested Spinraza is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in neurology with sub-specialty certification in pain medicine 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: An enrollee has requested authorization and coverage for Depend brand adult diapers. Urinary incontinence is the involuntary loss of urine. There are several types of urinary incontinence. The diagnosis is mainly based on history and examination. The treatment depends on the etiology of the incontinence. Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. Incontinence pads are used when medications or surgical treatments fail to control leaking. In this case, the patient has requested a specific brand of adult briefs or incontinence pads. There is no medical documentation to support that she has had a significant adverse reaction to the pads that are provided by her Health Plan. There is a lack of support for the requested equipment in this setting. Therefore, Depend brand adult diapers are not medically necessary for the 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 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 parent of an enrollee has requested reimbursement for psychiatric acute inpatient care. The submitted documentation supports the medical necessity of the services at issue. The progress notes indicate that the patient had daily episodes of agitation and aggression toward staff. She was given as needed medications on a daily, and often several times per day, basis. The progress notes indicate that the patient would attack staff without provocation. Per the records, her behaviors could not have been managed in a less restrictive setting due to her level of aggression and need for immediate medical intervention, including seclusion and as needed medications.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 4 due to her recent pattern of striking staff and biting herself. In terms of functional status, the records support a score of 5 due to numerous disruptions in her home due to her behaviors and symptoms. With regards to comorbidity, the records support a score of 4. The patient has significant psychiatric symptoms that impair functioning in the absence of stressors. In terms of level of stress of the recovery environment, the records support a score of 2. The patients home life is overall stable. With regards to level of support of the recovery environment, the records support a score of 2. The patients family is supportive. In terms of resiliency and treatment history, the records support a score of 5. The patient has not demonstrated significant remission of symptoms in the recent past. With regards to acceptance and engagement of the patient, the records support a score of 5. The patient showed almost no insight into her behaviors due to her profound impairment. In terms of acceptance and engagement of the parent, the records support a score of 2. The parent worked well with clinicians. Thus, the patient has a composite score of 29. This score correlates with secure 24-hour services with psychiatric management. The medical evidence supports the services at issue in this clinical setting. Therefore, psychiatric acute inpatient care was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. Patients diagnosed with stage III melanoma are recommended to undergo lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 facial feminization surgeries (CPT codes 21179, 15824, 30410, 30520, 15828, 40652, and 20926). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that [a]lthough [facial feminization procedures] are generally labeled purely aesthetic, these [procedures] in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. This patient has a history of gender dysphoria and has been living as a female for more than 20 years. She underwent breast augmentation and vaginoplasty, both without complication. She has been using hormones. Her treating physician explains that although the patients gender dysphoria has improved with hormone therapy, she continues to experience symptoms. Her mental health provider reports that the patient experiences discrimination due to her masculine facial features, and that she is fearful of violence because of her appearance; these facts, in turn, contribute to her gender-related anxiety and depression. Both providers indicate that the patient has been vetted for surgery and is physically and psychologically prepared for the procedure. Her providers contend that this surgery can alleviate the patients gender dysphoria and related anxiety and depression. In light of this patients unique clinical presentation, the requested facial feminization surgeries are supported by the WPATH as medically necessary for treatment of this patients gender dysphoria. 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 emergency medicine with expertise in transgender 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 reimbursement for adult detoxification treatment. The submitted documentation supports the medical necessity of the services at issue. The records noted a history of suicidal ideation, and the patient had been abusing alcohol for over 30 years. A typical cut-off CIWA score that would qualify the patient for receiving treatment on an ambulatory basis is 15. Given that the patient had a score over 15 and a history of hypertension, inpatient care was medically necessary. The patient also reported a history of cardiac surgery. This is another medical complication that would indicate the need for inpatient care. All told, adult detoxification treatment was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency ablation. Findings:  Three physician reviewers found that the currently accepted practice guidelines support the use of radiofrequency ablation in Barretts esophagus when high-grade dysplasia is present, and in particular cases in which low-grade dysplasia is present. There are no formal recommendations supported by high-quality evidence to perform ablation in patients with non-dysplastic Barretts esophagus. American College of Gastroenterology recommendations do not recommend ablation of non-dysplastic Barretts esophagus. As there is no evidence of dysplasia of Barretts esophagus in this case, the superior effectiveness of radiofrequency ablation has not been demonstrated. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: enrollee has requested authorization and coverage for a monthly injection of Saxenda 3 mg. The submitted documentation fails to demonstrate the medical necessity of the requested medication. According to the U.S. Food and Drug Administration (FDA), Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater or 27 kg/m2 or greater in the presence of at least one weight-related comorbid condition, such as hypertension, type 2 diabetes mellitus or dyslipidemia. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention, which includes a combination of diet, exercise and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise and goals for weight loss. When a patient with a body mass index of 30 kg/m2 or greater or a body mass index of 27 to 29.9 kg/m2 with comorbidities has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. However, the medical evidence has not demonstrated that Saxenda is more effective than the listed formulary drugs, diethylpropion or benzphetamine. Therefore, a monthly injection of Saxenda 3 mg is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Proton Beam Radiation Therapy (PBRT) services. Findings:  Three physician reviewers found that the current medical evidence has not established that treatment with PBRT offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. A position statement released by The American Society of Radiation Oncology (ASTRO) in 2013 stated, At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines (v1.2018) endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and IMRT technique. Therefore, the services in issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services in issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gluteal augmentation and hand feminization. The submitted documentation fails to demonstrate the medical necessity for the requested services. World Professional Association for Transgender Health (WPATH) notes that certain procedures, including fat transfer (specific mention made of buttocks, but not hands) may be medically necessary on a case-by-case basis. A search of the available literature reveals a lack of studies of hand or gluteal feminization outcomes for transgender women. In this patients case, the referral letter from her primary care provider is cursory. Additionally, the letter from plastic surgeon is somewhat vague with regards to approach and expected outcome. The records do not include a detailed plan which clarifies the source of fat for each location. The submitted records do not include a referral letter from a mental health professional indicating that an assessment and discussion of realistic goals and expectations were performed. All told, the requested gluteal augmentation and hand feminization are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency medicine with expertise in transgender 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services rendered on 4/06/18, 4/11/18, 4/12/18 and 4/16/18, as defined in the Health and Safety Code section 1317.1, subdivision (a)(1). Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on 4/11/18, 4/12/18, and 4/16/18. 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 chiropractic services on 4/06/18, 4/11/18, 4/12/18 and 4/16/18 were not necessary for treatment of an emergency medical condition. The submitted medical records did not include any evidence suggesting an emergency condition or treatment. The treating chiropractors notes classify the patients diagnosis as low to moderate severity condition with a good prognosis and moderate pain. Therefore, the chiropractic services rendered on 4/06/18, 4/11/18, 4/12/18 and 4/16/18 are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in chiropractic 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 urgent knee surgery for repair of a torn anterior cruciate ligament (ACL) and meniscus. In the medical literature, researchers reported on a study of 549 patients with ACL injury. The frequency of meniscal tear and location of tear were compared between acute and chronic ACL deficiency. The incidence of meniscal tear diagnosed by arthroscopic examination was 79.2% in all patients and 84.8% in the chronic group. Early ACL reconstruction is therefore recommended for the prevention of secondary meniscal tear. The records document that this patient has chronic instability of the left knee due to ACL deficiency with unpredictable episodes of giving way of the knee. Considering the patients history of frequent falls, the requested surgery should be performed on urgent basis to prevent additional trauma. The documentation also indicates a complex tear of the posterior horn and root of the medial meniscus which is the likely source of pain and joint effusion, and is contributing to the patients knee instability. The MRI scan report of 7/30/18 does not describe any arthritic changes in the joint. Given these findings, surgical reconstruction of the ACL and management of the medial meniscal tear is medically necessary. For these reasons, the requested urgent knee surgery for repair of a torn ACL and meniscus is supported as medically necessary for treatment of this 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 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.