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 emergency services. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient was found by paramedics in anaphylactic shock, likely due to ingestion of shellfish. Documents provided note the enrollee improved with intramuscular epinephrine as well as intravenous fluids and diphenhydramine. The enrollee was subsequently administered intravenous steroids as well. The half-life of intramuscular epinephrine is brief. The medical literature notes the existence of a biphasic reaction to food induced anaphylaxis (FIA) wherein recurrent symptoms occur following the resolution of the initial reaction. These reactions occur in 5% to 25% of patients with anaphylactic reactions, with the highest incidence involving FIA.  It is unclear whether the administration of epinephrine or steroids can prevent such reactions. Therefore, an observation period of four hours from the time of symptom resolution is recommended prior to discharging such patients.  Moreover, documented in the history and physical, completed three hours after the patients arrival in the emergency department, the patient still had periorbital swelling. Therefore, observation was required until the patients facial swelling had resolved, and for four hours following resolution of the symptoms. Due to persistent facial swelling, this patient was not stable for discharge from the emergency department. The risk of a biphasic response to FIA requires a four-hour period of observation following symptom resolution. As such, the hospital admission provided was emergency medical services as defined by California law.Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified 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: A 30-year-old female enrollee has requested authorization and coverage for atovaquone. The records provided for review document that testing dated 5/3/16 indicated a positive test for the medical condition. However, based on Centers for Disease Control and Prevention (CDC) criteria, a diagnosis must be made with either Wright-Gemsa, DNA in whole blood by nucleic acid amplification, or isolation of whole organism in blood. The testing method in this patients case was an antibody test, which does not meet the CDC criteria for the diagnosis. In addition, the recommended duration of treatment is 7-10 days for patients with the diagnosis. All told, atovaquone 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 sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incontinence supplies (adult diapers, disposable bed linens, feminine wash, and adult wipes) for treatment of the enrollees mixed urinary incontinence. Findings:  The physician reviewer found that based on the current medical literature and this patients diagnosis, the requested adult diapers are medically necessary. The patient has mixed urinary incontinence which is a medical problem with physical and social implications. The use of protective diapers is a safe, effective and generally acceptable standard of care for management of patients with urinary incontinence. However, the use of bed sheets/linen and feminine wash is not considered a standard of care for management of urinary incontinence. The proper use of appropriate protective diapers should improve the need to frequently change the patients bed linens. In addition, an over-the-counter body wash can be used to wash the patient and use of a specific feminine wash or adult wipes are not medically necessary. Thus, the requested adult diapers are supported as medically necessary while the disposable bed linens, feminine wash, and adult wipes are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in urology 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 reimbursement for positron emission tomography (PET) scan with gallium tracer Findings:  Three physician reviewers found there is an ongoing discussion regarding how to best monitor patients who have been treated for prostate cancer for recurrent disease. The National Comprehensive Cancer Network recommends following PSA levels. When PSA levels increase on two successive assays, the guidelines recommend consideration of imaging, such as chest x-rays, bone scans, computed tomography (CT), magnetic resonance imaging (MRI), and PET scans. Prostate bed biopsy is also a consideration. One problem is the lack of accuracy of the various imaging modalities when the post-radical prostatectomy PSA levels are low, but rising. These patients generally will have a recurrence, but it will often be undetectable with conventional imaging modalities. Bone scans are rarely positive in patients with PSA levels less than 10.  Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases). CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease. Microscopic or small lesions are difficult to detect. The value of PET scanning, especially when combined with CT scans, is that they depend on metabolic changes to detect abnormalities.  PET/CT scanning has become the imaging modality that is most appropriate in this setting. Conventional PET/CT scans will utilize fluorodeoxyglucose as an imaging agent.  However, other agents have been shown to be more specific for prostate cancer.  The use of gallium offers the major advantage of reliably detecting metastases when the PSA level is significantly lower (less than 0.5).  In sum, PET scan with gallium tracer performed was likely to have been of greater benefit than other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a gene test. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic myeloproliferative disorder.Findings:  Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient presented with persistently unidentified elevated WBC. In similar cases, either the bone marrow biopsy or molecular testing such as a Janus Kinase 2 (JAK2) or biospecimen core resource/Abelson tyrosine kinase (BCR/ABL) become necessary screening tests. This patient screened positive for JAK2 and was diagnosed with early myeloproliferative disorder. This diagnosis will help establish an adequate follow up and care plan for this patient. Therefore, the gene testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine with subspecialty certifications in hematology and medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  A 53-year-old female enrollee has requested reimbursement for emergency services including transportation. Findings: The physician reviewer found that according to the documentation submitted for review, the patient presented to the emergency department after an injury to the dorsum of her foot with a large piece of glass. She sustained significant continued blood loss following laceration repair, dropping her hematocrit from 32.8 to 30.6. After six hours of observation, the treating provider at the initial facility believed the patient required specialty consultation to assess for vascular and tendon injury. Failure to recognize a dorsalis pedis injury may result in acute foot ischemia or subsequent pseudoaneurysm formation. These services were not available at the initial facility. Despite the fact that the consultant believed that a significant arterial injury was not present, the patient yet may have injured a lesser artery or arteriole. The consultant still noted that there was a probable arterial injury but did not recommend further exploration. Further, due to continued active bleeding with a declining hematocrit, the patient required ambulance transport to the trauma facility for an evaluation. Until an acute vascular injury requiring surgical intervention could be ruled out, the patient continued to receive emergency services. For the reasons provided, the emergency services provided including transportation provided were emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Epclusa 400 mg-100 mg and ribavirin 1200 mg for 12 weeks. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees medical condition.According to 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 the medical condition should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment-naive genotype 3 patients, and those who failed peg-interferon and ribavirin. Both groups were studied in the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% in treatment-naive patients and 90% in treatment-experienced patients (Foster, et al). The use of ribavirin is recommended by the guidelines in patients with the Y93H mutation, which the patient has. AASLD/ISDA guidelines state If the Y93H substitution is identified, a different regimen should be used, or weight-based ribavirin should be added as an alternative option.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Epclusa 400 mg-100 mg and ribavirin 1200 mg for 12 weeks is supported as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medications 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight weeks for the treatment of this patients hepatitis C infection. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks. According to recent guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. Further, the guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the corneal collagen cross-linking. Collagen cross-linking has been approved by the U.S. Food and Drug Administration (FDA) for progressive keratoconus. The main criteria for treatment with collagen cross-linking is documentation of keratoconus progression. In this case, the records report progression of the keratoconus based on the topography from 2015 which showed an average keratometry of 45-46D to about 46-49D. Therefore, this patient has evidence of progressive keratoconus. Thus, the collagen cross-linking provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that given the limited randomized controlled clinical trials demonstrating the superiority of collagen cross-linking over standard available treatments for progressive keratoconus, the corneal collagen cross-linking provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was 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 ophthalmology and is actively practicing. One Reviewer is board certified in ophthalmology and is actively practicing.  One Reviewer is board certified in ophthalmology 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 54-year-old male enrollee has requested reimbursement for a carotid duplex scan of extracranial arteries with complete bilateral study for evaluation of the enrollees carotid bruit. Findings:  The physician reviewer found that There is support in the medical literature for the services at issue in this clinical setting. In an effort to reduce the incidence of stroke, there has been extensive research into the most efficacious means to evaluate susceptible patients. As written in Rutherfords Vascular Surgery textbook, Results from two separate guidelines endorsed by the Society for Vascular Surgery support the use of DUS [duplex ultrasound] as the initial imaging modality for both asymptomatic and symptomatic patients. Initial carotid evaluation with DUS is acceptable for patients with a carotid bruit and to observe known asymptomatic stenosis. In addition, the American College of Radiology (ACR) has also established guidelines for cerebrovascular disease for a variant of asymptomatic patients who have a bruit discovered on physical examination. For these patients, the ACR considers a carotid duplex study to be the most efficacious procedure. Similarly, the American Institute for Ultrasound in Medicine and the American College of Cardiology have developed appropriate indications for carotid duplex ultrasonography. These guidelines support the use of carotid duplex ultrasonography as an appropriate first-line study for patients with an asymptomatic bruit. The medical literature as well as in standard practice, recommends evaluation of a bruit before the patient develops symptoms. Therefore, the carotid duplex scan of extracranial arteries with complete bilateral study was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were 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 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.