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

Nature of Statutory Criteria/Case Summary: An enrollee has requested foot orthotics for treatment of the enrollees foot pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested foot orthotics. Custom foot orthotics are the standard of care for treatment of patients with over pronation, subtalar joint valgus, posterior tibial tendinopathy, hallux limitus, and heel pain. Custom foot orthotics are utilized to correct pathologic biomechanics of the foot, and in the case of this patient will correct his subtalar joint valgus, loss of medial column upon stance and reduce the dorsiflexion of the first metatarsal. In addition, custom foot orthotics have previously helped this patient and his current orthotics have lost their effectiveness to support his feet. Based on the patients right foot and ankle pain due to significant abnormal foot biomechanics, painful posterior tibial tendinopathy at insertion with pain upon palpation to the medial foot, abnormal and painful gait, loss of medial arch upon ambulation with severe over pronation, the requested equipment has been established as medically necessary.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 podiatry 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 Afirma gene expression classifier test for evaluation of the enrollee, who was diagnosed with a follicular thyroid lesion. Findings: Three physician reviewers found that a biopsy showed a cytopathology consistent with follicular neoplasm. The specimen was sent for genetic expression classifier to Afirma laboratory. The Health Plan denied reimbursement for the services at issue. Per the Health Plan, the services at issue were investigational for evaluation of this patient. The patient has a thyroid nodule, which is consistent with follicular neoplasm. The risk of malignancy is 5-15% in these nodules (Cibas, and Ali). The Bethesda System recommends a diagnostic thyroid lobectomy for this type of nodule (Cibas, and Ali). The 2015 American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If the genetic test is suspicious, the risk of malignancy increases to 40% (Cibas, and Ali; Haugen, et al). However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing (Cibas, and Ali; Haugen, et al). As such, based on clinical data, the Afirma test is beneficial for medical decision making. Proceeding directly to the genetic testing could have prevented a possible unnecessary surgery, if the result were benign, with possible complications. In this case, the results were suspicious. These results were helpful to direct subsequent management, in this case, surgery. Proceeding with genetic testing was highly effective and in line with current specialty standards. Therefore, Afirma gene expression classifier was superior to other standard 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for urgent care services provided on 10/6/14 and 10/8/14.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The urgent care services provided on 10/6/14 and 10/8/14 were not necessary for treatment of an emergency medical condition. In this case, the patient presented on 10/6/14 with abdominal pain for two days. Her vital signs were normal and no other data is available. On the visit 10/8/14, the patient returned to the same facility for her laboratory test results. She reported persistent abdominal pain. She denied any other symptoms such as dysuria, vomiting, or blood in her stool. There were no symptoms to suggest an acute decompensation in the patients condition or an emergency medical condition. Her vital signs and physical exam were normal. The patient refused further evaluation by pelvic exam. The documentation provided does not support that the patients symptoms were acute in onset or severe.  Final Result: The reviewer determined that 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 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 facet nerve  block injections treatment of the enrollees low back pain.  Findings: The physician reviewer found that based on the current medical literature and the presented clinical records, facet nerve block injections are medically necessary for treatment of the patients medical condition. Criteria for the use of diagnostic blocks for facet mediated pain include patients with low back pain that is non-radicular and documentation of failure of conservative treatments. In this case, the patient has low back pain with pain to the buttocks consistent with facet mediated pain. She does not have radicular pain symptoms and she had a normal neurological examination. Physical examination findings and the imaging results as well as the mechanism of injury are consistent with facet mediated pain. In addition, her pain is moderate to severe despite extensive conservative treatments. Therefore, the requested services are medically necessary for treatment of 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for the enrollee's breast cancer screening evaluation. Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the presence of asymmetry is an appropriate indication for breast tomosynthesis, as tomosynthesis can better separate out the overlapping structures, thus enabling the possibility of demonstrating an otherwise occult tumor.  Similarly, the heterogeneously dense nature of her breasts is another indication for breast tomosynthesis.  Based on the current medical evidence, breast tomosynthesis is likely to be more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue is 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 physician reviewers 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol is likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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 physician reviewers 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 an Afirma gene expression classifier for evaluation of the enrollee, who was diagnosed with follicular thyroid lesion. Findings:  Three physician reviewers found that the patient presented with thyroid nodules, sized at 1.5 and 1.3 cm in diameter.  The patient has past history of left breast ductal carcinoma. Thyroid biopsy was performed in two nodules.  The cytopathology diagnosis was consistent with atypia of undetermined significance (AUS) in both nodules. The specimen was then sent to genetic expression classifier (GEC). The Afirma GEC result was suspicious. The patient requested reimbursement for Afirma gene expression classifier test. Per the Health Plan, the services at issue were investigational for evaluation of the patients medical condition. The cytopathology of both nodules was consistent with atypia of undetermined significance. The 2015 American Thyroid Association's guidelines state that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat fine needle aspiration or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this patients case, the results were suspicious in both nodules. The fact that two nodules were suspicious, increase the certainty that this patient may have a multifocal thyroid cancer. The result from the gene testing was helpful to direct subsequent management, in this case, surgery. Proceeding with genetic testing was appropriate and in line with current specialty standards. Therefore, the Afirma gene expression classifier was likely to be more efficacious than other methods of evaluating of 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Forteo for treatment of the enrollees low density for age. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested medication. According to the National Osteoporosis Foundation guidelines for severe osteoporosis, sequential treatment with anabolic therapy followed by an antiresorptive agent is generally preferred to concomitant combination therapy (Cosman, et al). Teriparatide is an anabolic agent approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Teriparatide reduces the risk of vertebral fractures by about 65% and non-vertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy (Cosman, et al). Denosumab is an antiresorptive agent that decreases the risk of spinal fractures by 68% and hip fractures by 40% and is indicated for the treatment of osteoporosis in men and women at high risk for fracture (Cosman, et al). Early studies have shown that the use of antiresorptive agent prior to or concomitant to teriparatide blunt the beneficial effects of teriparatide. It has been demonstrated that sequential monotherapy of teriparatide followed by an antiresorptive agent is more effective than monotherapy with an antiresorptive agent alone. It has been shown that the greater effect of teriparatide occurs after one year of therapy, and the benefit is maintained when followed by an antiresorptive agent (Black, et al). If teriparatide is not followed by an antiresorptive agent, all effect may be lost (Cosman, et al; Black, et al). In addition, the mechanism of osteoporosis in a person with anorexia includes a decrease in bone resorption (Fazeli, et al), therefore an antiresorptive agent may not be as effective as an anabolic agent such as teriparatide. Teriparatide has been shown to be effective in women with anorexia and men with secondary osteoporosis (Fazeli, et al; Orwoll, et al). In sum, treatment with teriparatide is medically necessary for this patient for one or two years followed by antiresorptive agent such as denosumab. The reverse order may have blunted results. All told, the request for Forteo has been established as medically necessary for treatment of the 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 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:  The parent of a an enrollee has requested authorization and coverage of applied behavioral analysis (ABA) therapy and eight hours per month of supervision for treatment of autism.  Findings: The reviewer found that the request for 15 hours per week of direct ABA therapy and eight hours per month of supervision are medically necessary for treatment of the patients autism. In this case, the patient has made progress with ABA therapy. Per the most recent progress report, he met two goals and made progress with other goals. However, he continues to have issues with elopement and vocal stereotypy. At this time, a reduction of ABA hours is not indicated. This patient needs an increase to 15 hours per week with eight hours per month of supervision. Therefore, the requested hours, as recommended by the patients ABA provider, have been established as medically necessary for treatment of 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 with sub-specialty certification in developmental-behavioral pediatrics 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 magnetic resonance imaging (MRI) of the bilateral breasts for evaluation of the enrollees abnormal mammogram. Findings: The physician reviewer found that this patient has dense tissue on mammography which limits the sensitivity of mammography. However, the presence of suspicious calcifications is not to be addressed by further imaging but with stereotactic biopsy. There are no findings on MRI which can rule out ductal carcinoma in situ (DCIS) and the presence of suspicious calcifications raises the concern of that possible diagnosis. If the calcifications turn out to be malignant, an MRI may be indicated for evaluation prior to lumpectomy due to the dense mammographic breast tissue. All told, the requested MRI of the bilateral breasts is not supported as medically necessary for evaluation of this patients breast suspicious calcifications.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has a contraindication to the use of chronic opiates for pain given his history of alcohol abuse.  Additionally, he has received medications from two providers at the same time, which is another red flag in terms of chronic opiate administration.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Norco is not medically indicated 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 anesthesiology with sub-specialty certification in pain 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 for intravenous immunoglobulin, Gammagard (IVIG) treatment for treatment of the enrollee who has been diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy. Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  Intravenous immunoglobulin remains the appropriate treatment for this patients chronic inflammatory demyelinating polyradiculoneuropathy.  The patient meets clinical criteria for this diagnosis, and intravenous immunoglobulin remains a first-line medication in this clinical setting.  The current medical evidence supports the requested services for the treatment of this patient.  All told, intravenous immunoglobulin, Gammagard (IVIG) treatment, at the provider requested frequency is medically indicated for the treatment of this patient.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 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.