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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the skilled nursing facility (SNF) services rendered at Cedar Crest Nursing and Rehabilitation Center for treatment of the enrollees stage IV epidermal growth factor receptor (EGFR) mutation positive non-small cell lung cancer and a spindle cell cancer of the porta hepatitis/duodenum. Findings:  The physician reviewer found that the patients advanced metastatic cancer and resulting symptoms were appropriate for inpatient palliative care or hospice care, but did not require the skilled nursing services provided at the SNF level of care. The nursing notes state that the patient required significant help with her activities of daily living, received enteral feedings, and was monitored by nursing, but did not receive physical therapy or occupational therapy. As this patient did not receive skilled nursing services that can be provided only as inpatient, the patient could have been transferred to inpatient palliative care or hospice care. Thus, the SNF services rendered at Cedar Crest Nursing and Rehabilitation Center were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue 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 with sub-specialty certification in neuromuscular 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: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility services for treatment of the enrollee, who has a history of polyneuropathy with weakness. Findings:  The physician reviewer found that the records document a history of alcohol use disorder, polyneuropathy with weakness, hypertension and obstructive sleep apnea. The patient presented to the emergency department with increasing weakness as well as urinary and fecal incontinence. At the time of discharge from the hospital, the patient did not require any skilled nursing or rehabilitation services on a daily basis. The patient was not at his prior level of functioning. However, he did not require admission to a skilled nursing facility for inpatient skilled rehabilitation services. The patient was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The patient did not require skilled therapy to establish a safe and effective maintenance program. The patient did not require any skilled services on an inpatient basis, at a skilled nursing facility level of care.  He did not have any parenteral medications, complex wound care or nutrition given via a feeding tube. The patient was medically stable and could have received further services at a lower level of care. His physical function was near his baseline, and he could have received services at a lower level of care.  Final Result: The reviewer determined that the services at issue were not and 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that 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 chronic hepatitis C 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; in this case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa is recommended as a first-line regimen for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time, and the requested treatment with Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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 AndroGel 1.62% for treatment of the enrollees hypogonadism. Findings:  The physician reviewer found that proper treatment of hypogonadism is based on the improvement of symptoms related to erectile dysfunction, sexual dysfunction and related depressive symptoms, while maintaining normal testosterone levels. Other goals of therapy include prevention of osteoporosis, possible normalization of growth hormone and maintenance of virilization. The treatment has to be balanced against possible side effects. In younger men, the goal is to improve symptoms and maintain a testosterone level in the mid normal range. In older men, defined over 60 years of age in most studies, the recommendation is to keep levels in low normal range. In this patients case, the records support the requested medication dosage in order to optimize therapy and improve his depressive symptoms further. Therefore, AndroGel 1.62%, two pumps per shoulder daily is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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: A female enrollee has requested authorization and coverage for Harvoni 90/400 mg tablet for the duration of 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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. In patients with decompensated cirrhosis, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks. This recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population.  Zepatier is not recommended by the AASLD/IDSA guidelines for treatment of genotype 1, hepatitis C in patients with decompensated cirrhosis or severe hepatic impairment. Studies of Zepatier have not included patients with this level of liver disease, except for a series in which a patient with Child Turcotte Pugh Class B cirrhosis died a month after treatment with Zepatier. For these reasons, the requested treatment with Harvoni 90/400 mg tablet for the duration of 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 regimen 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings: The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the date of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The psychiatric services provided on were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency is defined as a patient who is an imminent danger to herself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation, homicidal ideation, delusions, and delirium. Per documentation, the patient had none of these symptoms. The patients Clinical Institute Withdrawal Assessment for Alcohol (CIWA) and Clinical Opiate Withdrawal Scales (COWS) scores were unremarkable. The patients vital signs were stable. The nurses note stated that the patient did not have any withdrawal symptoms. Urine drug screening was positive for methamphetamine, cocaine, benzodiazepines, and opioids. However, the documentation does not demonstrate that a psychiatric evaluation or risk assessment was performed. Based on the clinical documentation provided, the patient did not receive psychiatric emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the date of service at issue. Therefore, 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 mg one tablet every six hours at four times per day and morphine sulfate 15 mg twice per day for treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that the records demonstrate that this patient is a poor candidate for long-term opioid use. The provider has not included documentation of continued and improved function as a result of ongoing opioid treatment. In addition, the patient reportedly recently failed random urine toxicology tests. The providers recommendation for opioid tapering and enrollment in a dependency rehabilitation program is therefore appropriate. Final Result: The reviewer determined that the requested medications 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nifedipine 0.2% ointment for treatment of the enrollees hemorrhoids and anal fissure.  Findings:  The physician reviewer found that the request for nifedipine 0.2% ointment is not medically necessary for treatment of the patients medical condition. An anal fissure is a tear in the skin of the lower half of the anal canal, often with accompanying severe and sharp pain, irritation and tenderness. Sphincterotomy remains the gold standard, but it may lead to incontinence in some patients. Rectiv (nitroglycerin) and various calcium channel blocker therapies have been tested with varying outcomes. The study by colleagues compared the effect of the addition of oral and topical nifedipine to conservative measures in the treatment of fissure-in-ano. This studys small series was randomized into three groups of 30 each. Group I received conventional treatment, Group II received oral nifedipine and conventional treatment, and Group III received topical nifedipine along with conventional treatment. The patients were followed for eight weeks for pain relief and healing to evaluate the effect of treatment. The results showed that pain relief was significantly better in the Group III at three weeks and two months compared with group I.  Healing rates were significantly better in Group II and Group III compared with Group I, but Groups II and III were found to be comparable. Adverse effects were most commonly reported by Group II patients, but these were not significantly higher than in other two groups. However, colleagues performed a meta-analysis for non-surgical management for anal fissure. The authors concluded that Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. However, in this case, there is a lack of documentation to support that the patient has an anal fissure to warrant topical nifedipine use. Given the lack of adequate support in the peer-reviewed literature and clinical documentation provided for review, the requested medication is not medically necessary for treatment of the 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 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: The parent of an enrollee has requested reimbursement for a sleep study for evaluation of the enrollee who has a history of epilepsy and encephalitis. Findings:  The physician reviewer found that there is sufficient support in the documentation and in the medical literature for the services at issue in this clinical setting. This patient has been diagnosed with Hashimotos encephalopathy, a poorly understood clinical entity.  However, what is known about this disease complex is that the resultant encephalopathy is associated with sleep abnormalities in over one out of two patients with this treatable syndrome. Since this patient has encephalopathy, with diffuse evidence of brain dysfunction, it is also likely that the reticular activating system is dysfunctional. Thus, a sleep study will help characterize overall brain health and give a correlative index of treatment responsiveness to steroids. Based on these observations alone, a sleep study would have been warranted, regardless of whether there was a clinical history of sleep apnea. Additionally, the records documented a history of sleep disturbance in this patient, which further supported the request for a sleep study. For these reasons, the sleep study performed was medically necessary for the evaluation of this patients medical condition. 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 internal medicine with sub-specialty certification 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. The standard of care is to treat patients in the least restrictive environment possible. The patient was 96% of her ideal body weight (IBW) and 99% of her IBW later. The patient was medically stable. The patient did not have any suicidal or homicidal ideation. The patient did not have any psychosis, hallucinations, or paranoia. The patient continued to have anxiety around food and cravings for methamphetamine. The patient was motivated for treatment. Given that the patient was not medically compromised, there is data supporting that residential treatment center does not provide advantages over outpatient management. As such, the patient could have been treated in a less restrictive setting. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue 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 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: An enrollee has requested authorization and coverage for skin grafts, Grafix Prime Q4133, quantity of eight for treatment of the enrollees chronic right ischial and sacral ulcers. Findings:  The physician reviewer found that there is sufficient support the medical literature for the requested services in this clinical setting. Grafix has been U.S. Food and Drug Administration approved for chronic wound treatment and has shown improved success over standard wound therapy in diabetic foot ulcers. In a study by colleagues, the following was concluded, The results of this well-controlled study showed that Grafix is a safe and more effective therapy for treating DFUs [diabetic foot ulcers] than standard wound therapy. In this patients case, he had noted significant improvement in his ischial wound with an approximately 30 percent reduction in volume and resolution of approximately 2 cm of tunneling, based on the documentation provided.  The records also noted that this patient has failed standard wound therapy but had specifically improved while using Grafix. Therefore, Graphix Prime Q4133 skin grafts, quantity of eight, is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services 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 plastic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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 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 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is medically necessary for the treatment of the 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.