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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy once daily for treatment of enrollee's hepatitis B.  Findings: The physician reviewer has found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the formulary alternative, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease.  Therefore, the requested Vemlidy 25 mg tablets, once daily is medically necessary for the treatment of this patient.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyvanse 50 mg for treatment of the enrollees narcolepsy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Vyvanse is U.S. Food and Drug Administration (FDA) approved as a safe and effective medication for binge eating disorder and for attention deficit/hyperactivity disorder. This patients records do not document these conditions. Nuvigil does not stimulate the heart like other stimulants do, and the records do not show that she has tried this medication. Nuvigil is an FDA approved treatment for narcolepsy. There is no documentation that she has tried the long acting stimulants which are preferred medications according to her Health Plan, including Concerta, Ritalin LA and Adderall XR.  There are alternative drugs that are FDA approved for narcolepsy, including Xyrem. All told, the requested Vyvanse 50 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rosuvastatin calcium and Bystolic for treatment of the enrollees coronary risk and non-obstructive coronary stenosis.Findings: The physician reviewer found that the request for rosuvastatin calcium and Bystolic have not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient is a male with coronary risk and non-obstructive coronary stenosis. In this circumstance treatment with a statin medication is indicated and standard accepted practice in the medical community. However, the documentation provided does not support that the Health Plans covered formulary drugs will be or have been ineffective or have been tried and not tolerated. In addition the records provided do not support an accepted medical indication for treatment with a beta blocker medication such as Bystolic. Specifically there is no documented hypertension, angina, prior myocardial infarction, left ventricular dysfunction, tachyarrhythmia or other documented indication for a beta blocker medication. In addition, beta blocker medication can worsen lipid levels. For the reasons provided, the requested medications are not medically necessary for treatment of the patients medical condition.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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for low level laser therapy for lymphedema.  Findings:  The physician reviewer found there is sufficient medical literature supporting the requested services in this clinical setting. Robijns and colleagues examined literature on the effectiveness of LLLT in reducing limb volume and pain in adults with breast cancer-related lymphedema. The authors noted that LLLT increases the lymphatic drainage by stimulating the formation of new lymph vessels, by improving the lymphatic motricity, and by preventing the formation of fibrotic tissue. Similarly, Smoot and colleagues found that LLLT confers clinically meaningful reductions in arm volume and pain in women with breast cancer related lymphedema. In this case, LLLT in combination with the standard treatments the patient has been receiving 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve stimulation for treatment of the enrollees headaches.Findings:  Three physician reviewers found that There is a lack of large, rigorous, randomized and sham controlled trials to support the superior effectiveness of the requested services in this clinical setting. This patient has a headache history consistent with chronic migraine. She has tried several oral preventives, and one cycle of Botox. Nerve blocks have given her transient relief. However, the medical evidence regarding occipital nerve stimulation for chronic headache is very mixed. This patients history is not typical of occipital neuralgia, but rather, of chronic migraine. Moreover, there is documentation in the headache clinic notes reporting that not all oral medications have been tried and that there could be a reasonable probability of benefit. In addition, she has not had an adequate trial with Botox, which by the clinical evidence has the greatest likelihood of success for management of chronic migraine. A recent review of interventions for chronic headache by Ambrosini and Schoenen notes there is clear evidence for a preventative effect of suboccipital injections of local anesthetics and/or steroids in cluster headache, while evidence for such an effect is weak in migraine.  For the reasons noted above, occipital nerve stimulation is not likely to be superior to other therapies available for treatment of this patient.  Final Result: The three reviewers determined that the requested procedure is 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: All three physician reviewers are board certified in neurology 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 an office visit with a podiatrist for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The records noted that the patient has foot pain.  The foot pain is such that her provider cannot treat it, and therefore has requested a referral to podiatry. The patient noted that she has had bilateral foot pain for six months. The medical evidence supports the requested services in this clinical setting. Therefore, the requested office visit with a podiatrist is medically necessary 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services he received. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with flank pain and a fever. He reported body aches, chills, and dark urine. Laboratory data revealed significant transaminitis with thrombocytopenia. This prompted a CT scan of the abdomen to rule out a surgical emergency. A patient with severe flank pain rated 8/10 along with fevers, thrombocytopenia and significant liver function test abnormalities meets the criteria of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 60 minute physical therapy sessions for treatment of his low back pain and radiculopathy.  Findings: The physician reviewer found that per the clinical practice guidelines for the management of chronic musculoskeletal low back pain, the focus of treatment should be patient education, self-care, common analgesics, independent exercise and remaining active.  The benefit of prolonged formal therapy services is not established in the medical literature for this patients condition.  There is no proven marginal benefit of passive modalities such as massage/manual therapy and modalities provided in a formal setting on a prolonged basis on pain, health or functional outcomes over self-massage and topical treatments, such as ice or heat applied independently. There are no documented exercises that the patient was doing in therapy that could not be done independently or substituted with independent exercise.  Exercises such as planks do not require supervision on a prolonged basis. Overall, although the patient has ongoing symptoms, there is no expectation of a marginally significant difference in clinical course or outcomes with the requested physical therapy over an independent program. All told, the requested 60 minute physical therapy sessions 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zejula for treatment of the enrollees ovarian cancer.  Findings:  The physician reviewer found that Ovarian cancer consists of several histologic types and treatment depends on specific tumor type. Adenocarcinoma/epithelial, if metastatic, is treated initially with a carboplatin based regimen. Follow-up regimens are determined by whether the tumor appears to be carboplatin sensitive or resistant. The U.S. Food and Drug Administration (FDA) recently approved the use of Zejula based on the results of the NOVA trial in patients with ovarian cancer with and without BRCA1 and BRCA2 mutation. The trial demonstrated that regardless of mutation status there was an improvement in progression free survival in platinum sensitive patients. Although not listed in National Comprehensive Cancer Network (NCCN) guidelines, the FDA has approved the use of Zejula in this clinical setting and therefore it is medically reasonable for the patient to receive this drug and continue until progression. For the reasons provided, the request for Zejula is 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 medical oncology 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 Epclusa for 12 weeks for treatment of the enrollees hepatitis C. 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 regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. A delay in treatment may result in decreased survival. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MS Contin and hydromorphone 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 medications.  This patient has not been compliant with her opiate medication agreement.  She has tested negative for prescribed opiates twice, and tested positive for cannabis and alcohol. She has not complied with going to pain management and psychiatry consultations. Noted the dangers of high dose chronic opiate use and the need for careful supervision and also patient compliance to avoid serious complications. The repeated findings of abnormal urine toxicology shows a clear violation of the agreement. This patient is not a suitable patient for chronic opiate maintenance.  All told, MS Contin and hydromorphone are not medically necessary for the treatment of this patient.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard fecal testing performed for evaluation of the enrollee, who has a history of colon polyps. Findings: Three physician reviewers have found that Cologuard is not standard of care at this time. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect most (but not all) adenomas if they have high-grade dysplasia. However, the limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard, raising concern that Cologuard may have missed cancer. The evidence of the impact of Cologuard on patient care or health outcomes is lacking. There is not a consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. Finally, Cologuard is studied for average-risk patients, and this patient has a history of unspecified polyps which may have placed her in a higher-risk category. For these reasons, Cologuard fecal testing performed was not likely to be more beneficial for evaluation of this patient than other available modalities.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviews 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: An enrollee has requested reimbursement for the monitored anesthesia care (MAC) provided for evaluation of the enrollees screening for malignant neoplasm.Findings: The physician reviewer found that the patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given the patients low preoperative physical status classification score (Heuss, et al; Trummel; Saenz-Lopez, et al; Fanti and Testoni). For these reasons, the MAC service provided were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 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.