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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 137 hours per month of applied behavior analysis (ABA) one-to-one, 11 hours per month of supervision by a board certified behavior analyst (BCBA) and six hours per month of caregiver training. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Per the medical literature, the correlation between treatment outcomes and treatment intensity is well-documented.  Studies noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated.  In this article, 726 children (ages 1.5 to 12) were studied and were shown to make increased progress towards learning objectives with increased intensity of treatment.  In this patients case, he appears to have made progress in many areas over the last several years, but continues to demonstrate impairment in several areas including agitation, negative vocalizations, perseverations, and stereotypy.  These persistent struggles are making it increasingly difficult for him to be successful in more generalized environments.  The medical evidence supports the requested services in this patients case.  All told, the requested 137 hours per month of ABA one-to-one, 11 hours per month of supervision by board certified behavior analyst (BCBA) and six hours per month of caregiver training are 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xiidra droperette. Findings:  The physician reviewer found that anti-inflammatory therapy is an accepted treatment for dry eye disease. Xiidra is the latest anti-inflammatory treatment approved for dry eye disease. This patient has dry eye disease based on her need to use artificial tears and likely inflammation given the previous corneal transplantation. For these reasons, treatment with Xiidra is medically necessary in an attempt to provide this patient with clinical improvement in her dry eye symptoms. 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 ophthalmology 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 epoetin alfa (Procrit) 40,000 units per week. Findings:  The physician reviewers found that, although Procrit alone is not recommended for the use of sickle cell disease, the use of Procrit in combination with hydroxyurea may be considered as an adjunct to hydroxyurea therapy in patients with high risk sickle cell disease, anemia, low reticulocyte counts, and deteriorating renal function, particularly when hydroxyurea therapy is limited by the erythroid reserve. The National Institutes of Health (NIH) reported on the use of this combination based on an observational study and review of the literature. The NIH found that Procrit can help combat the side effects of higher hydroxyurea dosing. Thus, the use of Procrit 40,000 units per week in this patient is likely to be more beneficial than any other available standard therapy. Final Result: 2 of 3 reviewers determined that the requested medication is 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg/100 mg, one tablet daily for a duration of 12 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive or interferon-experienced genotype 2 patients.  A delay in treatment may result in decreased survival.  In sum, Epclusa 400 mg/100 mg, one tablet daily for a duration of 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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 reimbursement for residential treatment. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness.  In this case, the patient had a serious addiction to alcohol which contributed to interpersonal discord, occupational problems, depression, and health issues.  He had a co-occurring psychiatric disorder treated with a pro-serotonergic medication, escitalopram and then mirtazapine, in addition to quetiapine and gabapentin.  He had a complex medical history of hypercoagulability and thyroid disease, and concerning physical sequelae from his drinking, including a history of electrolyte imbalance, seizures, and delirium tremens.  The patient was unable to maintain sobriety in his environment.  Per the records, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting after just three weeks of care.  Further, he did not have a strong sober support network.  The patient was attending, participating and benefitting from the residential programming, which included family involvement, psychiatric services, individual therapy, group therapy, sponsorship and an array of chemical dependency non-pharmacologic interventions.  The treatment was appropriate and reasonably expected to further the patients improvement while minimizing the chance of relapse.  Further, the duration of treatment was well within community practice standards and facilitated a seamless transition to the next residential treatment setting.  All told, residential treatment provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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 reimbursement for residential treatment center services provided. Findings:  The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature. the patient was not a danger, nor was the patient aggressive or violent. The patient was cognitively intact and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. The patient was medically and psychiatrically stable. The patient's medication management could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with the patient's care. The patient was internally motivated and working the program and he had a sponsor. The patient was cooperative and participating in his treatment plan. Although the patient continued to struggle with emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting and could have been stepped down to an ambulatory level of care. 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 physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 Harvoni for 12 weeks. 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 or viral load, and advanced fibrosis is not required for treatment.  The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 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 a full treatment plan for 10 hours per week of direct applied behavioral analysis (ABA) therapy, 12 hours per month of supervision and four hours per month of parent training. Findings:  The physician reviewer found that 1n this case, the medical necessity for continued ABA services has been established. The medical literature supports a higher intensity of ABA treatment for children with autism . The correlation between treatment outcomes and treatment intensity is well documented. The Health Plans authorization of 26 hours per month, which is approximately 6.5 hours per week of direct ABA therapy, eight hours per month of supervision and two hours per month of caregiver training, is less than what is typically recommended for optimal response. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. In this case, the patient has made progress in many areas as evidenced by the progress reports over the last several years, but he continues to demonstrate impairment in several skills such as transitions and accurately interpreting the meaning of casual conversation. These persistent struggles are making it increasingly difficult for him to be successful in more generalized environments such as college. For the reasons provided, the patients request for a full treatment plan for 10 hours per week of direct ABA therapy, 12 hours per month of supervision and four hours per month of parent training is medically necessary for treatment of the patients autism. Final Result: The reviewers 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: Physician reviewer number one 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Afirma gene expression classifier CPT code 84999) performed. Findings:  The physician reviewer found that he Afirma gene expression classifier (CPT code 84999) testing performed was likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. The cytopathology of the 1.9 cm thyroid nodule was consistent with a FLUS. The risk of malignancy is 15-30% in follicular neoplasm nodules. The 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. In this case, the result of the gene expression classifier was benign. A benign Afirma test result likely prevented an unnecessary surgery and observation can be safely continued. Accordingly, the testing at issue 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: Physician reviewers 1, 2 & 3 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA gene test for evaluation of her risk for cancer. Findings:  The physician reviewer found that according to the National Comprehensive Cancer Network (NCCN) Guidelines, BRCA 1 and BRCA2 testing should be considered in individuals without a personal history of cancer when there is a first- or second-degree blood relative (same side of family) who themselves meet the BRCA 1 and BRCA2 testing criteria, or a third-degree blood relative who has breast cancer and/or ovarian carcinoma and who has two or more close blood relatives with breast cancer (at least one with breast cancer at age 50 or younger) and/or ovarian carcinoma. In this case, the patients family history, while not classic for BRCA mutations, does meet the NCCN criteria. The patients maternal grandmother, who is a second degree blood relative, has a history of breast cancer diagnosed at 50 years of age. The patients mother developed ovarian cancer, and it appears the ovarian cancer developed from metastasis from the colon, but primary peritoneal cancers cannot be ruled out from the data presented. Final Result: The reviewer determined that the requested testing 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: 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided.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. 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 were necessary for treatment of an emergency medical condition. The patient presented with an acute ankle injury. He had sustained an inversion injury the day prior and could not walk without the assistance of a cane. Physical exam noted swelling, ecchymosis, and tenderness. Trauma sustained when twisting a foot on a step can range from minor sprains to fractures or dislocations. The most severe and often missed injury is a Lisfrancs fracture/dislocation. Failure to recognize this in a timely fashion may lead to chronic pain and instability. Symptoms of ankle pain, swelling, and discoloration the day following trauma meets the criteria for an emergency medical condition. Therefore, the services provided on date of dispute  were necessary for treatment of an emergency medical condition.  Final Result: The reviewers determined that the enrollee received emergency medical services the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number one 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block injection for treatment of her chronic migraine. Findings:  Three physician reviewers found that the request for occipital nerve block injection is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a diagnosis of chronic migraine and occipital neuralgia. Based on a review of the medical record, the patients conditions may be exacerbated as a result of the occipital neuralgia. The use of nerve blocks for the treatment of occipital neuralgia is well established and is known to be an effective method of treatment of the condition. Furthermore, the treatment of this condition may result in the improvement in the patients chronic migraines as occipital neuralgia is known to be secondary cause for exacerbation of migraines. Final Result: The reviewers determined that the requested service is 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: Reviewers 1, 2, and 3 are board certified in neurology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.