Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure (placement of esophageal sphincter augmentation device) for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Researchers in Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. One peer-reviewed journal published a letter stating that there are 11 reports of endoscopically-confirmed LINX erosion through the esophagus in the publicly-accessible FDA Adverse Events database. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2 and 3 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 residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that A [partial hospitalization program] PHP is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight (e.g., greater or equal to 80% of ideal body weight) and maintain other evidence of medical stability. The patient had improved and weighed 113.6 pounds and was at 86% of her ideal body weight. The patient did not have any suicidal ideation. She was not administered any as needed medications. She reported on many occasions that she desired to be treated in a less restricted environment. She was medically stable and did not have orthostatic hypotension. The documentation reported that she continued to be anxious and depressed. Although the patient continued to require treatment, she did not require 24-hour supervision, and she could have been treated in a less restrictive environment. For the reasons provided, the residential treatment center services 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical treatment of rib fractures (CPT 21813) for treatment of the enrollees rib fractures. Findings:  The physician reviewers found that The surgical treatment of rib fractures (CPT 21813) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Surgical fixation of rib fractures sustained from flail chest injuries decrease intensive care unit (ICU) time, mortality, pulmonary complications, and hospital length of stay and result in improved health care-related outcomes. Multiple studies have shown that patients with flail chest have substantial benefit such as decreased ventilator, improved pulmonary function, and improved long-term functional outcome when they undergo surgery compared with non-operative management. Open reduction and internal fixation of the clavicle for stabilization of this patients unstable fracture was indicated and medically appropriate in this case. Plate fixation has been shown to be superior to intramedullary fixation for these clavicle fractures. Furthermore, the surgical treatment provided was better than any other standard treatment for management of the flail chest and unstable clavicle fracture in this clinical setting. Final Result: All three reviewers determined that the services at issue were 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: Physician reviewers number one, two, and three are board certified in orthopedic surgery and 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 authorization and coverage for oxycodone and surgery for the neck, mid-back and lower back for treatment of the enrollees neuralgia. Findings:  The physician reviewer found that the Centers for Disease Control and Prevention (CDC) has published guidelines based on best available evidence for prescribing opiates for chronic pain. The CDC noted that that opioid dosages should not be increased to 90 morphine milligram equivalents/day without careful justification based on diagnosis and on individualized assessment of benefits and risks. This patient is noted to have history of multiple surgeries, pain that is validated by EMG/NCV studies of the upper and lower extremities, chronicity of narcotics use, and tolerance of oxycodone in the past. The provider has recommended against use of short-acting narcotics. Thus, consistent with the CDC guidelines, the requested oxycodone is not supported as medically necessary for treatment of this patients medical condition. The requested surgeries of the patients cervical, thoracic and lumbar spine are not medically necessary for treatment of this patients neck and back pain. There is no radiographic evidence in the thoracic spine of any structural abnormality that can be surgically addressed. There is moderate disc degeneration of the cervical spine and MRI of the lumbar spine also failed to identify stenosis or degeneration. Given the abnormal postoperative EMG/NCV studies suggesting the possibility nerve impingement, the patient could be classified as having failed back surgery syndrome for which spinal cord stimulation may be indicated. However, there is inadequate evidence that surgery of the cervical, thoracic and/or lumbar spine is medically necessary for treatment of this patients neck and back pain. Final Result: The reviewer determined that the requested medication and surgery 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 neurological 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services received. 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 services at issue were not necessary for treatment of an emergency medical condition. The patient presented with a one-year history of bilateral arm pain with numbness and tingling. She underwent a nerve conduction study. One month later she underwent carpal tunnel surgery. There was no emergent medical condition noted in the records submitted for review. Based on the clinical documentation submitted for review, the medical services provided were not emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: 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 orthopedic 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 reimbursement and prospective authorization and coverage for residential treatment center services provided. Findings:  The physician reviewer found that according to the American Psychiatric Association Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this case, the patients substance use has been central to his daily routine and contributing to his significant impairment across multiple domains of functionality. He is homeless and unemployed. He has no meaningful sober support network. He frequently blacks out, and has shared needles, overdosed and seized while using. He also has a co-occurring formal thought disorder which represents the most devastating class of psychiatric illnesses. Discharge would have been incongruent with community practice standards. Upon admission the patient was disheveled, anxious, fidgety, and agitated with poor concentration.  In the absence of residential treatment at the time, the patient would have likely relapsed. Thereafter, it appears that the patient struggled to consolidate treatment gains while many medications were trialed. For example, earlier, the patient was agitated, hearing voices and thinking others were hearing voices as well. This prompted the provider to increase the antipsychotic, anxiolytic and wakefulness-promoting medications. The patient began showing signs of improvement a week later. For example, the patient was thinking more clearly and less psychotic. He was planning sober living aftercare and looking forward to his parents visit over the holiday weekend. In sum, the services at issue were and are safe, appropriate and consistent with good practice. The patient has been engaged in active treatment and benefitting from the care. Additionally, the services provided were and are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Final Result: The reviewer determined that the services at issue were and 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Decision Dx Melanoma blood test for evaluation of the enrollees melanoma. Findings:  The physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such at the Decision Dx Melanoma Gene Assay should not be used outside of clinical trials. Moreover, the testing at issue is not the standard of care in melanoma treatment. For the reasons provided, the Decision Dx melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was 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: Physician reviewers number one, two, and three are board certified in dermatology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma gene assay blood test for evaluation of the enrollees malignant melanoma on the mid upper back. Findings:  The physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma and can stratify whether a thin melanoma is high risk for metastasis or not. The patients provider recommended his tissue be sent for a test called Decision DX where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some impressive accuracy in thin melanomas like this patients. However, what to do with the results of the test are really indeterminate at this point. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Given these findings, the DecisionDx melanoma gene assay blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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: Physician reviewers number one, two, and three are board certified in dermatology and 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 Harvoni 90-400 mg medication, for 12 weeks for treatment of the enrollees hepatitis C infection. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and 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, Harvoni 90-400 mg for 12 weeks is supported as medically necessary for the treatment of the 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 Epclusa 400/100 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b.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, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Per the prescribing information approved by the U.S. Food and Drug Administration (FDA), Epclusa can be taken with omeprazole 20 mg with a four-hour time spacing. Delay in treatment may result in decreased survival. Given this support, the requested Epclusa 400/100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 conditions.Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not have a comorbid psychiatric or medical condition that would have necessitated a residential treatment setting. He was motivated in his quest for sobriety. At the time of discharge from detoxification, the patient was noted to be in stable condition and motivated for recovery. Aside from a muscle relaxant, the only medication prescribed was quetiapine as needed for anxiety and insomnia. During the episode of illness, the patient had no history of chemical dependency treatment, such as community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment.  This is significant in this case for two reasons.  First, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Second, there was a lack of evidence to suggest that comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time.  Thus, residential treatment center services provided were not medically necessary for the treatment of this patient.  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.