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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for procedure code 87486 (nucleic acid identification using direct probe, amplified probe, or quantification) she received. Findings:  Three physician reviewers found that the medical records fail to demonstrate the findings consistent with the Centers for Disease Control and Preventions definition (CDC) of Lyme disease, A systemic, tickborne disease with protean manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is the initial skin lesion (i.e., erythema migrans {EM}) that occurs in 60%-80% of patients. Studies find There is no well accepted definition of post Lyme disease syndrome. This has contributed to confusion and controversy. There is a lack of firm data on its incidence, prevalence, and pathogenesis. In an attempt to provide a framework for future research on this subject and to reduce diagnostic ambiguity in study populations, a definition for post Lyme disease syndrome is proposed in these guidelines. According to the CDC guidelines, the patients records fail to demonstrate that she has Lyme disease or that she needed testing. For these reasons, procedure code 87486 (nucleic acid identification using direct probe, amplified probe, or quantification) that was received was not likely to have been more effective than other methods of evaluating this patients medical condition. Final Result: Three 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 reviewers are board certified in allergy and immunology 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.
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 for treatment of his neck and chronic low back pain.  Findings: The physician reviewer found that based on the documentation submitted for review, Norco has not been established as medically necessary for treatment of the patients medical condition. In this case, the patients providers have advised against continued Norco use due to negative opiate drug screens that are inconsistent with his Norco prescription. In this clinical setting, the providers recommendation for treatment with pain management and physical therapy are medically reasonable and appropriate for treatment of the patients neck, shoulder and back pain. As such, Norco 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates 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 were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency consists of a patient who is an imminent danger to himself or to others. In this case, the patient was not an imminent threat to himself or others due to a mental illness. Further, the patient was not enduring a medical crisis secondary to substance use or physical ailments. Indeed, the patient presented with chronic alcoholism. However, his most recent alcohol consumption consisted of five beers two days prior to admission. His blood alcohol level was zero. His heart rate was normal. There was no evidence of a withdrawal syndrome in the initial history and physical. There was no report of prior withdrawal complications, such as seizures, hallucinations or delirium tremens. The patient had no thought impairment, cognitive compromise or suicidal ideation. In sum, upon presentation, the patient was not experiencing an acute psychiatric syndrome or an emergent psychiatric condition. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer ermined the patient did not receive psychiatric 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 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 Orthovisc injections for treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the requested service is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with severe osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. The authors noted that hyaluronic acid has been found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In this case, the patient has been diagnosed with severe end-stage osteoarthritis of the left knee. She has severe left knee pain that interferes with activities of daily living and work activities. She has failed to respond to conservative treatment, including physical therapy, medications, and activity modification. Given the patients young age, a trial of Orthovisc injections is medically reasonable and supported by evidence based medical literature. Therefore, the requested Orthovisc injections are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) from Hoag Neurobehavioral Health, LLC for treatment of his behavioral health condition.  Findings: The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The records did not show that the patient was in withdrawals. There was no evidence of suicidality, homicidality, violence or aggression towards others. There was no evidence of significant post acute withdrawal symptoms.  He was not a danger to self or others.  He was medically and psychiatrically stable.  He was on Naltrexone. He was not psychotic or manic. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant continued residential services. He was motivated and appeared to be working the program. He demonstrated insight and motivation.  There were no new problems that had arisen. There was no evidence to indicate that returning him to his environment would have led to destabilization.  Although he continued to struggle with his emotions and required further treatment to develop and solidify coping skills, this did not require the structured environment of a residential setting.  He could have received treatment at an ambulatory level of care.  For these reasons, RTC from Hoag Neurobehavioral Health, LLC were not medically necessary for the 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 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 and prospective authorization and coverage for vaginal Botox injections into the pelvic floor muscles for treatment of the enrollees pelvic pain.Findings: All three physician reviewers found that treatment of chronic pelvic pain often includes the use of narcotics, which have many negative properties and side effects. However, the medical studies have indicated that treatment of chronic pelvic pain with Botox is a relatively straight forward treatment with fewer serious side effects. The proposed mechanism of action blocks prolonged muscle contraction, spasm, and inappropriately high muscle tone.  There have been a number studies that support the use of Botox for the treatment of chronic pelvic pain.  Based on the literature, it is likely that this patient will experience improvement in her symptoms with this treatment regimen. The record noted that this patient has not found relief with traditional pharmacological and non-pharmacological therapies. All told, vaginal Botox injections into the pelvic floor muscles were and are likely to be more effective than the standard modalities for treatment of this patients medical condition. Final Result: The  three reviewers determined that the services at issue were and 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: All three physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewer 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 lumbar fusion for treatment of the enrollees low back pain. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature support lumbar fusion in the setting of degenerative spondylolisthesis with symptomatic radiculopathy or spinal stenosis when nonoperative treatment has failed. This patient presents with persistent low back pain with worsening right lower extremity symptoms. Significant functional difficulty is documented in ambulation and activities of daily living. She is status post L4-S1 fusion with pedicle screw fixation. Clinical examination findings were consistent with imaging evidence of adjacent segment disease including significant spondylosis at L2-3 with retrolisthesis and protrusion, and retrolisthesis with herniation at L3-4. At L2-3, she is collapsed to bone-on-bone with stenosis and retrolisthesis. The documentation indicates that the patient has failed nonoperative treatment, including activity modification, medication, and pool exercise. Therefore, lumbar fusion, multi level procedure is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for immunoglobulin G (IgG) 1, 2, 3 or 4 testing performed for evaluation of the enrollee, who had an elevated immunoglobulin A (IgA).Findings: The three physician reviewers found that patients are often referred to immunologists for the evaluation of reduced serum IgG levels. The presence of low IgG level may indicate early signs of humoral deficiencies, which are the most common of the primary immune defects. Early detection of humoral immunity defects in these patients is valuable. In this patients case, she presented with a reduced level of total IgG. The provider evaluated the patient for the presence of impaired immunologic function based on this laboratory finding by conducting a repeated IgG total level as well as IgG subclasses.  Per the medical evidence, the services at issue were an important step to evaluate or rule out primary or secondary immunodeficiency.  Therefore, IgG 1, 2, 3 or 4 testing performed was likely to have been more beneficial than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in allergy and immunology and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing performed for evaluation of his follicular lesion of undetermined significance. Findings: Three physician reviewers found that there are multiple peer-reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. This type of testing is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network (NCCN) 2016 guidelines. In this patients case, the cytopathology of the 1.3 cm thyroid nodule was consistent with a FLUS. The risk of malignancy is 5-15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The 2015 American Thyroid Associations guidelines state that investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision making. If the genetic test is suspicious, the risk of malignancy increases to approximately 40%. In this case, the result of the Afirma GEC was suspicious for malignancy. This information was important to help decide whether to perform thyroidectomy and may prevent a diagnostic hemithyroidectomy. The sample was obtained at the same time of the fine needle aspiration biopsy and no additional procedure was needed. In sum, the gene testing performed was likely to have been superior to other available options for the evaluation of this patients medical condition.Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the prostatic lift implant.Findings:  Two physician reviewers found that the prostatic UroLift system is a minimally invasive approach to treating benign prostatic hyperplasia (BPH) that lifts or holds the enlarged prostate tissue out of the way so that it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift system treatment is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. However, other treatment options including medications and transurethral surgery were offered to this patient. It is unclear if the patient was a good candidate for UroLift procedure from the records provided for review. The patient has urinary retention from unknown etiology but there is no evaluation to determine etiology as from bladder outlet obstruction or detrusor dysfunction. The current medical literature does not support use of UroLift in patients with urinary retention. Final Result: Two reviewers determined that the service at issue was 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 urology and are actively racticing. 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 Zepatier for treatment of the enrollees hepatitis C. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including or Zepatier, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure (esophageal sphincter augmentation device) for treatment of her gastroesophageal reflux disease (GERD).Findings: Three physician reviewers found that the request for the LINX procedure (esophageal sphincter augmentation device) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a diagnosis of GERD based on pH recording but whether she is medically refractory to acid blocker drugs cannot be determined. The records do not specify the PPI brand, dose, or duration. Also, implantation of LINX in this clinical setting must be approached with caution given her documented solid food dysphagia and known history of Barretts. LINX may exacerbate dysphagia, and is not indicated for patients with Barretts esophagus. As such, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: All three physician 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 number are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewer 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.