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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with myofascial pain syndrome. Magnetic resonance imaging (MRI) of the left shoulder revealed supraspinatus and infraspinatus tendinosis with minimal acromioclavicular osteoarthritis. MRI of the cervical spine showed multilevel disc desiccation, moderate to severe canal stenosis at C3-4, and mild canal stenosis at C6-7. The patient reported four years of constant left sided neck pain with radiation to the trapezius area, left medial arm, and middle finger. She also reported numbness in the same distribution as the pain. Physical examination findings included full strength in all major muscle groups of the upper extremities. Tenderness to palpation was noted over the left cervical paraspinous muscles, left trapezius muscle, and periscapular area with radiation to the left upper extremity. The patient has been treated with physical therapy and acupuncture, with no significant pain relief. She was also treated with a left acromioclavicular joint injection and biceps tendon injection with no relief. The patient has requested authorization and coverage for MRI of the back, shoulder, and pectoralis region. The Health Plan has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. At issue in this case is whether an MRI of the back, shoulder, and pectoralis region is medically necessary for the evaluation of the patients medical condition. This patient has had an MRI of the cervical spine and the left shoulder with no documentation of any significant change in symptoms since examinations. Nerve conduction study results were not noted in the medical records. The symptoms the patient exhibits can be seen with brachial plexopathy, but the hallmark of that diagnosis is a positive nerve conduction study. While radiculopathies tend to be sensorimotor, brachial neuritis is often motor-dominant. Electrophysiological studies help in the confirmation of diagnosis, extent of lesion, and prognostication. Due to the lack of a nerve conduction study and lack of documentation of significant change in symptoms since the MRI studies, the requested MRI of the back, shoulder, and pectoralis region is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injections. An exhaustive review of current medical literature pertaining to the viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective.  The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the options are limited, with the alternative being a total knee arthroplasty. As such, the requested Synvisc One injections are medically necessary for treatment of patients knee osteoarthritis.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 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:  The enrollee has requested reimbursement for a home sleep study. Based on the records, the enrollee underwent a neurology consultation for complaints of possible Obstructive Sleep Apnea (OSA). Her past medical history included migraine headaches and chronic sinus infections. Her chief complaint was trouble sleeping at night for 20 years and she complained of being sleepy all day, teeth grinding and snoring.  She had broken several night mouth guards as a result.  The enrollee also had a sinuplasty and septoplasty but the sleeping and snoring did not improve. Her total amount of sleep per night was 5 to 6 hours.  The record indicated no restlessness, tingling or crawling in her arms and legs and she did not experience an inability to keep her legs still prior to falling asleep.  The enrollees provider indicated the enrollee had many symptoms consistent with OSA and was to undergo a diagnostic sleep study. According to the medical literature, the two accepted methods of objective testing for patients suspected to have obstructive sleep apnea (OSA) are an in-laboratory polysomnography and home testing with portable monitors. Specifically, polysomnography is recommended for the diagnosis of all sleep-related breathing disorders to include OSA. An attended, in-laboratory polysomnography is performed rather than home testing, in patients with suspected complicated OSA, such as in enrollees with cardiorespiratory disease or narcolepsy. Home sleep apnea testing may be used for the diagnosis of OSA in enrollees with a high pre-test probability of moderate to severe uncomplicated OSA, such as in enrollees without medical co-morbidities. According to the sleep study report, this enrollee had an elevated Epworth Sleepiness Scale (ESS) score of 13. The records also indicate she has a diagnosis of hypersomnia. It was not noted to be idiopathic hypersomnia, and she had no major co-morbidities. However, the enrollee did have a high pre-test probability of moderate to severe uncomplicated OSA as indicated by her ESS. Therefore, the home sleep study performed was medically necessary to treat the enrollees condition.Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Armour thyroid. According to medical literatures, 48.6% of patients preferred desiccated thyroid extract (DTE), such as Armour thyroid. In the subgroup analyses, those patients who preferred DTE, lost four pounds during the DTE treatment, and their subjective symptoms were significantly better while taking DTE as measured by the general health questionnaire-12 and thyroid symptom questionnaire. Similarly, researchers found a higher satisfaction rate in patients on DTE. According the researchers, clinical evidence is not sufficiently strong to support LT4/LT3 combination therapy in patients with hypothyroidism. Medical Literatures noted that providers should consider adding T3 as a therapeutic trial in selected patients. Overall, the data supports T3 therapy, either as liothyronine added to levothyroxine, or as DTE as an add-on or in lieu of LT4, as this patient is requesting, due to persistence of hypothyroid symptoms. Therefore, the records have established that the requested Armour thyroid is medically necessary for treatment of this patient.  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 subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The enrollees representative has requested authorization and coverage for Diagnostic Genetic Testing. Review of the medical record indicates an enrollee who has been diagnosed with autism, as well as intellectual impairment.  The enrollee was nonverbal at baseline so her parents are typically her source of information.  The enrollee does have a history of cataracts, urinary incontinence, rectal bleeding and abnormal plasma amino acids.  She has undergone previous genetic testing revealing chromosome every 4 deletion.  The submitted documentation includes multiple notes to include previous hospitalizations. The submitted documentation detailed the enrollee has undergone MicroArray testing as well as FISH testing.  The enrollee has had an increase in complications to include a ruptured esophagus with intractable emesis and has had cataract removal over the past few years.  Current peer-reviewed literature indicates mitochondrial genetic disorders may be caused by changes in either the mitochondrial DNA or nuclear DNA. Most DNA is packaged within the nucleus of each cell. However, mitochondria contain a small amount of their own DNA. Mitochondrial genetic disorders can be inherited but may be difficult to diagnose. Literature indicates when a mitochondrial genetic disorder is suspected but the signs and symptoms do not suggest a specific diagnosis a more extensive workup may be required. In the same cases testing levels of certain substances in the blood or cerebrospinal fluid may be appropriate.  In this case, the records show the enrollee had previously undergone genetic testing revealing a Q4 deletion.  The patients representative requested additional testing for possible oxidation phosphoric ablation defect, possible nonketotic hyperglycemia, or a mitochondrial disorder.  However, the records do not demonstrate how this will change the treatment plan given the enrollee has undergone multiple extensive work-ups, and results from specialists such as urology were not provided.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Clinical Cytogenetics and Clinical Genetics 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for occupational therapy using sensory integration therapy once a week and normal occupational therapy (OT) once per week. According to the enrollees medical record, this enrollee is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and Sensory Processing Disorder. His parent reported that the enrollee was having behavioral issues at school such as over stimulation, mimicking other children and being troublesome and disruptive in class. Previously, he did fine in a smaller group of children and the issue had started when he was sent to a bigger group. He was fine when with his parents. The enrollee could not sit still in the classroom, but his father did not want to start him on medications. The enrollee did not have problems learning or doing what he was told to do, but could not focus for long. The enrollee was diagnosed with Attention Deficit Hyperactivity Disorder and was said to be sensitive to noise. The enrollee was seen by occupational therapy for evaluation of motor skills, which was found to be fine. His father states his son has difficulty in loud or crowded places and is causing an issue for him to have a successful career in school. According to the medical literature, there is no universally accepted framework for diagnosis and sensory processing disorder generally should not be diagnosed. Children with a range of neurodevelopmental and behavioral disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and anxiety disorders have symptoms of sensory processing disorder. A review of the peer-reviewed medical literature found no role for the use of occupational therapy to treat Attention Deficit Hyperactivity Disorder or Sensory Processing Disorder in the absence of a substantiated deficit in fine motor skills. In this case, average fine motor precision, fine motor integration and manual dexterity were found. The medical literature identified few positive effects were found in sensory-based intervention studies and suggest interventions may not be effective.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Pediatrics and Pediatric Developmental Medicine and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for Xeljanz XR for the treatment of psoriatic arthritis. The Health Plan denied this request as not medically necessary on the basis that he has not tried two of the preferred (formulary) drugs to treat his condition. They assert that studies do not show that Xeljanz XR works better than other drugs to treat the enrollees condition.Findings: The physician reviewer found that a review of the medical record indicates the enrollee was diagnosed with psoriatic arthritis that has involved his scalp, fingers, ankles, and other joints.  He has tried other medication with no change in his condition. He has been taking Xeljanz XR for several months and reports it is very effective for his condition and has no side effects.  A review of the medical literature indicates Xeljanz is now approved for adults with active psoriatic arthritis (PsA) who have had an inadequate response or intolerance to methotrexate or other disease-modifying antirheumatic drugs (DMARDs). In a trial involving patients with active psoriatic arthritis who had had an inadequate response to TNF inhibitors, Xelanjz (tofacitinib) was more effective than placebo over three months in reducing disease activity. Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy. Therapy with anti-tumor necrosis factor (TNF) agents represents the first therapeutic choice for moderate and severe forms; however, PsA patients can experience anti-TNF failure, lack of efficacy, or adverse events. Evidence exists on the effectiveness of switching among different TNF inhibitors and most of the studies report that the main reason for switching to a second anti-TNF agent is represented by lack of efficacy (primary or secondary) and, more rarely, adverse events. This enrollee has documentation of treatment failure of two TNF inhibitors, whether these are the specific preferred TNF inhibitors or not, treatment with a third TNF inhibitor, such as Humira, has very low likelihood of benefit. Therefore, a biologic with a different mechanism of action, such as Xeljanz, is medically necessary.   Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for Benlysta that was denied by the health plan as not medically necessary. A review of the medical records indicates the patient with systemic lupus erythematous was seen by her rheumatologist.  She was having a mild flare in symptoms and wanted to re-start the medication.  Physical examination showed slight tenderness over some joints, no acute synovial swelling or effusion and good range of motion.  There was no evidence of rashes.  Labs results showed a negative double-stranded antibody and negative Smith antibody. According to the medical literature, serologically positive systemic lupus erythematosus (SLE) patients responded favorably to treatment with belimumab plus standard of care therapy. This is consistent with the phase III belimumab trials.  There is no documentation of any positive autoantibodies or low complement levels.  Thus, there is no evidence of active lupus to the extent that would require use of Benlysta based on the data available in the time frame under review.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Rheumatology 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 similar medical condition.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for prophylactic extraction of third molars. Findings:  The physician reviewer found that age at loss of primary teeth and eruption of the succedaneous teeth can follow a wide normal range. However, it is typical that the primary second molars are lost close to age 12. In patients with mixed dentition, the primary molars are wider than the erupting premolars, which typically provides several millimeters of space in the arch. The panoramic image provided for review is a planar image and is not reliable to predict impingement of the adjacent teeth. With additional room in the arch to be gained upon loss of the remaining primary teeth, prophylactic third molar extraction is not indicated. While recommendations for extraction of wisdom teeth vary, current peer-reviewed dental literature provides a paucity of data to support prophylactic removal of asymptomatic third molars. As teeth numbers 1, 16, 17, and 32 demonstrate no pathology, the requested prophylactic extraction of third molars is not medically necessary for treatment of the 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 dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for Jaw Reconstruction Surgery-Reconstruct Full Maxilla. According to the enrollees medical record, he sustained an injury resulting in a broken jaw and loss of teeth. He had open reduction internal fixation surgery to fix his broken jaw. His physician states he has multiple issues directly as a result, including malnutrition, digestive problems, mood disorders, limited social activity, and speech problems. He has been diagnosed with moderate atrophy of the maxilla, hyperactive gag reflex, and myalgia. This enrollee sustained maxillofacial trauma. Due to the trauma, he lost his maxillary dentition, is currently edentulous in the maxilla, and has presumably been functioning with a full denture maxillary removable prosthesis since that time. The recommendation was for maxillary bone grafting and implants related surgical services to restore normal anatomy, function and esthetics.  It is evident based on the radiographic CT images that the enrollee exhibits a maxillary defect and edentulism in the maxilla.  Further, it is documented that function has been impaired since the time of initial trauma.  Despite documentation that indicates that the trauma was many years prior, the trauma was the proximate cause of the loss of function and directly resulted in the current condition and functional impairment. Given the clinical and radiographic findings, reconstruction of the maxilla and implant placement is indicated to restore function. Lastly, the services to be performed meet the expanded concept of medically necessary reconstructive criteria as defined by California law as follows: The requested jaw reconstruction surgery (reconstruct full maxilla) is medically necessary to treat the enrollees condition. The alleged abnormality does constitute an abnormal structure of the body. The abnormal structure of the body is caused by Trauma. The requested surgery is performed to improve function and create a normal appearance to the extent possible. The surgery does provide more than a minimal improvement in the appearance of the enrollee. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The reviewer is board certified in Oral and Maxillofacial 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 similar medical condition.