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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for OvaGene gene expression testing for evaluation of the enrollees recurrent ovarian cancer.  Findings: Three physician reviewers found that the current medical evidence has not established the superior effectiveness of the services at issue.  With regards to OvaGene testing, there is insufficient evidence to supplant standard of care chemotherapy.  There is a lack of support for chemotherapy sensitivity and resistance assays in this clinical setting.  The use of these assays has not been shown to improve survival in women with ovarian cancer.  There is a lack of evidence indicating that OvaGene gene expression testing is more beneficial than standard chemotherapy choices.  Therefore, OvaGene gene expression testing was not likely to have been of greater benefit than other methods of evaluating this patient.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested for platelet-rich plasma injection for treatment of the enrollees chronic knee pain.  Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Middleton and colleagues concluded that despite its pervasive use, the clinical efficacy of platelet-rich plasma therapy in the healing of soft tissue injuries and varying mechanisms of action have yet to be established.  Moraes and colleagues concluded that overall, there is currently insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries.  There is a lack of long-term high-volume studies that establish the efficacy of leukocyte-poor, platelet-rich plasma therapy for intraoperative use to minimize postoperative inflammation or recurrent scar tissue formation in this clinical setting.  There is some evidence of benefit in the setting of cartilage or meniscal degeneration, which is not the case for this patient. Therefore, platelet-rich plasma injection was not likely to have been more effective than other treatment options.Final Result: Three reviewers determined that the services at issue were 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 orthopedic surgery 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 coverage for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result:  Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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 reimbursement for air and ground ambulance transportation services for treatment of the enrollees traumatic brain jury. Findings:  The physician reviewer found that the air ambulance and ground ambulance transportation services were medically necessary for treatment of the patients medical condition. In this case, the patient sustained a brain injury and hip fracture over one thousand miles from home. The patient was recommended for inpatient rehabilitation at RIC for treatment of functional deficits related to hip fracture surgery and a brain injury. Due to his weight bearing restrictions and confusion, medical monitoring during air travel was medically necessary. To receive early specialized rehabilitation with his support network, the patient required transport home by air ambulance. As such, transport home by air and ground ambulance was medically necessary for the patient to receive early specialized rehabilitation in close proximity to his support network. 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 reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested for emergency services. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with an acute knee injury. The patient was unable to straighten the knee and/or bear weight on the knee. He had pain with ambulation. The differential diagnosis of knee trauma in this case includes fracture of the tibial plateau, meniscal injury, anterior cruciate ligament tear, patellar dislocation, and others. These potential injuries may be of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions and/or serious dysfunction of the knee joint. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the ED services met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion for treatment of the enrollees spondylolisthesis. Findings:  The physician reviewer found that evidence based medical guidelines support lumbar spine fusion for isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Fusion be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. The peer-reviewed literature supports lumbar fusion in the setting of isthmic spondylolisthesis with symptomatic radiculopathy or spinal stenosis when non-operative treatment has failed. This patient presented with a history of chronic low back pain radiating to the right buttock and left leg. There is imaging evidence of isthmic spondylolisthesis at L5/S1 with moderate lateral recess and foraminal stenosis. Evidence of long-term reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Therefore, the requested lumbar spinal fusion is medically necessary for the treatment of this patient. Final Result: The reviewer determined that I have 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 10 treatments of MLS laser therapy for treatment of the enrollees foot pain. Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent medical guidelines for this case, the 10 sessions of MLS cold laser therapy were not medically reasonable or necessary for treatment of this patients Mortons neuroma. MLS cold laser therapy has not been proven to be significantly effective in the treatment of Mortons neuroma pain. While studies show some promising efficacy for this modality, there is a lack of double-blind placebo-controlled studies on Mortons neuroma to demonstrate its superior effectiveness versus surgical excision of neuroma, alcohol injection sclerosis of neuroma, or orthotic therapy with metatarsal raise pads. For these reasons, the 10 treatments of MLS laser therapy was not medically necessary for 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of the enrollees sacroiliitis. Findings: Two physician reviewers found that the requested radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In well-selected patients the medical literature supports the utility of sacroiliac joint neurolysis for the treatment of sacroiliac joint pain. In this case, the patient has evidence of sacroiliac joint dysfunction which is confirmed by her positive results from the sacroiliac joint injections. However, there is a lack of documentation demonstrating that the patient has tried rest, activity modification, exercise, and medication management with inadequate relief in pain. In addition, the relief obtained with the right sacroiliac joint injection was not specified. After a review of the clinical records, it is not confirmed that the patient has refractory sacroiliac pathology for which radiofrequency neurolysis is an appropriate treatment. Therefore, based on current medical literature and in consideration of the presented clinical records, radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with fever, headache, chills, abdominal pain and nausea. These symptoms can indicate possible sepsis, a potentially life threatening infection. In addition, nausea precludes the ability for the patient to take oral medications such as oral antibiotics. She reported her pain rating at 10/10. Finally, the patients symptoms had been persistent for 10 days which indicates a more serious infection as most minor illnesses resolve within one week. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the ED services met prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. Findings:  The physician reviewer found that for this patient, there is no documentation of clinical findings that would support the need for anesthesia services. The patient had an (ASA) preoperative physical status classification score of 1 which indicated low preoperative risk. Intravenous sedation, performed by a non-anesthesiologist and non-certified registered nurse anesthetist, is well supported in both clinical practice and in the medical literature. Therefore, given a low preoperative physical status classification score of 1, the anesthesia services administered were not medically necessary. 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 anesthesiology 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 collagen meniscus implant of the right knee for treatment of the enrollees medical condition. Findings:  The physician reviewers found that there is sufficient support for the requested services in this clinical setting.  This patient does not have advanced disease that would require a total knee arthroplasty.  Individuals who have this procedure are improved because their previous quality of life was significantly limited due to advanced arthritis.  For an individual with mild arthritis, however, a total knee arthroplasty would be a poor choice as the kinematics of a knee arthroplasty are poor in relation to a normal knee.  However, although this patient does not have advanced arthritis, he continues to be symptomatic.  He has no history of degenerative meniscal tears that occur through activities of daily living.  Per the medical records, he has had acute meniscal tears due to trauma.  This patient appears to be an appropriate candidate for a cartilage meniscus implant.  In sum, the requested collagen meniscus implant of the right knee is likely to be of greater benefit than other treatment alternatives. Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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 reimbursement for vision therapy services for treatment of the enrollees bilateral essential emmetropia. Findings:  The physician reviewer found that there is a lack of scientific evidence that vision therapy is of benefit for a young patient who has trouble reading but has a normal eye exam. There has been a great deal of controversy on this topic over time, but to date, there is no data to suggest that such therapy helps. There can be a multitude of reasons why a patient at this age has difficulty with reading, which may have nothing to do with the eyes if the vision and eye exam is normal. The American Academy of Ophthalmology and the American Academy of Pediatrics have both stated that they do not endorse vision therapy as a valid treatment in this clinical setting. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for stereotactic body radiation therapy (SBRT) for treatment of the enrollees prostate cancer. Findings:  The physician reviewers found that SBRT for prostate cancer is an emerging technology. At the present time, SBRT of prostate is being evaluated in phase I-II trials. While SBRT is a promising technology, it is considered experimental/investigational in this clinical setting due to insufficient data in the literature supporting its use. Until the clinical outcomes (local control, survival, toxicity) relative to intensity modulated radiation therapy (IMRT) with or without brachytherapy are known from these trials, SBRT is not considered standard of care for localized prostate cancer. There is very limited published data on the long term efficacy and safety of SBRT for prostate cancer when compared to standard fractionated IMRT or brachytherapy. A few available articles on SBRT treatment of prostate cancer are from single institution studies with a small number of patients and short follow up. They are mostly technical feasibility studies and do not provide data on the long term efficacy and safety. Until the results from the current trials can demonstrate long term efficacy of SBRT for early stage prostate cancer, SBRT cannot be considered as a standard of care. For these reasons, SBRT is not likely to be more effective than any conventional modality for treatment of this patient. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in radiation oncology 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.