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

An enrollee has requested reimbursement for physical therapy sessions including the use of an AlterG anti-gravity treadmill. The medical literature does not support that physical therapy sessions that include the use of an AlterG anti-gravity treadmill are superior to traditional physical therapy. The literature cited in support of the patients request are limited to case studies that have a small sample size. A study that considered rehabilitation with anti-gravity treadmill after Achilles tendon surgery had roughly 16 patients. Their study found that the group of patients who used the specialized treadmill returned to ground running only a short time prior to those patients who had traditional physical therapy. The article suggested that this difference was not statistically significant. In this case, the patient underwent open reduction internal fixation of a navicular stress fracture and was advised to engage in physical therapy to provide intrinsic muscle strength, proprioception, gait/balance, and running conditioning. The orthopedic surgeon specifically recommended the use of a particular type of treadmill, the AlterG anti-gravity treadmill, which would allow the patient to run on the treadmill while removing a percentage of his body weight (anti-gravity). The medical literature, however, does not establish that the use of this anti-gravity treadmill is superior to traditional physical therapy. Accordingly, the physical therapy sessions including the use of an AlterG anti-gravity treadmill were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with medically monitored residence based services, such as RTC. Given these findings, the RTC services were and are medically necessary for treatment of this patient.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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Linzess 72 mcg twice a day. The American Gastroenterological Association medical position statement on constipation states, We suggest a gradual increase in fiber intake, as both foods included in the diet and as supplements and/or an inexpensive osmotic agent, such as milk of magnesia or polyethylene glycol. Depending on stool consistency, the next step may be to supplement the osmotic agent with a stimulant laxative (e.g., bisacodyl or glycerol suppositories). In this case, the patient has failed an osmotic laxative, MiraLAX, but has not attempted other laxative classes recommended by the American Gastroenterological Association before the use of advanced pharmaceutical laxatives such as Linzess. The medical evidence does not support the requested medication in this clinical setting. Therefore, Linzess 72 mcg twice a day is not medically necessary for the treatment of this patient. 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 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

An enrollee has requested reimbursement for monitored anesthesia care (MAC) provided during a colonoscopy procedure. The submitted documentation supports that the services at issue were medically necessary. According to American Society of Anesthesiologists (ASA) guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE), during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with moderate sedation), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. In this case, the patient underwent a complex large polyp resection requiring submucosal injection, polyp lift, and en bloc endoscopic mucosal resection, which meets the complex polyp resection recommendation of the American Society of Anesthesiologists. Under these circumstances, monitored anesthesia care (MAC) provided during the patients colonoscopy procedure was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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 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

An enrollee has requested authorization and coverage for a Miami Adjustable LSO back brace. Medical literature does not support that LSO back braces are an effective measure to treat even severe low back pain in the absence of objective instability or in an appropriate postoperative setting. Back orthoses are generally considered contraindicated because they can promote core weakness, which is the opposite of appropriate treatment. In this case, there are no indications in the submitted documentation that the patient has a condition that requires the use of a back orthosis. The submitted records indicate that the patient has chronic, intermittent and functionally incapacitating back pain following an old, unspecified back injury. Despite the patient's symptoms, a back orthosis is not necessary or appropriate under these circumstances for the patients condition. Accordingly, the requested Miami Adjustable LSO back brace is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

The patients enrollee requested coverage for the Nutropin AQ Nuspin. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug administration approval for this indication is for non-growth hormone-deficient short stature and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The patient had growth hormone administered in the past with documented benefits. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for the VenaSeal vein closure procedure. The enrollee has had worsening, bulging varicose veins over the last ten years. Symptoms include itching, tightness, swelling, and discoloration, with symptoms worse on the right side than on the left. A progress note included a diagnosis of bilateral varicose veins. A progress note from a subsequent visit reported compression stocking and leg elevation interventions have not been successful. The providers recommendation was for venous ablation, VenaSeal, or sclerotherapy. In the context of unsuccessful conservative measures, including lower extremity elevation and compression stockings, the use of endovenous technology, including VenaSeal, is likely to be more beneficial than previously tried conservative attempts at symptom relief. This enrollee has tried and failed such conservative therapies, with a clinical result that is unsatisfactory. Therefore, this enrollee is an appropriate and suitable candidate for such technology. Final Result: Two of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease and are actively practicing.  All three 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

The patient is requesting reimbursement for the left L4-5 epidural steroid injection with fluoroscopy. The patient has a history of chronic low back pain, with an injury in his late teens, followed by several low back injuries with sciatica over the years. The record indicates treatment with physical therapy (PT), chiropractic care, medications and epidurals with fair relief. He had an exacerbation of his chronic low back pain treated conservatively. He underwent magnetic resonance imaging (MRI) of the lumbar (L) spine revealing multilevel degenerative changes most pronounced at the L4-L5 level producing severe left and moderate right foraminal stenosis with moderate left foraminal stenosis at L5-sacral (S) 1 level. The provider recommended an epidural steroid injection to the low back. The patient underwent an interlaminar steroid epidural injection at the L4-L5 level on the left and follow-up two weeks later reported that he was better after the injection. He underwent an additional steroid epidural injection at the L4-L5 level with follow-up two weeks later reporting about relief from the injection.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for a bilateral temporal hairline brow lift. Medical literature states that special attention must be given to brow position and that brow position plays a significant role in eyelid crowding. They indicate that providers cannot improve brow ptosis with a blepharoplasty procedure, and attempts to do so will cause complications. They advise that providers must look at the position of the lower border of the actual brow skin, and if the lower border of the brow is significantly below the superior orbital rim, this must be noted. Medical literature also states that brow ptosis is defined as brows that rest below the supraorbital ridge and can compromise vision via obstruction of the superior visual fields. In this case, the patient had clinically significant visual obstruction, confirmed by physical examination, visual field examination taped and untaped, and clinical photos. The patients upper eyelid skin was markedly redundant, and her brows were significantly below the supraorbital ridge, confirmed by physical examination and clinical photos. Under these circumstances, upper lid blepharoplasty alone would not adequately restore the patients superior visual field. Accordingly, bilateral temporal hairline brow lift was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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

The patient has requested authorization and coverage for Serostim 6 mg vial. Anorexia-cachexia syndrome is a clinical problem present in patients with AIDS characterized by loss of appetite and weight loss. The U.S. Food and Drug Administration (FDA) has approved Serostim to treat AIDS-related cachexia. Serostim (somatropin) is a recombinant human growth hormone, which has been used to treat cachexia. Although there are limited options for the treatment of AIDS-associated cachexia, the current evidence supports a role for Serostim in the treatment of patients with this condition. This patient has a diagnosis of AIDS-related cachexia and he has benefited with Serostim treatment in the past. Therefore, the requested Serostim 6 mg vial 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 patient has requested authorization and coverage for diazepam (Valium) 2 mg tablet. In this case, the patient has chronic neck and back pain with a history of two neck surgeries. After her initial fusion surgery, she was treated with Valium in the immediate postoperative period, and then with Baclofen. Her medical records do not report that the patient has attempted treatment with other muscle relaxants. The current medical literature indicates that there is a lack of evidence demonstrating that Valium is superior to other muscle relaxants for chronic pain or muscle spasms. There is evidence that chronic use of Valium carries increased risks of dependence and sedation compared to other medications in this class. All told, the requested diazepam (Valium) 2 mg tablet is not medically necessary for treatment of this patient.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 subspecialty certification in pain management 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

The patient has requested authorization and coverage for a COVID-19 test. As reported by the Centers for Disease Control and Prevention (CDC), the symptoms required for COVID-19 polymerase chain reaction (PCR) testing have varied since the onset of the pandemic. Per the California Department of Public Health (CDPH) guidance, this patient does not meet the criteria for COVID-19 testing. The guideline notes that patients with mild respiratory symptoms who do not otherwise need medical care...should not be routinely tested for COVID-19. This patient reports symptoms including shortness of breath and a mild cough. On physical examination, the patient did not have a fever or significant cough. The patient has comorbid asthma, which is another condition that would account for his shortness of breath. Based on the current recommendations from the CDC and CDPH, the requested COVID-19 test is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious disease 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 patient has requested authorization and coverage for hydrocodone (Norco). The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain state that providers should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. The CDC states that opioid benefit should be clinically meaningful and defines this as clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function. The Federation of State Medical Boards (FSMB) guidelines recommend opioid therapy for chronic pain that is not cancer-relatedonly when non-opioid and non-pharmacological options have not been effective, and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic pain that has been treated with Norco as well as Flexeril and Robaxin. The patient also takes Soma, which is a muscle relaxer. The providers notes document concern over the concurrent use of Norco and Soma due to the risks of dependence, sedation, and possible overdose. Based on the CDC guidelines, the patients pain scores demonstrate less than 30% improvement in pain, which is not clinically meaningful. All told, the requested hydrocodone (Norco) is not medically necessary for treatment of this patient. 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 subspecialty certification in pain management 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.