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 the cell function assay involving stimulation for evaluation of the enrollees ulcerative colitis. Findings:  Three physician reviewers found that there is a lack of sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to a study, the ImmuKnow Immune Cell Function Assay has been developed to measure the activity of CD4+ T cells as a marker of global immune-competence. The changes in T cell activation were correlated with the relative risk of rejection and infection. However, the most significant utility of the ImmuKnow test, in combination with other clinical parameters, is to identify immune-compromised patients and to help to tailor individualized immunosuppression regimens. None of the conditions listed in the study fit the patients clinical setting. Moreover, the available literature does not support use of the cell function assay for treatment of patients with ulcerative pan-colitis. Based on the medical literature available, the use of cell function assay involving stimulation was not clinically indicated for this patient. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  Three physician reviewers found that based on the records provided, the patient has a history of increased cardiovascular risk and known vascular disease. In this circumstance aggressive risk factor modification including highest tolerable -statin dose is indicated regardless of results on advanced lipoprotein testing. Guidelines for the management of cardiac risk and dyslipidemia are available and endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including Lp-PLA2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), CRP, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for bilateral Orthovisc injection series for treatment of the enrollees degenerative osteoarthritis. Findings:  The physician reviewer found that Intra-articular injection of hyaluronic acid is an established part of treatment algorithms for management of osteoarthritic knee pain and is generally considered a second-line therapy after treatment with nonsteroidal anti-inflammatory medications. Multiple studies have documented the efficacy of intra-articular hyaluronic acid injections for osteoarthritic knee pain. All told, the requested bilateral Orthovisc injection series is medically necessary for this patient with documented osteoarthrosis which persists despite treatment with oral and topical nonsteroidal anti-inflammatory medications. 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement for continued acute inpatient psychiatric treatment. Findings:  The physician reviewer found that the discharge summary documented that the patient was not unsafe and was considered a leader among his peers.  There were no major medication changes other than changing his lorazepam from every night at bedtime to an as needed basis.  The patient's neurological consultation and electroencephalogram did not uncover any pathology.  There were no special treatments that were administered during this time which required acute inpatient level of care.  The current medical evidence does not support the services at issue in this clinical setting.  All told, continued acute inpatient psychiatric treatment was not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in psychiatry with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography/computed tomography (PET/CT) scan for evaluation of the enrollees rectal cancer. Findings:  The physician reviewer found that there is some debate concerning the use of PET/CT as a surveillance tool in colorectal cancer cases. However, the current literature tends to favor this technique particularly in the post-operative patient with surgical deformity and scar formation as the normal anatomic planes are obscured in this scenario making conventional imaging studies less advantageous. Recent articles support the use of PET and the calculation of the standardized uptake value (SUV) as a physiologic assessment of abnormal tissue and a differentiator between post-operative scar and tumor. Moreover, since this patients chemotherapy ended, a PET/CT will serve as a post treatment baseline. For these reasons, the requested PET/CT scan is medically necessary for evaluation of this patients rectal carcinoma. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of varicose veins for treatment of the enrollees varicose veins. Findings:  The physician reviewer found that the request for endoluminal ablation of varicose veins is not medically necessary for treatment of the patients medical condition. The patient has recurrent superficial venous reflux with limited documentation of symptoms that support endoluminal ablation in this clinical setting. According to colleagues recurrent varicose veins (RVV) occur in 13% to 65% of patients following treatment. Three types of RVV have been reported, namely residual veins, true RVV, and new varicose veins. Repeated intervention is associated with reduced patient satisfaction. Therefore, a less invasive approach, consisting of multiple phlebectomies or alternative techniques, has been advocated to replace invasive redo surgery including re-exploration of the groin or popliteal fossa. Extensive redo surgery should be performed only in selected cases. Ultrasound-guided foam sclerotherapy or liquid sclerotherapy is the preferred form of treatment for recurrent varicose veins. Accordingly, the request for endoluminal ablation of varicose veins is not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Synvisc One injections for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines stated that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. Colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period.  As such, evidence based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with 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. In this case, the patient was diagnosed with bilateral knee osteoarthritis. He presented with worsening knee pain and difficulty in walking and performing activities of daily living. He has been treated with corticosteroid injections, bracing, home exercise, medications, and activity modification without sustained relief. He has undergone prior series of Orthovisc injections with reported significant sustained pain relief and improvement in his functional ability to perform activities of daily living. These injections have been recommended to delay total knee arthroplasty. Therefore, the Synvisc One injections were medically necessary for the treatment of this patients medical condition. 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 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 the medical model of rehabilitation at Valley Recovery Center (VRC) of Sacramento services provided for treatment of the enrollees alcohol dependence. Findings: The physician reviewer found that this patient reported withdrawal symptoms, however they were not rated via Clinical Institute of Withdrawal Assessment (CIWA) scales. In addition, he was not a danger to himself or others, and he was not aggressive or violent. The records describe the patient to be medically stable, although there is no medical admission physical. He was psychiatrically stable as his depression and anxiety did not require the confines of a residential setting and could have been safely and adequately managed on an outpatient basis. He attended group therapy, but the records do not document that the patient received individual psychotherapy or psychiatrist visits. He verbalized motivation and worked on steps. However, there was no mention of 12 step meetings or the attempt to obtain a sponsor. Based on the information provided, the patient did not require residential treatment, and the treatment at River City authorized by the Health Plan, would have been more than adequate to address the patients issues. Therefore, the medical model of rehabilitation services provided at VRC of Sacramento were not medically necessary for 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 with sub-specialty certification in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for assay of lipoprotein (a) for evaluation of the enrollees lipoprotein level. Findings:  The physician reviewers found that while some providers advocate use of the advanced lipoprotein analysis, this testing has not been recommended by standard guidelines from the American College of Cardiology (ACC). Rather the ACC guidelines recommend use of standard risk factor analysis and standard lipid panels. All told, the assay of lipoprotein (a) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Optune Tumor Treatment Fields Therapy (E0766) device for six months rental/six total units for treatment of the enrollees glioblastoma multiforme. Findings: Three physician reviewers found that Optune Tumor Treatment Fields Therapy has been approved for use in the treatment of glioblastoma.  It is a helmet-like device that is attached to the shaved scalp, and continuous treatment is recommended.  There are sufficient studies supporting the efficacy of this modality.  One study performed a randomized study of 210 patients with recurrent glioblastoma, comparing treatment with Novo-TTF with Temodar, versus Temodar alone.  There was improved median progression-free survival and median overall survival with the combination.  Clinical benefit was also seen in another study.  Therefore, Optune Tumor Treatment Fields Therapy (E0766) device for six months rental/six total units from 10/04/16 forward was and is likely to be more beneficial than other treatment options. Final Result: The 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and for continued skilled nursing facility (SNF) level of care services with physical therapy for treatment of the enrollees West Nile Virus complicated by respiratory failure. Findings:  The physician reviewer found that the available medical records document that the patient has made excellent progress in self-care and functional mobility with skilled therapies. The American Academy of Physical Medicine and Rehabilitation states that skilled services are medically necessary when the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel. This patient is at a functional level where she does not require inpatient skilled therapy. She is not able to fully care for herself and requires the non-skilled assistance of her family at home. She may need outpatient physical therapy and occupational therapy but the records do not support a need for intensive skilled therapy. All told, continued SNF level of care services with physical therapy were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine 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.