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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Applied behavior analysis (ABA) therapy services: direct 1:1 ABA services, supervision by BCBA, caregiver training, and a re-assessment. Medical guidelines for the treatment of patients with autism spectrum disorder detail essential assessment and treatment components to support a treatment plan. In this patients case, the provider did not include direct observable forms of data collection in their analysis, and the provider did not report standardized measures throughout the patients treatment. In addition, the ABA services fail to meet several requirements outlined by researchers. According to researchers, documentation to support medical necessity criteria includes a) Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) autism diagnosis supported by symptoms; b) symptoms of diagnosis causing impairment; c) motivation for change exemplified by family involvement; d) interventions are evidence-based and consistent for type, frequency, and duration of treatment; e) goals are constructed with patients family; f) outcomes are measurable; g) occurs in least restrictive environment; h) required for purposes other than convenience of patient or provider; i) measurable reduction in symptoms; j) symptoms are manageable; and k) day-to-day functioning has improved over baseline. The submitted information fails to meet criteria (a) and (b). Specifically, the submitted psychological assessment from 2005 was based on DSM-IV criteria, and none of the assessments used were specific to autism. On review of the available records, there is a lack of an updated information to fully elucidate the depth of the patients delays and autism specific symptoms to support the ABA services as requested. Moreover, the ABA services are not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of type, frequency, extent, site, and duration for treatment of this patient. Given these findings, the ABA therapy services: direct 1:1 ABA services, supervision by BCBA, caregiver training, and re-assessment were not and are not medically necessary for treatment of this patient.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 a licensed B.C.B.A, board certified in psychology, 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 Takhzyro 300 mg/2 mL. Researchers describe angioedema as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). In this case, the patient has a diagnosis of hereditary angioedema, and the records document body edema along with episodes of abdominal pain. Given that the patients symptoms have been controlled on a regimen of Takhzyro, the requested medication is medically indicated. Therefore, Takhzyro 300 mg/2 mL is medically necessary for the 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 and in allergy and immunology 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 fat grafting to the hips.At issue is whether fat grafting to the hips is medically necessary to treat the enrollees gender dysphoria as defined in Health and Safety Code section 1374.72(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.World Professional Association for Transgender Health (WPATH) lists body contouring procedures as treatment for gender dysphoria. WPATH indicates, For the male-to-female (MtF) patient, surgical procedures may include nongenital, nonbreast surgical interventions: facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures. WPATHs Position Statement on Medical Necessity of Treatment states, Non-genital procedures are routinely performedthese surgical interventions are often of greater practical significance in the patients life than reconstruction of the genitals.In this case, the patient has sufficient documentation for the proposed procedure. In this patients case, fat grafting to the hips is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, the requested fat grafting to the hips are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of the tongue (CPT 41530). Patients with mild to moderate obstructive sleep apnea (OSA) are candidates for submucosal radiofrequency tongue base ablation. Radiofrequency ablation of the tongue base and/or palate has been evaluated and reported to be safe and effective in the management of well-selected patients with OSA. Baba and colleagues evaluated temperature controlled radiofrequency tissue ablation for the management of patients with symptomatic OSA. The authors found that temperature controlled radiofrequency tissue ablation was clinically effective in reducing RDI [respiratory disturbance levels] and symptoms of sleepiness in patients with OSA syndrome when directed at the base of tongue or as a multilevel procedure. This patient presents with OSA associated with poor sleep quality with associated daytime sleepiness, fatigue, and decrease in sleep-related quality of life. The patient was reportedly intolerant to treatment with positive airway pressure (PAP) and his symptoms have persisted. Therefore, the requested radiofrequency ablation of the tongue (CPT 41530) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested radiofrequency ablation of the tongue (CPT 41530) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in sleep medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL injection every 28 days. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has symptoms consistent with active  disease on Stelara 90 mg every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory results reported a low Stelara level of 3.2 ug/mL. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL injection every 28 days is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiotherapy (IORT) (CPT 77424, 77425, and 77469). Based on the available documentation, this patient has a history of left breast invasive ductal carcinoma in situ (DCIS). Pathology revealed the patients breast cancer to be estrogen receptor (ER) positive, progesterone receptor (PR) positive, and HER2Neu non amplified. The patients provider has recommended treatment with a course of radiation therapy using IORT. On review of the medical literature, there are sufficient outcomes data published demonstrating the safety and efficacy of IORT for patients with breast cancer who are suitable candidates for partial breast irradiation (Correa, et al.). Specifically, the TARGIT-IORT study is a high quality trial which supports the use of IORT as within the standard of care in this patients clinical setting. Vaidya and colleagues found that, For patients with early breast cancer who met our trial selection criteria, risk adapted immediate single dose TARGIT-IORT during lumpectomy was an effective alternative to EBRT [external beam radiotherapy], with comparable long term efficacy for cancer control. Given this support, the requested IORT (CPT 77424, 77425, and 77469) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested IORT (CPT 77424, 77425, and 77469) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Optune device (CPT E0766 - electrical stimulation device used for cancer treatment, includes all accessories, any type) provided on 4/01/21 through 5/01/21.Findings: Three out of three physician reviewers found that Optune device provided on 4/01/21 through 5/01/21 was likely to have been more beneficial for the enrollee than any available standard therapy.Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the glioblastoma maximally followed by treatment with temozolomide. Most glioblastoma tumors recur, and then the treatment options are limited. In 2011, the U.S. Food and Drug Administration approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent glioblastoma. Stupp and colleagues conducted a study comparing NovoTTF to the best standard of care chemotherapy. The authors found, No improvement in overall survival was demonstrated, however efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma. Toxicity and quality of life clearly favored NovoTTF. In this case, the patient has exhausted standard treatment. Therefore, Optune device (CPT E0766 - electrical stimulation device used for cancer treatment, includes all accessories, any type) provided on 4/01/21 through 5/01/21 was likely to have been more beneficial for the patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for gait analysis study. Due to the complexity of gait and especially pathological gait, clinical gait analysis is commonly used to identify, quantify, and understand the deficits of a specific patient. Gait analysis findings can be fully integrated into the clinical decision making of patients with complex gait disorders and provides objective identification of gait deviations (Armand, et al.). This patient has a congenital motor movement disorder that resulted in a complex pathological gait pattern causing functional deficits and safety concerns. She has been treated by a multidisciplinary team and has failed to make further progress with serial casting, weekly physical therapy, and daily orthotic use. She remains a high risk for worsening of existing and development of new skeletal deformities and functional decline. The goal for her orthopedic and rehabilitation care is to correct her skeletal malalignment and maximize her physical function. This patient would benefit from a clinical gait analysis to help determine the next steps in her care. Clinical evaluation is part of the assessment but does not provide the level of precise and objective evaluation available with a computerized three-dimensional (3D) clinical gait analysis. The current evidence supports the efficacy of gait analysis for treatments on this patients gait deviations. Given this support, the requested gait analysis study is medically necessary for evaluation of this patient. 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for food allergy testing services. Researchers note that the general approach to diagnosis of food allergy include modalities such as medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin E (IgE) measurements, and oral food challenges. Current medical literature does not support the inclusion of an assessment of immunoglobulin (Ig) G, IgA, IgE, IgM and IgG subclass levels in the work-up of an individual with food allergies. The quantitative immunoglobulins are usually measured in the work-up of immunodeficiency. Basophil activation testing and mast cell receptor activity values are not standardized and are not supported as being of value in a standard evaluation of a patient with food allergies. While testing IgE levels to specific foods in question may be part of a food allergy evaluation, an extensive array of blood tests that examine aeroallergen component IgE as well as food IgG4 testing is not of demonstrated benefit in the evaluation of food allergies. A complete blood count (CBC) with differential is not generally indicated for the evaluation of a food allergy patient. Therefore, food allergy testing services are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested food allergy testing services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services  are 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 1 is board certified in internal medicine and in allergy and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for magnetic resonance imaging (MRI). Findings:  The physician reviewer found thatmedical literature supports the use of MRI, especially when a significant etiology is being considered.  The American College of Radiology appropriateness criteria on neck mass-adenopathy identify two variants that were applicable to this patient, a non-pulsatile neck mass, not parotid region or thyroid, and a neck mass in child, not parotid or thyroid. In both variants, the guidelines note that an MRI of the neck is usually appropriate. Razek and colleagues note regarding soft tissue tumors of the head and neck, We recommend that MR imaging be performed in all patients in whom the presence of a soft tissue tumor of the head and neck is suspected. MR imaging has superior soft tissue contrast resolution, which allows excellent characterization of the internal architecture and extent of tumors. In this case, while the typical common presentation of a 17-year-old with cervical adenopathy would likely only involve an ultrasound study, given the treating dermatologists concern of a primary tumor and possible metastases, the service at issue was medically indicated. Therefore, the MRI was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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.