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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultrasound guided sclerotherapy and short saphenous vein (SSV) ablation. The records provided for review do not support the medical necessity of ultrasound guided sclerotherapy and SSV ablation for treatment of this patients medical condition. The patient presented with a three month history of left calf and foot pain. However, the lower extremity venous studies demonstrated no evidence of significant reflux in the superficial veins of the left lower extremity. Additionally, there is a lack of documentation that the patient has completed an adequate trial of properly fitted medical grade compression stockings. For these reasons, ultrasound guided sclerotherapy and SSV ablation are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in general surgery with sub-specialty certification 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for PERFOROMIST (formoterol fumarate) 20 mcg/2 mL inhalation solution. The Health Plan has denied this request indicating that the requested medication solution is not medically necessary for treatment of the enrollees asthma.The medical literature and guidelines do not support the requested medication solution in this clinical setting. PERFOROMIST (formoterol fumarate) nebulized is a long-acting beta-2-adrenergic bronchodilator. The records provided document the severity of the disease and the patients poor control of her asthma. However, there is little support in the medical literature for the efficacy and safety of PERFOROMIST (formoterol fumarate) for the treatment of asthma. Despite this patients poor control of her severe persistent asthma, there is very little evidence that an inhaled long-acting beta-2-adrenergic bronchodilator has any role in the management of her symptoms. Additionally, the use of this agent has not been U.S. Food and Drug Administrative approved for the treatment of asthma. The documentation does not indicate that this patient has been diagnosed with chronic obstructive pulmonary disease or bronchiectasis. Therefore, PERFOROMIST (formoterol fumarate) 20 mcg/2 mL inhalation solution has not been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication solution 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 internal medicine with sub-specialty certification in pulmonary disease and critical care 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

Findings:  The physician reviewer found On 3/15/18, the patient weighed 133.4 pounds and had a body mass index (BMI) of 25.6. The patient continued to have chronic suicidal ideation with no intent or plan. The patients vital signs were stable, and the patient was medically stable. The patient has a distant past of self-harm at the age of 16 by cutting her arms with a razor blade. She continues to struggle with purging and restricting her diet. The patient is motivated for treatment. The patient was previously treated in 2017 and continues to require services to stabilize her condition. For these reasons, the requested PHP services are medically necessary for treatment of this patients behavioral health issues.  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 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 speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The documentation provided as well as current medical literature support the medical necessity of the requested services in this clinical setting. The medical literature indicates that individuals who are in the process of transitioning from male to female may often benefit from speech/language pathology services. Speaking fundamental frequency (pitch) and resonance are part of gender transitioning treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speakers gender. Intonation, voice quality, pragmatics and nonverbal communication contribute to a lesser extent but are usually recommended in treatment guidelines. Voice and communication treatment results in gains in areas important to listeners perception of gender. Review of the literature suggests that speech and language therapy is successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviors. Outcome measures have indicated that speech therapy is effective in increasing vocal pitch and perceptual femininity without compromising vocal quality. Voice feminization therapy for male-to-female transgender individual typically targets increasing fundamental frequency (F0). Increasing vowel formant frequencies increases the perception of voice femininity beyond that of raising F0 alone. Earlier studies confirmed that an increase in voice pitch is achievable for many transgender individuals. In addition, it is now accepted that pitch is not the sole contributor to perceptions of gender. Modification of vocal resonance has been shown to increase perceptions of a speaker as female. There is evidence that encouraging precise articulation results in increased perceptions of the speaker as female. Accordingly, in this patients case, speech therapy can be an effective treatment method of her symptoms related to gender dysphoria. Therefore, the requested speech therapy has been established as medically necessary for treatment of this patients medical condition.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 internal medicine with sub-specialty certification in endocrinology, diabetes 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 enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The records provided for review document that this patients post-acute withdrawal symptoms were not severe in nature. She was not a danger to herself or others, she was not aggressive or violent, and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant services at the RTC level of care. She was medically and psychiatrically stable to the extent that she did not require a 24-hour facility to render the remainder of her care. Her medication management and anti-craving medication could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was motivated and was noted to be working the program. She was cooperative and participating in her treatment plan. She had prior exposure to 12 step programs and had a sponsor. Although she continued to struggle with her emotions and required further treatment to continue to develop and solidify coping skills, this did not require the structured environment of a RTC setting. She could have been stepped down to an ambulatory level of care. For these reasons, the RTC services provided 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 psychiatry with sub-specialty certification in addiction 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 and prospective authorization and coverage for a wearable cardioverter defibrillator rental. Based on the records provided, this patient sustained a ventricular fibrillation arrest after coronary artery bypass surgery. In the circumstance of ventricular fibrillation that is not in the setting of an acute coronary ischemic event within the previous 24-48 hours and not in the setting of any documented transient reversible cause, placement of an implantable defibrillator is considered the standard of care. Thus, a wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. There is no documentation supporting that an implantable defibrillator needed to be delayed or could not be placed. Given these findings, wearable cardioverter defibrillator rental was not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the device at issue was not and 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 cardiovascular 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: An enrollee has requested authorization and coverage for repair of her wheelchair. Findings:  The physician reviewer found that this patient has spina bifida, and she requires a manual wheelchair for all aspects of basic mobility and social/community integration. Her ultralight manual wheelchair frame is damaged. Her wheelchair is more than seven years old. Repairing a damaged frame on an ultralight manual wheelchair that is more than seven years old is not reasonable, as the repaired wheelchair would not be expected to last very long, if it can even be fully repaired to provide full propulsion efficiency. Therefore, the requested repair of the patients wheelchair is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: IVIG is the standard therapy for patients with multifocal motor neuropathy. There is robust literature demonstrating its efficacy in patients with multifocal motor neuropathy. Undertreated multifocal motor neuropathy can cause progressive functional decline. The use of IVIG in this patient with documented multifocal motor neuropathy is reasonable and medically necessary. 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 neurology 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 Ensure Complete Liquid. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested supplement. The records do not document malabsorption, metabolic syndrome or enteral nutrition given via a feeding tube. The documentation does not support that the patient experienced significant recent weight loss. The treatment of weight loss should be aimed at the underlying illness or medical condition, as well as dietary modification. Nutritional supplements are recommended when patients experience weight loss and dietary modification has not been effective to help them gain weight. This patient has a diagnosis of chronic fatigue syndrome. Various therapies have been tried in patients with chronic fatigue syndrome. Management is supportive and focused on treating common symptoms and comorbid conditions, which include sleep disorders, pain, depression and anxiety, memory and concentration difficulties, dizziness and lightheadedness. In this case, the records do not document a medical condition that would prevent the patient from consuming a regular diet. The records do not support that the patient has dysphagia or dental problems. Therefore, the requested Ensure Complete Liquid is not medically necessary for this patient.Final Result: The reviewer determined that the requested supplement 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 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: The enrollee has requested reimbursement for the skin grafts. The use of Neox skin grafting is not supported, as there is a lack of support in the prevailing peer-reviewed medical literature regarding efficacy and safety. There is no indication in the documentation provided that the patient is a diabetic or has venous insufficiency. The use of Neox has not been demonstrated to be safe and effective for non-healing neuroma. Accordingly, the use of Neox skin grafts were not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.One reviewer found that the use of Neox skin grafts were likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in infectious diseases and is actively practicing. One Reviewer is board certified in family practice with sub-specialty certification in undersea and hyperbaric medicine and is actively practicing.  One Reviewer is board certified in podiatry and is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for speech therapy. Findings: This patients records do not include a thorough evaluation for autism spectrum disorder. If the patient is found to meet the criteria for autism, then applied behavioral analysis (ABA) therapy would be indicated. Medical literature noted that treatment with speech therapy shows benefits in expressive language. However, there are fewer benefits in receptive language. Although children with language delays require speech therapy, this patient may require special education or ABA therapy to help him obtain the skills to be able to participate in speech therapy. Thus, the requested speech therapy is not medically necessary for treatment of this patients language delay at this time. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 documentation does not support that the requested gait trainer is medically necessary for this patients medical condition. The current medical literature does not include adequate data demonstrating improved health outcomes with use of gait trainers in this clinical setting. There is a lack of research in adults with cerebral palsy on the effects of   functional mobility. Additionally, a review of the records provided for review reveals the patient has impaired upper and lower extremity coordination. In addition, the records do not report that the patients alignment of the lower extremity is such that the foot and ankle can tolerate a standing or upright position as well as independent reciprocal movement. All told, the requested Meywalk gait trainer is not supported as medically necessary for treatment of this patients cerebral palsy and dystonia.  Final Result: The reviewer determined that the requested device 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 28-year-old male enrollee has requested reimbursement for ophthalmology services provided on the basis the services were emergent in nature.  Findings:  The physician reviewer found that a central retinal vein occlusion whether ischemic or non-ischemic is not a medical emergency that requires emergent treatment (Hahn, et al. and Ho, et al.)  While it is a serious problem, in this case, appropriate treatment was being provided in-network. Although the in-network specialist did not order a fluorescein angiogram to distinguish ischemic from non-ischemic, this is not necessary for making the diagnosis and proper management and is also not an emergency. Therefore, the condition for which the patient sought services on did not meet the definition of an emergency medical condition under California law. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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.