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

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with Beckwith-Wiedemann syndrome, macroglossia, obstructive sleep apnea, and tracheostomy dependence. The provider noted that the patient underwent a drug induced sleep endoscopy that revealed a tongue- based obstruction. Subsequently, a tracheostomy was performed. Physical examination findings noted that the patient had very full cheeks, and that his tongue fit behind and between his teeth at rest. The patient's tonsils were rated as two plus. The records noted that tonsillectomy and adenoidectomy with glossectomy were recommended by the patients in-network provider. In a letter, the patients parent reported that she desired for surgery to be performed by an out-of-network provider due to his surgical experience and patient outcomes. The patients parents also requested an adenoidectomy/tonsillectomy not be performed. The patients parent has requested authorization and coverage for an anterior wedge reduction with a W-shaped cut without a tonsillectomy and adenoidectomy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether an anterior wedge reduction with a W-shaped cut without a tonsillectomy and adenoidectomy is medically necessary for the treatment of the patients medical condition. BeckwithWiedemann syndrome is a rare congenital overgrowth disorder with macroglossia being one of the cardinal symptoms. In pronounced cases, macroglossia can lead to airway obstruction, musculoskeletal alterations, and functional deficits. Operative tongue reduction exerts a positive influence on skeletal, dentoalveolar and functional development with sufficient long-term outcome and high grade of satisfaction of the patients. A study of national trends showed that partial glossectomy for macroglossia is typically performed prior to age two in the United States. In this case, the patient was diagnosed with Beckwith-Wiedemann syndrome, macroglossia, obstructive sleep apnea, and tracheostomy dependence. Treatment of rare disorders is best performed by specialists with experience in treating these conditions. The medical evidence supports the requested services in this clinical setting. Therefore, an anterior wedge reduction with a W-shaped cut without a tonsillectomy and adenoidectomy is medically necessary for the treatment of this patient. 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 otolaryngology 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 enrollee has requested authorization and coverage for acupuncture. The enrollee has chronic low back pain without sciatica. The provider indicated the referral was concerning the enrollees left side low back pain originating in the left piriformis area and radiating down the enrollees entire left leg. Magnetic resonance imaging (MRI) of the left spine showed evidence of bilateral recess stenosis at L4-5 due to facet hypertrophy and a left L4-5 nerve encroachment due to a bulging disc. There was also evidence of hyperlordosis indicating muscle involvement. The enrollees condition causes her pain 24 hours a day and is a physical burden. She has been to physical therapy and chiropractic treatment but the pain does not subside. Current peer reviewed literature and evidence based guidelines support the use of acupuncture for chronic low back pain. According to one study, many current guidelines recommend acupuncture in specific circumstances for back pain or headache. Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Systematic reviews show that acupuncture, used either in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic low back pain.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The reviewer is board certified in acupuncture 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services.  Findings:  The physician reviewer found that the enrollee has a history of depression, psychosis, substance use, including cannabis and prescription amphetamines. He was actively abusing marijuana and prescription amphetamines. He transitioned from PHP to an intensive outpatient program (IOP). Notes indicated no current suicidal ideation. He denied a history of ever acting on suicidal ideation. Psychiatry notes indicated improvement in mood, good energy, feels rested, normal speech, no suicidal/homicidal ideation, no auditory verbal hallucinations, started gaining insight into connection between substance use, psychosis and social isolation. Individual therapy indicates the enrollee expressed insight into understanding on how structure, abstinence and medications can improve his lifestyle. Improvement in his mood and sleep was noted and he denied suicidal ideation and cravings. Review of the record indicates the enrollees symptoms could have been managed at a lower level of care than the intensive outpatient (IOP) level. The enrollees composite score of 14 correlates with Level II: Low Intensity Community Based Services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 a catheter ablation procedure to correct her symptomatic, paroxysmal atrial fibrillation. Data from Holter monitoring showed premature atrial contractions (PACs). Multiple options were discussed and the enrollee selected Eliquis and flecainide.  At a subsequent visit, notes indicate she had started Eliquis but the decision was made to perform catheter ablation rather than a class I or III antiarrhythmic medication. Atrial fibrillation ablation (pulmonary vein isolation), mapping atrium of ventricle, intracardiac echocardiography, and ultrasound guided vascular access were performed due to having highly symptomatic paroxysmal atrial fibrillation refractory to medical therapy.  According to the medical literature, there is limited evidence that catheter ablation is more effective than medical management with class I or III antiarrhythmic agents.  Recent guidelines and expert consensus statements rate catheter ablation for symptomatic paroxysmal atrial fibrillation a class II, (reasonable) recommendation for enrollees prior to class I or III arrhythmic medications. This enrollees clinical characteristics did not put her at increased risk from these medications and there is insufficient evidence in the record of a medication trial prior to the catheter ablation.  As to date, literature does not support catheter ablation as first-line therapy for paroxysmal atrial fibrillation. Rather, literature supports a trial on an antiarrhythmic medication (i.e. Flecainide), and consider catheter ablation if the enrollee continues to have break-through atrial fibrillation on the antiarrhythmic medication.Final Result: Two of the three reviewers determined that the requested service is not 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the fetal chromosomal aneuploidy genetic testing. Findings:  Two out of three physician reviewers found that the enrollee presented at twelve weeks gestation for genetic counseling due to advanced maternal age. Paternal family history is positive for autism and liver disease. She planned to complete the California prenatal integrated screening and was also considering expanded carrier screening and/or cell-free DNA screening. Cystic fibrosis, spinal muscular atrophy, and Fragile X carrier screening results were pending through her obstetricians office.  The cfDNA detects Down syndrome with 99 percent efficiency.  Guidelines consider it the most sensitive screening option for detecting trisomy 21, 18, and 13. Cell free DNA is a standard of care for high-risk enrollees. Studies demonstrate DNA-based testing of maternal plasma for high-risk enrollees can detect fetal abnormalities with a high degree of accuracy. These studies form the basis for the recommendation of this diagnostic. Ante-natal screening can increase the likelihood of identifying an abnormal fetus and reduce the number of invasive diagnostic tests and procedure-related losses of normal fetuses. This enrollee was counseled by her geneticist that she was at greater risk for fetal chromosomal aneuploidies due to her advanced maternal age and gestational diabetes. The risk of Down syndrome for this age group is estimated to be 1 in 267. The risk of any chromosomal abnormality is 1 in 148. An aneuploidy screening discussion is recommended for all women early in pregnancy; ideally at the first prenatal visit. The standard aneuploidy screening includes a nuchal translucency ultrasound exam in the first trimester, with maternal serum PAPP-A and HCG levels, and the Quad screen in the second trimester; which measures maternal serum levels of HCG, AFP, inhibin A, and estriol.  Using these screening exams, the detection rate for Down syndrome is about 95%. With cell-free DNA screening, the detection rate is as high as 99.9%. Cell-free DNA prenatal screening is superior to standard first and second trimester screening tests.  Because of the higher precision of this test, as compared to standard prenatal screening, many enrollees can avoid invasive diagnostic testing; such as chorionic villus sampling (CVS) or amniocentesis. The lower false positive rate found with cell-free DNA prenatal screening may also contribute to enrollee preference for this diagnostic. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard testing for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Regenexx spine platelet-rich plasma treatment. Findings:  Three physician reviewers found that per clinical practice guidelines for the management of chronic musculoskeletal low back pain, the focus of treatment should be patient education, self-care, common analgesics, independent exercise and remaining active. In the present case, the patient does not have documented impairments that would preclude him from performing an appropriate exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, such as self-massage using foam rollers or massage balls, and topical treatments, such as ice or heat. Autologous platelet-rich plasma therapy has not been proven to be an effective treatment for spinal musculoskeletal conditions. Its mechanism of action in this clinical setting remains unclear. Platelet-rich plasma treatment protocols have yet to be standardized. The preponderance of published clinical data to date is anecdotal. One study performed a small clinical trial and reported modest symptomatic improvements with intradiscal platelet-rich plasma versus control in some parameters over a short follow-up period. This trial was small and low quality, and was properly reported to be a preliminary study by its authors. This trial supports the need for higher quality research. Therefore, Regenexx spine platelet-rich plasma treatment is not likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 inpatient treatment with electroconvulsive therapy (ECT).The submitted documentation supports that the requested inpatient treatment with electroconvulsive therapy (ECT) is medically necessary for the patient. Researchers have noted that the rapid relief of severe depression, mania, and psychosis by electroconvulsive therapy (ECT) is accompanied by the rapid reduction in suicide drive. In this case, the patient has multiple risk factors that are consistent with Centers for Disease Control and Prevention (CDC) Risk Factors for Suicide. The patient is single, living alone, has bipolar disorder, is unemployed, has a history of trauma (an abusive boyfriend), has suicidal ideation, would be returning to an unsupportive environment, and was hopeless and helpless. The patients chart includes the indication that she was depressed and had suicidal ideation, and the chart indicated that ECT had not kicked in. It is common for ECT to not yet have effect under such circumstances, especially as the patients first four treatments prior to admission are unavailable for review, and the patient had only received two ECT treatments at this point in her hospitalization. The submitted documentation does not support that the patient was ready for discharge, given the patients suicidal ideation and her ongoing symptoms through discharge. Given the patients risk factors for suicide and the evidence that ECT relieves the suicidal drive of bipolar depression, ongoing ECT in the safe environment of the inpatient setting was, and is, in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness. Accordingly, the requested inpatient treatment with electroconvulsive therapy (ECT) is medically necessary for treatment of the 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 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 sodium hyaluronate injection to bilateral knees. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. The patients options are limited. The patient has failed surgeries of the knee. There is documentation of chondral loss with progressive patellofemoral arthritis and severe pain. The provider has recommended viscosupplementation of both knees with sodium hyaluronate. The enrollee has tried and failed other conservative as well as surgical treatments with the alternative being a total knee arthroplasty. However, only the patellofemoral compartment is involved in this case, and a total knee arthroplasty is not indicated. Under these circumstances, the request for sodium hyaluronate injections of both knees is reasonable, appropriate, and medically necessary for management of patellofemoral arthritis associated with severe pain. Therefore, the requested sodium hyaluronate injection to bilateral knees is medically necessary for treatment of the 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 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:  The enrollee is requesting authorization and coverage for Orthovisc injections for both knees. The patient has a history of bilateral knee pain and osteoarthritis. The pain has been present for at least one decade and has progressively worsened. She utilizes diclofenac one to two times per week for pain control.  She tried physical therapy without success. Records indicated improvement after the first visit and a worsening of symptoms after the second. She consulted with a sports medicine specialist, who administered Orthovisc injections. The record indicates the patient experienced moderate, short-lived relief from the hyaluronic acid injections. Guidelines do not support the use of hyaluronic acid because studies have demonstrated that it is not superior to other treatments; including placebo. The literature summarizing the hyaluronic acid injections is well documented. In general, this procedure is not supported because most studies show it does not demonstrate superiority over other treatments; including placebo.  While a meta-analysis of studies revealed statistically significant treatment effects from the procedures, the improvements did not meet minimum clinically important improvement thresholds. There is no benefit from this treatment for patients with OA of the knee.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and sports 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 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 partial hospitalization program services. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with stable psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 due to success in the recent wilderness residential treatment program with a good level of cooperation and stabilization of symptoms. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into the need for treatment.  This score correlates with low intensity community-based services. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. 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 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.