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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. The medical literature indicates that treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for lung cancer in this clinical setting. Due to this patients diagnosis of Li-Fraumeni syndrome and necessity of treating the mediastinum and hilum, treatment with protons is likely to decrease his risk of developing cardiac and pulmonary complications and a secondary radiation-induced malignancy. Patients with Li-Fraumeni syndrome benefit from treatment with proton beam radiation therapy because of the lower integral dose which would lead to lower secondary malignancies compared to photon techniques. Proton beam radiation therapy would reduce the heart and lung dose in this case. Therefore, proton beam radiation therapy is medically necessary for the treatment 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 radiation oncology 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 a mechanical seat lift with a remote. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Durable medical equipment is defined as equipment which can withstand repeated use and is primarily and customarily used to serve a medical purpose. Additionally, durable medical equipment is appropriate for use in a patients home. Medicare guidelines indicate that in order to qualify for a mechanical seat lift, a patient should be unable to stand up from a regular arm chair and once standing should be able to ambulate. In this case, the records document osteoarthritis and rheumatoid arthritis of the back and lower extremities. The records do not document that this patient is incapable of standing up from a regular arm chair and that once standing she is able to ambulate. The medical evidence does not support the requested equipment in this clinical setting. Therefore, the requested mechanical seat lift with a remote is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for bilateral Euflexxa injections or Synvisc injections. Findings:  The physician reviewer found that the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. According to a medical study, intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. In addition, another study reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The latter study found that the current highest level of evidence suggests that intra-articular hyaluronic acid as a viable option for knee osteoarthritis. Viscosupplementation resulted in improvements in knee pain and function that can persist for up to 26 weeks. Given the support in the current medical literature, the requested bilateral Euflexxa injections are medically necessary for treatment of this patients osteoarthritis of the knees. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services and prospective authorization and coverage for future residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. The progress notes indicate that the patient had abnormal vital signs, panic attacks and passive suicidal ideation symptoms during her stay. 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 the necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 3 due to recent suicidal ideation without plan. In terms of functional status, the records support a score of 4 due to poor overall daily function. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 4 due to medical conditions made worse by lack of eating as well as daily cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3 due to family discord. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 5 due to minimal past treatment response. With regards to engagement and recovery status, the records support a score of 4 due to inaccurate symptom reporting and refusal to eat on numerous occasions. Thus, the patient has a composite score of 25. This score correlates with residential treatment center services. Therefore, residential treatment center services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for subcutaneous immunoglobulin therapy. As noted in the medical literature, patients with postural tachycardia syndrome (POTS) can have numerous complaints including syncope, paresthesias, lightheadedness, fatigue and headache. Therapies include increased water or salt intake, support hose, fludrocortisone, clonidine, propranolol, midodrine, and pyridostigmine. There is limited data to suggest immunoglobulin is effective or more effective than any other therapy for POTS. Additionally, repeat autonomic testing evidence is limited to support improved outcomes. This patient has undergone a comprehensive work-up and no underlying autoimmune diseases have been identified to support an indication for treatment with immunoglobulin. Accordingly, the requested subcutaneous immunoglobulin therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for intravenous (IV) Rocephin therapy: 2 g/day, four days on and three days off, for three months. Findings:  The physician reviewer found that The records provided for review indicate that this patient was diagnosed with Lyme disease. However, the laboratory testing criteria used for the diagnosis is not considered within the current standard of care from the Centers for Disease Control and Prevention (CDC). Further, the specific indication for Rocephin is neurolyme, which requires evidence of a central nervous system infection. In this case, there is no documentation of a lumbar puncture or other modality confirming the presence of a central nervous system infection. Moreover, the recommended treatment for Lyme disease is doxycycline, which is one of this patients prior medical therapies. All told, IV Rocephin therapy: 2 g/day, four days on and three days off, for three months, is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anterior Optical Coherence Tomography (OCT) testing. The Health Plan indicates that the services at issue are investigational. Therefore, the Health Plan has denied reimbursement for the services at issue.Findings:  Two out of three physician reviewers found that the OCT testing was not likely to be more beneficial for treatment of the patients medical condition than any other standard therapy. Anterior chamber OCT and other types of anterior chamber imaging have been reviewed and assessed for their usefulness by the American Academy of Ophthalmology (AAO). Although the AAO did not take a final position on the usefulness of this imaging, the Technology Assessment committee concluded that the current literature indicates that anterior segment imaging demonstrates good correlation with gonioscopy and the presence of primary angle closure (PAC). However, there have been few studies that provide level I evidence of its usefulness as a supplement to gonioscopy in the evaluation of patients at risk for primary angle closure glaucoma (PACG). There have been no appropriately powered longitudinal clinical studies demonstrating that imaging can be used to predict the future development of PAC and PACG. Because our understanding of the specific anatomic parameters that may be most useful in the diagnosis of PAC and the prospective validation of such parameters remains incomplete, the added benefit of using these devices for clinical care is not clear.  Other reviews of the current medical literature confirm that further studies are needed to clarify the anterior segment OCT findings that are useful for glaucoma management.  The standard therapy for this patient with anatomically narrow angles is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. Therefore, the anterior OCT performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: The patient has a medical history of gender dysphoria. A letter from the patients representative dated 12/7/18 states that the patient has been taking cross gender hormone therapy since July 2018. The letter reported that the patients symptoms of gender dysphoria have manifested with persistent anxiety, depression, agoraphobia, and overall distress. She has met with her medical provider to discuss laser facial hair removal, and the provider determined that facial laser hair removal is appropriate to treat her gender dysphoria. The letter states that the patients facial hair severely limits her ability to be perceived as female and thus negates her gender identity. Being constantly mis-gendered due to the presence of facial hair exacerbates her symptoms of gender dysphoria. At issue in this case is whether facial laser hair removal is medically necessary for treatment of the patients medical condition. Feminizing hormones can reduce the density and quality of facial and body hair. The World Professional Association for Transgender Health (WPATH) cites reviews at 6-12 month follow-up for assessment of patient response. In this case, the patient was on hormone therapy for three months and no assessment was made during the office visits of any changes in facial or body hair. The providers progress notes fail to document any discussion with the patient about expectations of hormone therapy on hair growth, evaluation of any impact of initiating cross gender hormones, or justification for laser hair removal. Overall, the records do not support that the patient has undergone an adequate trial of hormone therapy and assessment of its impact on facial and body hair. Therefore, the requested laser facial hair removal is not medically necessary for treatment of the 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a power recline feature for her existing power wheelchair. The Health Plan has denied this feature as not medically necessary for treatment of the patients medical condition. Power seating functions such as power tilt-in-space and power recline can provide relief from discomfort in persons who use wheelchairs as their primary means of mobility but do not have the means to independently reposition themselves without assistance. Given the considerable amount of time wheelchair users spend in their wheelchairs, powered seating functions that allow for posture changes and pressure management are important for those who cannot independently adjust their positions or who are at risk for pressure ulcers. In this case, there are no indications that the patient has any upper limb impairments that would preclude maneuvers for repositioning in the seated position to alleviate her discomfort or lumbago. Notably, the patient also uses a manual wheelchair indoors, which suggests that she has sufficient upper limb functionality to manage her repositioning needs when she uses her power wheelchair. There are no indications that the patient has any pelvic obliquity, spinal deformities or other conditions complicating her ability to alleviate discomfort using standard repositioning maneuvers with the upper limbs. There are no indications that the patient requires power recline functionality for accomplishing her mobility-related activities of daily living, such as dressing or bowel/bladder care. There are no indications that the patient requires power recline functionality for management of hypotension or other cardiovascular or respiratory conditions. The records, overall, do not establish that the patient has impairments or conditions for which power recline functionality on a power mobility device is medically necessary. Under these circumstances, the power recline feature that has been requested for the patients existing power wheelchair is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested feature 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested reimbursement and prospective authorization and coverage for weekly exposure therapy. Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder. Prior to the disputed timeframe, the patient was engaged in outpatient therapy and reported infrequent panic attacks. The records do not document that the patient had suicidal or homicidal ideation. She was not displaying aggression or self-injurious behaviors. The patient was not experiencing signs of psychosis. She was able to manage her activities of daily living in a developmentally appropriate manner. During the dates of service in dispute, the patient was calm and cooperative, without suicidal or homicidal ideation. The records do not document that the patient was an immediate danger to self or others. The clinical notes do not document that the patient was immediately unable to care for herself. The patient did not display significant symptoms that warranted emergency treatment or evaluation according to Health and Safety Code section 1317.1. Therefore, weekly exposure therapy were not emergency psychiatric services as defined by the Health and Safety Code section 1317.1.With regards to weekly exposure therapy from, the records support the medical necessity of the services at issue. Exposure therapy is typically used for anxiety disorders. This patients therapy sessions have addressed psychoeducation. The sessions discussed thoughts associated with anxiety. Per the records, the sessions were cognitive behavioral therapy (CBT) focused as well as exposure focused. The medical literature suggests that exposure therapy is similar to the outcome with treatment with CBT. These two forms of psychotherapy are evidence-based treatments in this clinical setting. Therefore, weekly exposure therapy from was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not emergency services as defined by California law. The reviewer determined that the services at issue were and are medically necessary to treat the enrollees medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer 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: The patient has requested authorization and coverage for an orthopedic referral. This patient presents with a history of chronic right-sided lower rib pain related to exercise. The chest x-ray and chest CT with contrast have revealed an incidental hamartoma of the apex of the lung which has no relationship to this pain. Based on the current literature, the causes related to exercise are diverse and include slipping rib syndrome, which requires a clinical evaluation by an orthopedic surgeon familiar with this condition. The diagnosis of this condition is based on the patients history as well as the hooking maneuver on physical examination. Additionally, pain radiating to the lumbar region and the hip may represent an upper lumbar herniated intervertebral disc. Pain in the lower ribs may also represent a possible stress fracture related to rowing type exercise. All of these conditions necessitate an orthopedic consultation. Given this support, the request orthopedic referral is medically necessary for evaluation and treatment of this patients right-sided rib pain. 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.