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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transport services provided from California to Illinois for treatment of the enrollees traumatic brain injury following a high speed motor vehicle collision.  Findings:  The physician reviewer found the air ambulance transport services were medically necessary for treatment of the patients medical condition.  Medical monitoring can minimize health risks during air travel and timely rehabilitation can improve functional outcomes. In this case, the patient sustained a brain injury and multiple fractures. Due to her brain injury and orthopedic injuries, monitoring during air travel with air ambulance transport services was medically necessary. Moreover, early specialized rehabilitation with her support network was clinically indicated. As such, air ambulance transport services provided from California to Illinois were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as being heterogeneously dense. It is specifically the patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued inpatient mental health treatment from 2/28/16 through 3/01/16.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  On 2/28/16, the patient did not have any suicidal or homicidal ideation.  The patient did not have any psychosis, mania, delusions, hallucinations, or agitation.  The patient was calm, cooperative, and engaged in groups.  She was sleeping well and was compliant with medications. The patient was medically stable and did not require 24-hour monitoring. The patient had a supportive environment to return to after discharge. The patient continued to require treatment, but this could have been done in a less restrictive environment such as an intensive outpatient program.  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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood test (advanced lipoprotein testing).Findings:  Three physician reviewers found that in this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, insulin resistance testing, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: Three reviewers determined that the 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation for treatment of the enrollees thoracic pain. Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  Per the medical records, the dual medial branch tests were negative.  The documentation indicated that the pain increased with the second injection, and did not decrease.  The test showed that this approach would not benefit this patient.  There is a lack of support for the requested services in this clinical setting.  Therefore, the requested radiofrequency ablation is not likely to be of greater benefit than other 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for water circulating cold pad with pump for treatment of the enrollee, who is status post anterior cruciate ligament reconstruction. Findings:  The physician reviewers found that the records support a portion of the device at issue.  In this case, the patient underwent anterior cruciate ligament reconstruction.  There exists significant evidence that the use of a motorized cooling pump after knee surgery improves pain outcomes in the early postoperative period.  However, this case involved a purchase of the device at issue.  The scientific literature supports a seven-day rental of the water circulating cold pad with pump.  In sum, a seven-day rental of the device at issue was likely to have been more efficacious than other treatment options. Final Result: Two of three reviewers determined that a portion of the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in orthopedic surgery and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation for suction-assisted lipectomy surgery for evaluation of the enrollee who has a history of lymphedema. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. The submitted records indicate a progressive left lower extremity lymphedema following a previous left inguinal node biopsy. She is well-documented to have suffered complication with cellulitis/sepsis related to her condition. She has undergone typical conservative management, including compression garments, physical therapy, pumps and elevation. This has failed to control or treat her condition.  Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lymphedema. As recommended in the medical literature, surgical treatment is reserved for these types of patients. The documentation provided has indicated that current standard of care management has failed in this patient. Her condition has been documented to have affected her function with significant infection/sepsis. The patient has significant functional compromise related to her progressive lymphedema that has failed reasonable conservative measures. Thus, it is medically appropriate to consider other forms of treatment when non-operative measures have failed. There is enough evidence in this patients case to suggest surgical intervention and lymphatic liposuction is one of them. As such, it would be reasonable for this patient to seek consultation prior to determining surgical options. Thus, a consultation for suction-assisted lipectomy surgery is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and associated ground ambulance services.Findings:  The physician reviewer found that in this clinical setting, the submitted documentation does not support the medical necessity of the services at issue. Air ambulance is considered medically necessary under certain circumstances. The medical literature identifies these circumstances to include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport. Another circumstance would be when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance. Patient conditions to be considered include: unstable vital signs, spinal cord injury, severe chest or abdominal injury, severe burns, or amputations. In such cases, the service is covered to transport the patient to the closest inpatient facility capable of caring for the patient.  In this case, while the patient was approved to receive services at an out of state facility, transport to that facility could have been accommodated by commercial flight or private vehicle. The records indicate the patient had one glucose level tested at the beginning of her transport. Her vital signs were stable and the patient did not require supplemental oxygen. Additionally, the flight paramedics noted that no intravenous access was warranted. As such, the documentation submitted did not meet the recommended guidelines for air ambulance transportation. 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 emergency 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 enrollee has requested authorization and coverage for bilateral platelet-rich-plasma (PRP) injections in both elbows for treatment of the enrollees epicondylitis. Findings:  Two physician reviewers found that the patient has been diagnosed with epicondylitis. The medical records document the use of tennis elbow bands, prior cortisone injections, wrist brace and a 24-month duration of symptoms. Clinical notes document comorbidities of acute coronary syndrome, diabetes mellitus type 2, headache, diabetic retinopathy, gastroesophageal reflux disease, coronary artery disease and hypertension. The patient reported pain with resisted wrist extension and pain at lateral epicondyles. The patient reported continued symptoms after conservative therapy. The provider discussed surgery as a treatment option. The patient requested coverage for bilateral platelet-rich-plasma (PRP) in both elbows for treatment of epicondylitis. The Health Plan denied the requested services as investigational for treatment of this patient. While there have been studies comparing PRP injections to other treatment options, there is a lack of high quality evidence showing the superior efficacy of PRP for treatment of epicondylitis. Further high level studies are needed to define the efficacy of PRP.  In one study, a double blind placebo controlled randomized trial was performed with evaluation at six months utilizing a visual analog scale scoring technique. Twenty-five patients were randomly assigned to each group. The study found that two ultrasound guided PRP injections for epicondylitis were not more efficacious than saline injections at six month follow-up. In another study, the researchers reported on a systematic review of the literature as to the efficacy of PRP injections for chronic lateral epicondylar tendinopathy. Six studies were reviewed, four considered of high quality and two low quality studies. The researchers concluded that based upon the best evidence synthesis, there was strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy. In sum, based upon the medical literature, bilateral platelet-rich-plasma in both elbows are not likely to be superior to alternative therapies for treatment of this patient. 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: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued acute rehabilitation services for treatment of the enrollees intracranial hemorrhage (ICH) status post craniotomy. Findings: The physician reviewer found that the documentation does not support the requested continued acute rehabilitation services as medically necessary for treatment of this patients medical condition. The records do not indicate that the patients condition and functional status are such that the patient can reasonably be expected to make measurable improvement within a prescribed period of time as a result of the intensive rehabilitation therapy program, or that the services will be of practical value to improve the patients functional capacity or adaptation to impairments. The documentation does not reveal evidence of medical instability that requires supervision by a rehabilitation physician or that the intensity of an acute inpatient rehabilitation admission is indicated. In addition, the providers notes suggest that the patient has largely plateaued in his therapy. There has been caregiver and family education and training. All told, the patients needs can be met at a lower level of care. Thus, the request for continued inpatient acute rehabilitation 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 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: An enrollee has requested reimbursement for urgent care services provided on 3/19/16.Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The urgent care services provided on 3/19/16 were not necessary for treatment of an emergency medical condition. In this case, the patient presented with the gradual onset of sore throat over two days. She was not experiencing difficulty breathing or swallowing. The patient was afebrile and in no acute distress. The patients symptoms were not sudden in onset or severe. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records note dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed was likely to have been more efficacious than other methods of evaluating this patient.  Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewers are board certified in diagnostic radiology 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.