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

Nature of Statutory Criteria/Case Summary: A retrospective request was received for a Synvisc One injection that had been administered to the left knee joint. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees osteoarthritis.A review of the records revealed she was status post arthroscopy of the left knee for degenerative meniscal tears and chondromalacia. The documentation indicates persistent pain, mechanical symptoms, and lack of response to conservative treatment. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee chondromalacia/osteoarthritis. Recommendation of intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis.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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 24-year-old female enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that Final Result: The reviewer determined that the enrollee did not receive psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. At issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The patients diagnoses included acute psychiatric needs for major depressive affective disorder, recurrent episode, without mention of psychotic behavior, anxiety disorder, unspecified, panic and worry, and self-injury behavior, self-cutting. While psychiatric services may have been indicated, there is a lack of evidence that treatment in a less restrictive setting would have been inadequate to safely address the patients issues. Moreover, there is no documentation that the patient has failed treatment in a less restrictive setting. Thus, the PHP services were not provided for the treatment of a psychiatric medical emergency. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. The Health Plan has denied this request indicating that the services at issue were not emergency medical services. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The patient presented with a history of major depression with severe, single episode, without psychotic features, generalized anxiety disorder, panic disorder with agoraphobia, thoughts of harming others, and obsessive compulsive disorder (OCD). The multiple diagnoses, notably agoraphobia, and possibly OCD, are not supported by the history or symptoms. The patient has multiple friends, is active in surfing, soccer, and skateboarding, and attends school regularly. The services at issue were not necessary for treatment of a psychiatric emergency 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested reimbursement for emergency services. Health and Safety Code section 1317.1, subdivision (a)(2)(A) notes Emergency services and care also means an additional screening, examination, and evaluation by a physician, or other personnelto determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The patient was offered treatment within the facility but chose treatment elsewhere thus disqualifying himself from emergency treatment within the facility. The American Psychiatric Association (APA) treatment guidelines recommend that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this patients case, the medical documentation does not indicate this patient met the criteria for a residential program as he was not previously treated in a less restrictive treatment setting such as IOP. Residential treatment was not in accordance with generally accepted standards of medical practice and not clinically appropriate for the patients illness. Thus, the emergency services provided from were not provided for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the date of service at issue.Final Result: The reviewer determined that the services at issue were not provided for treatment of a psychiatric emergency 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Repatha . In this setting, there is adequate data in randomized controlled trials that have demonstrated safety and efficacy at lowering cholesterol and improved cardiac outcomes using inhibitors. This patient meets the criteria for Repatha since he cannot tolerate statins. Thus, the requested Repatha is supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entyvio. Entyvio is an integrin antagonist specific to the gastrointestinal tract; it has a different mechanism of action than immunosuppressants and anti-tumor necrosis factor (TNF) agents such as Remicade and Humira for ulcerative colitis. Per the American Gastroenterological Association (AGA), Entyvio is recommended as a first-line therapy for ulcerative colitis. In this case, Entyvio is more appropriate than anti-TNF medications, as its action is specific to the gastrointestinal tract. Furthermore, systemic risks and risk of opportunistic infections are absent with Entyvio. Entyvio is therefore supported over the formulary alternatives in this case. For these reasons, Entyvio medically necessary for the treatment of this patients ulcerative colitis.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the brand name drug Zoloft. According to the U.S. Food and Drug Administration (FDA), a generic drug is created to be the same as an existing brand name drug in dosage, form, safety, effectiveness, strength, stability, and quality, as well as in the way is taken and should be used. In this case, there is a lack of documentation of failure or intolerance to the generic form of Zoloft. Thus, the requested brand name drug Zoloft is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested brand name 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 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

An enrollee has requested authorization and coverage for a 90-day partial hospitalization program. The American Psychiatric Association (APA) treatment guidelines for substance use disorders recommends that partial hospitalization should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. The APA guidelines further state that PHP is frequently used for patients leaving hospitals . . . who remain at high risk for relapse. These include patients who are thought to lack sufficient motivation to continue in treatment, have severe psychiatric comorbidity and/or a history of relapse to substance. In this case, the patient has relapsed several times in recent years, on each occasion requiring admission for detoxification. This patient is therefore at a high risk for relapse. She has been in an IOP since 10/19/18, but her condition has not improved during that time. Per the most recent notes, the patient remains nervous, depressed and anxious, and demonstrates poor insight and judgment. A higher level of care is needed to address this patients conditions. Therefore, the requested 90-day PHP is medically necessary.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Synvisc One injection. The American Academy of Orthopaedic Surgeons (AAOS) guidelines do not recommend hyaluronic acid for patients with symptomatic osteoarthritis, based on strong evidence. Fourteen hyaluronic acid studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects. When combined in a meta-analysis, however, the evidence did not meet the minimum clinically important improvement thresholds. It was conceded that there might be some subgroup of responders who could be helped by hyaluronic acid, but that subgroup has not yet been identified.  While it is noted that this patient has reported prior benefit from Synvisc injections, current evidence does not support the use of this treatment for patients with osteoarthritis. Therefore, a Synvisc injection is not medically necessary for this patient.Final Result: The reviewer determined that the requested service 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 anesthesiology with subspecialty certification in pain 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, authorization and coverage for inpatient mental health care provided. Most evidence-based treatment guidelines concur that the deciding factor in determining the necessity of inpatient psychiatric care is whether patients appear to be a harm to themselves or others. Medical literatures guidelines agree on this point and additionally cite factors such as overt psychotic ideation; complex biomedical issues; grave disability impairing daily living function; and/or high levels of impulsivity, aggression or mania.In this case, the patient had begun to show response with decrease in psychotic symptoms, thought blocking, and argumentativeness. The patient was not a danger to self or others and was cognitively intact. She demonstrated no self-injurious behavior, no uncontrolled risky behaviors and no uncontrolled destructive behaviors. The patient was compliant with medications and her regimen could safely be managed at a lower level of care. Therefore, the inpatient mental health care provided was not and is not medically necessary.Final Result: The reviewer determined that the requested services were not and are not medically necessary for treatment of the patients mental health conditions. 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: An enrollee has requested authorization and coverage for cryosurgical ablation of the lung. The submitted documentation fails to demonstrate the medical necessity of the requested services. A recent meta-analysis by researchers assessed survival and quality of life in advanced-stage non-small cell lung cancer patients receiving cryoablation. The results showed that cryoablation can improve the quality of life in this group of patients, and that chemotherapy or radiotherapy do not have clinical advantages over cryoablation alone. However, in this enrollees case, the enrollee has not been determined to have advanced stage or intermediate stage non-small cell lung cancer. The enrollee has an indeterminate lung nodule which has not been biopsied or resected. The lesion is of uncertain significance. Cryotherapy is not recommended as superior to resection for lesions which are otherwise amenable to local resection. Current National Comprehensive Cancer Network (NCCN) guidelines do not support cryotherapy for this indication. Cryotherapy treatment protocols and indications have not been universally established for early stage lung cancers. Therefore, cryosurgical ablation of the lung is not medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: The parent of an enrollee has requested authorization and coverage for Remicade infusions. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Crohns disease. It has been well established that response to Remicade is more likely when serum trough levels are greater than 3 micrograms per milliliter. Below this level, both primary non-response and secondary loss of response are more common.  It is also clear that Remicade dosing requirements vary from patient to patient, and that a large percentage of children on standard dosing have inadequate trough levels.  Researchers developed a pharmacokinetic model that accurately predicts trough concentrations in children with Crohn's disease receiving Remicade. This individualized dosing strategy with plans for future dose de-intensification is more likely than standard dosing to achieve and maintain clinical remission. Here, the same dosing strategy was employed by the patients treating pediatric endocrinologist. Recent medical evidence supports this approach to treating children with Crohns disease. Therefore, Remicade infusions are medically necessary for this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees scar after removal of basal cell carcinoma.The submitted documentation supports the medical necessity of scar revision. Skin cancer is the most common of all cancers. Mohs surgery is an effective technique for removing common types of skin cancer. A successful reconstruction mimics the premorbid state and maintains function. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue, with good contour the aesthetic endpoint. The use of perioperative antibiotics, sterile technique, meticulous hemostasis, subcutaneous dissection and deep sutures to minimize wound tension should be considered for all Mohs reconstructions. Cartilage grafting can minimize nasal deformity and obstruction. Secondary procedures such as dermabrasion, steroid injection, scar revision and laser resurfacing can help optimize aesthetic outcome. In a large series from an academic medical center, eighty-one percent of reconstructions were completed in three or fewer stages, and seventy-five percent of reconstructions were completed in two stages. This patient underwent reconstruction after Mohs. Additional procedures are medically necessary to complete the reconstruction. Therefore, the scar revision is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 with sub-specialty certification in plastic surgery within the head and neck 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.