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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral functional custom foot orthotics. The requested bilateral functional custom foot orthotics are medically necessary to treat this patients plantar fasciitis. The current standard of care utilizes custom functional supportive orthotics to treat plantar fasciitis, arch pain, and heel pain. In this case, the patient has plantar central arch and heal pain bilaterally. Physical therapy reported a diagnosis of plantar fasciitis. The patient previously underwent surgical correction of plantar fasciitis on the right side. The progress notes from patients provider recommended custom functional orthotics to treat the patients arch and heel pain and plantar fasciitis. Based on current medical guidelines, the requested bilateral functional custom foot orthotics are medically necessary.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 parent of an enrollee has requested reimbursement for residential treatment center services.On admission, the patient indicated that anxiety was an issue she had struggled with for years. She was noted to be calm and cooperative in treatment, without any oppositional behaviors. Her grades in school were good, and her activities of daily living appeared intact. She denied suicidal ideation.  During the disputed timeframe, the patient demonstrated cooperative behavior. She followed treatment programming as she was instructed. The patient did not display aggression towards peers or staff during the disputed timeframe. Her family was involved with treatment.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 1. The patient was not actively or passively suicidal. With regards to functional status, the records support a score of 2. The patient has had some issues with level of functioning due to mental illness and substance use, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 2. The patient did not have active medical problems. The records documented cannabis use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 2. The patient demonstrated cooperative behavior with symptom resolution in the residential treatment center. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 15. This score correlates with outpatient services. Therefore, residential treatment center services were not medically necessary for the treatment of this patient.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
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The enrollee has requested an ultrasound of both breasts. Findings:  The physician reviewer found that according to the record, breast examination was within normal limits and ultrasound results were discussed. The recommendation was for a clinical breast exam every year, annual mammogram, and a genetics referral, given family history. The enrollee was to undergo genetic screening prior to any screening imaging. A mammogram was negative.  The genetic counselor recommended genetic testing for hereditary cancer syndromes with screening recommendations deferred until genetic test results are available. The enrollee has a family history of Ashkenazi Jewish ancestry and reports that none of her relatives has undergone any genetic testing to her knowledge.  The enrollees mother, maternal grandmother, paternal aunt and paternal cousin all have history of breast cancer.  The patient requested her physician to order a breast ultrasound.  However, it was explained that if a hereditary mutation were identified appropriate screening/surveillance management would be advised for her based on the respective findings. According to the medical literature, breast sonography is indicated for evaluation and characterization of palpable masses and other breast related signs or symptoms including evaluation of suspected or apparent abnormalities detected on mammography, screening for occult cancers in certain populations, including heterogeneously or extremely dense breasts. The documentation indicates the enrollee underwent a mammogram that was negative. A family history of cancer and patient history of dense breast tissue is noted. However, there is no indication the patient has a palpable mass, which required ultrasound evaluation. Further, there was insufficient documentation in the record of recommendations by the genetic counselor for additional screening for occult cancers that may occur in certain populations. Therefore, the requested bilateral breast ultrasound is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Diagnostic Radiology 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 requested authorization and coverage for Roux-en-Y gastric bypass procedure. The enrollee has diagnoses of systemic lupus erythematosus (SLE), morbid obesity, obstructive sleep apnea, hypertension, and asthma. Findings:She was evaluated for bariatric surgery due to her body mass index (BMI) of 43. She underwent a gastric sleeve procedure. Her weight at that time was 277 lbs. A follow-up visit demonstrated a 79-lb. weight loss. She reported attempts to adhere to dietary and exercise routines, but other physical maladies had limited her exercise abilities and her weight had increased to 230.5 lbs. Her physician began a weight-loss regimen that consisted of a 1200-calorie-per-day dietary modification, instructions to engage in 30 minutes of physical activity three times per week, and the addition of Phentermine, an appetite suppressant, to her medication regimen. A polysomnogram did not reveal evidence of obstructive sleep apnea. The dietitians report from recommended dietary changes. BMI at this time was 41.03. Her primary care physician indicated the enrollees weight had trended up from 235 lbs. to 251 lbs. and her co-morbidities would improve with weight loss. Her BMI was 40.67. Non-compliance with the Contrave regimen was reported. She had multiple joint pains with significant low back and knee pain, and stress fractures of the spine. Follow-up with her bariatric surgeon was recommended, as well as the need for permanent lifestyle changes and strict adherence to her prescribed postoperative diet. Based on review of the records, there is not sufficient evidence of compliance to post-operative dietary and lifestyle modifications following the enrollees initial sleeve procedure and she does not have any related post-procedure complications. According to the medical literature,  adherence to dietary, exercise and lifestyle modifications post-operatively is one of the key factors related to a successful procedure. The primary reasons for conversion to Roux-en-Y are either an anastomotic leak, or the onset or worsening of gastroesophageal reflux disease. The records do not show there is a technical complication of the current sleeve gastrectomy requiring revision or conversion into a Roux-en-Y gastric bypass. Therefore, the Roux-en-Y gastric bypass procedure is not medically necessary for treatment of this enrollees medical condition.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 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 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 Percocet. The patient has some risk factors for opiate misuse, including a history of alcohol abuse. She underwent a right total hip arthroplasty following a failed pinning of the right hip. The patient reports significant pain and needs physical therapy following her surgery. In this case, Percocet is medically appropriate to assist the patient in completing physical therapy sessions. She is status post major hip surgery and may require pain medication postoperatively for physical therapy sessions. Although the requested medication regimen of Percocet is not medically necessary, a low dosage of Percocet, is medically appropriate while the patient participates in physical therapy. The medical evidence supports weaning Percocet down following completion of physical therapy and eventually discontinuing opiates completely. In sum, while the patient participates in physical therapy, a low dosage of Percocet,is medically necessary.Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certificate 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that Per Health and Safety Code section 1317.1,(a)(1) Emergency services and care means 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. (b) Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or joint. The records indicate the enrollee presented to an urgent care clinic with complaints of strong back pain after falling in her bathtub on a previous date. The enrollees blood pressure was 131/85, with pulse 94 beats per minute. Physical examination revealed normal gait with no tenderness or effusion. Her muscle strength and tone were normal.  Her spine was non-tender and there was no deformity, ecchymosis or rash noted. However, the enrollee had lumbar spasms with pain level of 7 out of 10.   Her diagnoses were lower back contusion and lumbar spasm.  Treatment was with baclofen and ketorolac.  In this case, the enrollee presented to the urgent care clinic with severe lumbar spine pain rated at 7 out of 10.  She appropriately received emergency medical services where she underwent a medical screening, examination and evaluation by an appropriate licensed physician to determine if an emergency medical condition existed. Although the enrollee had fallen previously, she had evidence of acute symptoms of sufficient severity (severe pain), such that the absence of immediate medical attention could reasonably be expected to place her health in serious jeopardy or result in serious impairment to her bodily functions. She received care and medication for her lumbar spasms within the scope of the physicians license to relieve the severe back pain, which was within the capability of the urgent care facility. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for the OncotypeDX Prostate Assay. There currently are three major therapeutic strategies to the management of localized prostate cancer: surgical prostatectomy; various forms of radiation; or surveillance only with no specific cancer treatment. Clinical stage, PSA and biopsy pathology determine an individual patients risk category. Applying the current National Comprehensive Cancer Network (NCCN) guidelines, he falls in the favorable to unfavorable intermediate-risk category. This patient population provides a challenge in terms of treatment selection. The provider recommended testing to help determine whether he should have surveillance only, or undergo specific treatment. OncotypeDX Assay is a 17-gene assay of an individual patients cancer cells, with good predictive of recurrence after radical prostatectomy. For patients with localized prostate cancer, OncotypeDX can provide guidance for therapeutic decision-making. In this particular situation, OncotypeDX Prostate Assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the OncotypeDX Prostate Assay was likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 requested authorization and coverage for Norco, hydrocodone, and acetaminophen. Researchers noted that opioid medications are utilized routinely and effectively as a short-term analgesic treatment for a variety of acute pain conditions such as occur following trauma, and for patients with painful terminal diseases such as cancer. However, the author cautioned that due to the highly addictive nature of opioids their use in the treatment of chronic non-malignant pain remains controversial. This patients records do not include adequate diagnostic data to support an indication for opioid pain medications for low back pain. The patient reports that the requested medications have controlled his pain in the past. However, there is a lack of objective data or imaging findings showing sufficient disease to support opiate use. The patient has not exhausted alternative non-opiate pain medications, epidural injections, physical therapy, or a home exercise program. Therefore, the requested Norco, hydrocodone, and acetaminophen are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty certification in pain management 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 a consultation with a vascular surgeon. The submitted documentation supports the requested services in this clinical setting. This patient has painful varicose veins and swelling, and her primary care provider has recommended evaluation with a vascular surgeon. Primary care providers may not be up-to-date on the appropriate compression to order for patients. Additionally, primary care providers may have difficulty with ultrasound interpretation. Based on this patients reported pain, a consultation with a vascular surgeon is medically appropriate. Therefore, the requested consultation with a vascular surgeon 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 general vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for laparoscopic anti-reflux procedure utilizing LINX reflux management system, According to the medical record, the patient has diagnoses of Gastroesophageal Disease (GERD), grade A esophagitis and a two cm hiatal hernia. An esophagram was normal.  Additional studies included an upper endoscopy, which revealed mild inflammation in the gastric antrum and; esophageal manometry, which showed a hypotensive lower esophageal sphincter. Surgery clinic notes indicate he had been taking omeprazole for many years, stopped taking it one year ago and is now taking Dexilant 60 mg daily. He has some regurgitation and the pH study revealed a DeMeester score of 25.5.  He is advised to have a LINX procedure for treatment of GERD. The medical literature cites an updated safety and effectiveness analysis of the LINX Reflux Management System. With regard to safety, the conclusion was that long term follow-up supports the FDA conclusions the device is safe. With regard to efficacy, there were several conclusions. The LINX implant results in pH normalization, improved quality of life and cessation of regular proton pump inhibitor use on a consistent basis. The long-term follow-up data demonstrates that the LINX Reflux Management Systems is effective in the management of GERD. Patients with moderate to severe reflux, especially if on proton pump inhibitor (PPI) therapy should be considered for minimally invasive treatment rather than increased PPI therapy. This enrollee was having continued symptoms while on PPI therapy and an abnormal pH impedence study. Laparoscopic placement of the LINX reflux management system is likely to be more beneficial than any available standard treatment for this patients medical condition.Final Result: Three of the three reviewers determined that the requested service is 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 Gastroenterology 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.