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

The parent of an enrollee has requested reimbursement for residential treatment level of care services. Findings:  The physician reviewer found that the documentation provided do not support the medically necessity of the services at issue in this clinical setting. The progress notes indicate that the patient showed openness to discussion of her issues. She was cooperative in treatment.  During the period in dispute the patient did not show any dangerous behaviors towards herself or others. She was not displaying any significant or severe behavioral problems. It is evident that she needs more treatment to further improve her social functioning, depression, school participation, and family relationships. However, the records indicate that she did not need the restrictiveness of a residential psychiatric treatment facility. The medical literature support residential treatment when used for acute stabilization but is not evidenced based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care as referenced by the American Academy of Child and Adolescent Psychiatry. The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports. It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  A study found that treatment outside of a residential setting is effective and are as beneficial as RTC programs: children in intensive in-home therapy were more likely in the future to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth in residential treatment. This patient could have been treated in a less restrictive setting safely and effectively. Therefore, RTC services during the dates of services in question were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility care for treatment of the enrollee, who has a history of a stroke. Findings:  The physician reviewer found that chronic pressure ulcers generally require multimodal interventions for resolution, including nutritional support, pressure relief, wound debridement and appropriate topical wound management.  The records in this case indicate that the patients pressure ulcers have been improving slowly on the current treatment regimen, which includes up to twice daily routine topical product application and dressing changes. The records do not indicate that the patient has any pressure ulcer management needs that could not be provided in the community setting with home nursing visits and outpatient follow up.  The prognosis for her clinical course and outcomes would remain guarded on account of her underlying conditions which include old stroke, multiple limb contractures and deconditioning. Ongoing skilled nursing facility level care would not have been expected to marginally improve clinical course or outcomes over community-based care.  The records do not otherwise document services that the patient needed in an inpatient setting that could not otherwise have been delivered in the community setting. Final Result: The reviewer determined that the services at issue were not and 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 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 Afirma Gene Expression Classifier testing performed.Findings:  The physician reviewer found that While a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Therefore, Afirma Gene Expression Classifier testing performed on the disputed date in question was likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers all three determined that the services at issue were 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 1, 2& 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for mental health services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was struggling with behavioral outbursts prior to his admission.  The medical records do not support active suicidal ideation or psychosis during the several weeks after the patient was admitted.  The records indicate the patient was open in his individual and group therapy sessions throughout his stay.  He was not displaying any significant or severe behavioral problems after his admission.  Per the records, he needed additional treatment to further improve his social functioning, mood, anxiety, family relationships, and behavioral issues. However, it appears that he did not need the restrictiveness of a residential psychiatric treatment facility in order to receive his care.  Residential treatment is used for acute stabilization of psychiatric conditions. It is not evidenced-based for long-term type treatment.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  In this patients case, he could have been treated in a less restrictive setting safely and effectively.  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 a 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 reimbursement for a biopsy. 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 biopsy performed was not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with ductal carcinoma of the breast. Breast cancer is often slow growing and the goal for surgery or chemotherapy is within 30 days of diagnosis. Many breast cancer patients are seen within a week of diagnosis to decrease fear and anxiety not for risk of harm to limb or life. Therefore, the service at issue was not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cologuard test. Findings:  The physician reviewers found that evidence on impact or on healthcare outcomes of Cologuard versus standard medical care is lacking at this time. Cologuard is not standard of care. Cologuard is U.S. Food and Drug Administration approved to test for colon cancer.  However, the limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard, raising concern that Cologuard may miss cancer. The evidence of the impact of Cologuard on patient care or health outcomes is also lacking. There is a lack of consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes, as national guidelines from The United States Preventive Services Task Force and the American Cancer Society currently disagree (ACS guidelines; USPSTF recommendations). Notably, the USPSTF states that the specificity of FIT-DNA (Cologuard) is lower than that of FIT alone, which means it has a higher number of false-positive results and higher likelihood of follow-up colonoscopy and experiencing an associated adverse event per screening test. There are no empirical data on the appropriate longitudinal follow-up for an abnormal FIT-DNA test result followed by a negative colonoscopy; there is potential for overly intensive surveillance due to clinician and patient concerns about the implications of the genetic component of the test. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer.  For these reasons, Cologuard is not likely to be more efficacious for evaluation of this patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are 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 gastroenterology 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 the Afirma Gene Expression Classifier test. Findings:  The physician reviewers found that the cytopathology of the 2 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in these nodules. The American Thyroid Associations (ATA) guidelines state that for nodules with AUS after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. The ATA guidelines also recommend taking the patients history, ultrasound appearance and other clinical factors, in making medical and surgical decisions. The benign result prevented the risks of an additional biopsy or diagnostic surgery. As such, the Afirma Gene Expression Classifier test performed was likely to be more beneficial for evaluation of the patient's medical condition. Final Result: 3 of 3 reviewers determined that the testing 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 the Afirma Gene Expression Classifier (gene test). Findings:  The physician reviewers found that there is sufficient support for the Afirma Gene Expression Classifier (gene test) in this clinical setting. This patients biopsy revealed for atypia of undetermined significance. The Afirma testing was suspicious, and a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for transurethral prostatic thermoablation procedure. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the services at issue in this clinical setting. The transurethral prostatic thermoablation procedure is a novel technique to treat male urinary symptoms secondary to BPH due to an enlarged prostate. The technology uses water vapor (steam) therapy to create necrosis within the transitional zone, which eventually shrinks the prostate, thereby improving urinary symptoms. A recent sham-controlled trial showed improved storage and voiding symptoms after the thermal therapy procedure. The symptoms remained significantly improved over 24 months.  However, current medical literature does not support improved efficacy of this procedure over first line therapy like transurethral resection of prostate. In addition, long term outcomes for transurethral prostatic thermoablation are largely unknown. As such, the medical necessity for the transurethral prostatic thermoablation procedure performed has not been established in this patients case. 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 urology 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 the magnetic resonance imaging (MRI). Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. Thyroid cancer is the most common of the endocrine neoplasms. There are multiple different cell types, and the survival rates and rates of recurrence are highly related to specific cell type. Treatment of thyroid cancer is most commonly a total thyroidectomy followed by radioactive iodine as was performed in this case. The modalities most commonly used in suspected cases of metastasis are direct physical exam, ultrasound, thyroglobulin monitoring, chest x-rays, computed tomography (CT) scanning, and positron emission tomography/computed tomography (PET/CT) scanning. A study discussed current surveillance strategies of differentiated thyroid cancer. The authors stated that Current surveillance strategies rely primarily on serial serum thyroglobulin (Tg) measurements in combination with cervical sonography to identify local-regional nodal recurrence and image-guided fine needle aspiration (FNA) of suspicious lesions. The authors further discuss the use of PET/CT scanning in patients with metastases. There is a lack of published studies that recommend MRI as a first-line diagnostic procedure in the evaluation of recurrence.  Moreover, the National Comprehensive Cancer Network (NCCN) recommends physical examination and sonography as surveillance. In this case, there is a lack of clinical rationale to suspect that the patients three to four days of neck pain and chest pain were related to her thyroid cancer diagnosis. Further, there were no physical findings to warrant MRI. All told, the MRI was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin. Findings:  The physician reviewer found that the requested lipectomy/panniculectomy surgery after sleeve bariatric surgery performed  to remove excess skin is medically necessary for treatment of the patients medical condition. According to  a study The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. In this case, the patient presents with evidence of a symptomatic abdominal pannus related to excess soft tissue from weight loss. Symptoms include sores, ulcers and rashes due to overlapping abdominal skin. The records document a large, symptomatic abdominal pannus in association with a ventral hernia. Based on the documentation provided for review, there is sufficient evidence supporting a functional deficit related to chronic rashes unresponsive to dermatologic management. All told, the request for a lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin is medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician 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.