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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) level of care services. Findings:  The physician reviewer found that At issue in this case is whether any or all of the Residential Treatment Center (ASAM 3.5) level of care services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the enrollees mental health or substance use disorder.American Society of Addiction Medicine (ASAM) level 3.5 criteria focus on six dimensions to determine the appropriate level of care. In this case the patient meets the criteria for ASAM dimension 1 (Acute Intoxication and/or Withdrawal Potential), dimension 2 (Biomedical Conditions and Complications), dimension 4 (Readiness to Change), and dimension 6 (Recovery Environment). However, the patient does not meet the criteria for dimension 3 (Emotional, Behavioral, or Cognitive Conditions and Complications) or dimension 5 (Relapse, Continued use, or Continued Problem Potential). Therefore, the patient does not meet the specifications for each of the six dimensions for medical necessity.The patients scores under the six ASAM dimensions consider the specific needs of the patient for the purpose of treating their illness and its symptoms. The ASAM criteria for determining the appropriate level of care are consistent with generally accepted standards of mental health, and they provide determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The ASAM criteria are also free from consideration of the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the Residential Treatment Center (ASAM 3.5) level of care services at issue and requested services were not, and are not, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A). 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 DecisionDx-Melanoma test. For a thin melanoma, pathologic stage 1B, the current standard of care involves wide excision of the lesional site with appropriate margins and consideration of sentinel lymph node biopsy. This patient underwent a biopsy with pathology results describing the tumor to have a thickness of 1.5 mm with evidence of ulceration, regression, satellitosis, perineural invasion, or lymphovascular invasion. The patients provider recommended gene expression profiling (GEP) with the DecisionDx-Melanoma test. The standard of care per National Comprehensive Cancer Network (NCCN) guidelines includes re-excision with appropriate margins and discussion, consideration of sentinel lymph node biopsy (SLNB), and dermatologic surveillance. The current consensus statements published by the Melanoma Prevention Working Group (MPWG) state that more evidence is needed to support use of GEP testing to inform recommendations about sentinel lymph node biopsy, follow-up, or other adjuvant treatment (Grossman, et al.). The MPWG also advises against routine use of GEP testing to direct patient management. Thus, the DecisionDx-melanoma testing was unlikely to have added any significant benefit above the standard clinical care treatment as recommended by the NCCN guidelines namely re-excision with clinically appropriate margins and discussion of SLNB. Accordingly, the DecisionDx-Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology and is 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for the use of a power scooter to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Sund and colleagues report that the use of powered mobility devices, including power scooters, may contribute to mobility-related participation for patients with impaired mobility. This pertains to the subgroup of patients who cannot perform their daily activities or participate in community activities without a power scooter or wheelchair. In this case, a mobility assessment dated 3/29/22 reported that the patient is a functional ambulator within the home and limited with community distances. The patient is able to safely ambulate within the home with the assistance of a cane and is able to ambulate to a car and operate a car for medical appointments and community-related activities. The patient's upper and lower extremity range of motion was noted to be within functional limits and strength was noted as 4/5 bilaterally. The patient had a history of falls. The patient currently uses a cane, walker, manual wheelchair, and bath/shower chair. Given that the patient is a functional ambulator, does not require the use of a power scooter to perform the activities of daily living and participate in community activities, is able to propel a manual wheelchair, and has assistive devices to aid in community mobility and fall prevention, the requested equipment is not medically indicated. Therefore, the use of a power scooter to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Concerta.Findings: A study has concluded that adult ADHD is a prevalent but under-recognized disorder in psychiatry. Failure to identify and treat adult ADHD is linked to negative outcomes. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention.In this case, the patient has been diagnosed with adult ADHD previously and has benefited from treatment with Concerta. The submitted records are consistent with a lack of misuse of the stimulant, and they reflect a clear benefit in her ADHD symptoms from the medication regimen. The patient has benefited from a low dose of Concerta, with her medication dosage remaining stable for 18 years, and without any medication adverse effects. The patients symptoms have been stable on the medication, and she has experienced worsened functioning in work and home without the medication. The requested medication addresses the specific needs of the patient, for the purpose of treating her diagnosed adult ADHD. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention, and treatment with the requested medication is in accordance with the generally accepted standards of mental health care. Treatment with the requested medication is clinically appropriate and it is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the requested medication Concerta is medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the requested medication is medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Based on the patients primary tumor stage and the presence of other risk factors on a pathology report, a wide local excision and sentinel lymph node biopsy (SLNB) are recommended by the American Joint Committee on Cancer (AJCC). The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1a score. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient, namely, how much less follow-up or screening would be safe for the patient given his current AJCC stage combined with GEP score. The use of the service at issue is currently not endorsed by the National Comprehensive Cancer Network (NCCN) and it is not incorporated into the most widely used treatment and management protocols. Therefore, DecisionDx-Melanoma genetic testing provided by Castle Biosciences on 10/8/21 was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma genetic testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The enrollee has requested authorization and coverage for the medication Wegovy.Semaglutide is an anti-diabetic agent, glucagon-like peptide-1 (GLP-1) receptor agonist. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention which includes a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a BMI greater than 30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. Wegovy and Ozempic are brand names for semaglutide. Wegovy is a brand name form of semaglutide that is indicated for chronic management of obesity. Wegovy has been approved by the United States Food and Drug Administration (FDA) for use as an adjunct to diet and exercise in individuals with a BMI greater than 30 kg/m2 or for individuals with a BMI greater than 27 kg/m2 and one or more weight-associated comorbidities. In this case, the submitted documentation supports that the patient has failed treatment with counseling, calorie restriction and increased physical activity to achieve weight loss goals. The patient has a BMI that is greater than 30kg/m2 and has had good past results with the requested medication. Under these circumstances, the requested medication Wegovy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter aortic valve replacement (TAVR). Based on the records provided for review, this patient has critical aortic valve stenosis with new symptoms likely related to stenosis. In addition, the patient was found to have high risk echocardiogram features with a peak gradient greater than 100 mmHg. In this clinical setting of symptomatic critical aortic valve stenosis, the requested TAVR is reasonable according to the current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines (Nishimura, et al.; Otto, et al.). Per the ACC/AHA guidelines, The decision to intervene, as well as the type of procedure recommended, is based on an assessment of patient-, procedure-, and institution- or operator-specific short-term risks and long-term benefits. Given this patients symptomatic critical aortic valve stenosis, intervention with TAVR is appropriate and consistent with the ACC/AHA guidelines. Therefore, the requested TAVR is medically necessary for 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 internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs) and several months of physical therapy without benefit. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Monovisc injection to the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for cyanoacrylate adhesion procedure of one vein in the right lower extremity. The U.S. Food and Drug Administration (FDA) approves the use of the VenaSeal closure system for the permanent closure of lower extremity superficial truncal veins, such as the great saphenous vein (GSV), through endovascular embolization with coaptation. In this case, in a letter, the provider reported that the patient had undergone proximal GSV ablation many years ago. In an undated letter, the patient reported that the previous procedure did not extend into the calf due to concerns of nerve damage due to the heat. Heat related nerve damage is more of an issue in the calf than in the thigh due to the location of the nerve. As the VenaSeal procedure does not utilize heat and poses no risk of a thermal burn to the adjacent nerve, this nonthermal option is likely to be more beneficial for the treatment of this patient over laser or radiofrequency endovenous ablation. Therefore, cyanoacrylate adhesion procedure of one vein in the right lower extremity is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested cyanoacrylate adhesion procedure of one vein in the right lower extremity is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasound guided trigger point injections. Within the documentation provided for review, there is report that this patient underwent treatment for myofascial pain status post fusion. The patient has a history of Ewing sarcoma at T3. The medical records note that the patient has tried and failed conservative treatments including physical therapy and medications. In a progress note, the provider recommended an ultrasound guided trigger point injection. The peer-reviewed medical literature suggests that trigger point injections are an appropriate treatment option in the management of myofascial pain syndrome where trigger points are present. The current medical literature supports use of ultrasound guided trigger point injections for the treatment of patients with acute and chronic pain in the context myofascial pain syndromes. Appasamy and colleagues noted that, Trigger point injections can be performed with or without imaging guidance such as fluoroscopy and ultrasound; however, the use of imaging in years past has been recommended to improve patient outcome and safety. Furthermore, there is support for this treatment modality in cancer patients with myofascial pain syndrome. Lee and colleagues found that, Trigger point injection is an alternative and effective pain control modality for advanced cancer patients with myofascial pain syndrome. Given these findings, the ultrasound guided trigger point injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is 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.