Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient presented to labor and delivery on 6/23/17 at 25 weeks gestation with complaints of vaginal bleeding. An ultrasound showed a foreshortened cervix of 1.9 cm with old blood and mucus in the vaginal vault. The patient was admitted to the hospital. Irregular but frequent contractions were noted on tocometry that resolved shortly after admission. Fetal heart tones were reassuring and maternal vital signs were hemodynamically stable. The amniotic fluid index was 21 cm. Laboratory results showed mild iron deficiency anemia and a normal urinalysis. The patient was treated with magnesium and betamethasone. She continued to be monitored without acute issues and was given Procardia with subsequent discharge on 6/26/17. The patient has requested reimbursement for emergency medical services from 6/24/17 at 3:53 pm through 6/26/17. The Health Plan denied the request and reported the services at issue were not emergency medical services. At issue in this case is whether the services that were provided from 6/24/17 at 3:53 pm through 6/26/17 were emergency medical services. Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical manifests 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 placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The American College of Obstetrics and Gynecologists (ACOG) notes that a diagnosis of preterm labor is defined by the clinical criteria of regular uterine contractions and a change in cervical dilation, effacement, or both. The medical records reflect that this patient had uterine contractions but no evidence of cervical dilation despite serial examinations. Therefore, preterm labor was not present. Further, chorioamnionitis, fetal distress, maternal disease, and vaginal bleeding were not diagnosed. The patient had normal hemodynamics, and her fetus had category I fetal heart tracings. Tocolytic therapy was provided with magnesium for less than 24 hours. The patient was noted to be stable and without fetal distress or evidence of progressive cervical incompetence. Therefore, the services provided from  6/24/17 at 3:53 pm through 6/26/17 were not emergency medical services.Final Result: The reviewer determined the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: The patient has requested reimbursement for: 1) advanced lipoprotein testing services; 2) advanced lipoprotein testing services; 3) advanced lipoprotein testing services; 4) advanced lipoprotein testing services; 5) advanced lipoprotein testing services; and 6) the blood genetic testing services. Based on the records provided, this patient has known obstructive coronary disease. In this circumstance, guidelines for the management and dyslipidemia and coronary disease 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 (CRP), high sensitivity CRP, insulin, fibrinogen, homocysteine, and genetic testing. 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. In addition, this patient has known obstructive coronary disease, which warrants aggressive risk factor reduction with high dose statin therapy regardless of lipoprotein test results. Given these findings, the 1) advanced lipoprotein testing services; 2) advanced lipoprotein testing services; 3) advanced lipoprotein testing services; 4) advanced lipoprotein testing services; 5) advanced lipoprotein testing services; and 6) the blood genetic testing services, were not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The current evidence is limited on viscosupplementation, and the guidelines from organizations such as the American Academy of Orthopaedic Surgeons (AAOS). Thus, the AAOS does not support routine use of viscosupplementation as standard treatment for osteoarthritis of the knees. However, viscosupplementation is recommended for patients with a history of lasting benefit from prior injections and in well-selected patients when treatment options are limited. This patient meets these criteria as she has benefitted from prior viscosupplementation and her treatment options are limited. The patients post-traumatic osteoarthritis of the left knee has responded well to prior viscosupplementation with at least six months of pain relief and improvement in mechanical symptoms. Accordingly, Orthovisc injections are medically necessary for treatment of this patients medical condition.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS guidelines, the RTC services were not and are not medically necessary. The patient presents a composite score of 17, which correlates with intensive outpatient services. Moreover, the records do not establish that the patient has required the 24-hour supervision and medical monitoring provided at the RTC level of care. Given these findings, the RTC services were not and are not medically necessary for treatment of this patients behavioral health issues. 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 psychiatry with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male who has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request, indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD).Findings:  Two out of three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures for the treatment of GERD. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. One best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX is associated with severe dysphagia, requiring endoscopic intervention more than surgical fundoplication. Another evidence review concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies, remain to be determined. There are 29 reports of LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administration (FDA) Adverse Events database, among other reported side effects. Finally, there is a lack of data regarding safety and efficacy of LINX in patients with Barrett's esophagus. For these reasons, the LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer disagreed with this decision because a five-year cohort data was recently published establishing the durability of the LINX device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a five-year follow-up period.Final Result: The reviewers determined that the requested procedure is 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 reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient requested Gel One injections. Findings: The physician reviewer found that requested injections are medically necessary. The submitted orthopedic report documented complaints of bilateral knee pain. Functional limitations were noted in sitting, standing, and walking for prolonged periods of time, and pain interfered with activities of daily living. Bilateral knee X-rays demonstrated severe bilateral osteoarthritis. The diagnosis included severe bilateral medial compartment degenerative and post-traumatic osteoarthritis. The provider recommended the Gel One injections for the patients bilateral knees for primary osteoarthritis. In a meta-analysis of 137 studies with 33,243 participants, hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The meta-analysis concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis.Evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with significantly symptomatic osteoarthritis of the knee. Moreover, repeat viscosupplementation has been found to be safe and effective; more effective than corticosteroid injections and allows for delay of total knee replacement. In this case, the patient presents with progressively worsening bilateral knee pain. Functional limitations affecting the ability to perform activities of daily living are noted. There is radiographic evidence of near complete medial compartment joint space narrowing, subchondral sclerosis, and periarticular spurring. The patient failed to adequately improve with activity modification and non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, the requested bilateral knee injections (Gel-One injection) are medically necessary for treatment of the patients medical condition.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 10-year-old male who has been diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder. Findings:  The physician reviewer found that the time of evaluation  his speech was 80% intelligible in unstructured settings. He was using four to five word phrases 50% of the time with minimal prompting, and answering wh questions 50% of the time. According to a speech and language pathology noted, he has been receiving speech therapy for 60 minutes once per week.  His mother notes that he was non-verbal until three years ago. The reports show that the patient has been making progress with speech therapy. His intelligibility increased to 85% intelligible to familiar and unfamiliar listeners , with a significant decrease in jargon and gibberish, and increased frequency of independently facing his listener. The raspy quality of his speech had decreased. He was using three to five word phrases in structured and semi-structured tasks in 70% of opportunities, and answering wh questions had increased to 80% of the time with minimal prompts. He had difficulty with pragmatic language, with breakdown of communication with over five exchanges of non-preferred topics.Speech therapy is a crucial intervention for children with autism spectrum disorder. Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words (Paul). Treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming, along with traditional ancillary services, such as speech and language, occupational, and physical therapies. In addition, older children with autism spectrum disorder require speech therapy that addresses pragmatic language. The substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. This patient has autism spectrum disorder, and has only been verbal for the past three years. Although his expressive and receptive language are still significantly delayed, he is documented as making progress with weekly 60-minute therapy sessions. Given this support, the requested speech therapy services once a week are medically necessary for treatment of the patients medical condition.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The patient has a history of Crohns disease.  There was concern for an increase in symptoms and a fecal calprotectin test was ordered. Three physician reviewers found that various studies have found that fecal calprotectin correlates with endoscopic findings of inflammation and serum markers of inflammation in Crohns disease. Further studies have found that fecal calprotectin is useful to assess disease activity in Crohns disease. The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease recommend fecal calprotectin to assess disease activity in patients with Crohns disease. In this case, the patient had symptoms of active Crohns disease, which should be addressed to prevent complications of Crohns disease. For these reasons, fecal calprotectin test at issue was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the requested test was likely to have been 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 and 3 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a male with a history of chronic left knee pain. The patient has degenerative changes of the left knee joint, which have been managed by viscosupplementation injections with good long-term pain and activity levels and reduction in the use of over-the-counter medications and assistive devices.  The provider noted that Euflexxa was preferred due to risk of synovitis. The orthopedic report indicated that the patient had tricompartmental changes of the left knee, worse at the patellofemoral compartment. The left knee examination documented normal alignment, joint line anterior retropatellar tenderness to palpation, unchanged range of motion, normal strength, and no instability. The diagnosis was left knee tricompartmental osteoarthritis. In January, the left knee examination documented tenderness to palpation over the joint line and retropatellar regions, unchanged range of motion, normal strength, and no instability. The treatment plan included Euflexxa injections.a  study found with 33,243 participants, hyaluronic acid was found to be better than injected placebo or injected corticosteroids (Bannuru, et al.). The authors concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. In addition, the American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network . Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with significantly symptomatic osteoarthritis of the knee. Moreover, repeat viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections.In this case, the patient has been diagnosed with osteoarthritis of the left knee. He has worsening left knee pain and functional impairment in mobility that has failed to respond adequately to conservative treatment, including corticosteroid injections. Prior viscosupplementation have reportedly provided good long-term pain relief and allowed him to continue with higher-level activities. Therefore, the requested Euflexxa injection to the left knee is medically necessary for treatment of the patients medical condition.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. Findings:  The physician reviewer found that Findings:  The physician reviewer found that