Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: This patient presents with persistent right knee pain with mechanical symptoms of swelling, popping and catching. She has failed to achieve adequate symptom relief with activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and a corticosteroid injectionFindings:  Two out of three physician reviewers found that evidence-based medical guidelines and literature do not support the use of hyaluronic acid injections in this patients mild osteoarthritis or for treatment of her medial meniscal pain. Therefore, the Synvisc One injection is not likely to be more beneficial for the treatment of the patients medical condition than any standard therapy.Final Result: The reviewers determined that the requested service 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 orthopedic surgery 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 is with a diagnosis of physiologic phimosis. On 6/29/17, the records noted the presence of smegma under the foreskin. The records noted no issues with urination. Consultation dated 1/28/19 reported the patient had no voiding problems and had no infections. The provider reported the distal foreskin was tight with phimosis. The provider is recommending a circumcision. On 3/12/19, the parents reported that they noticed blood and irritation on the penis. The parents did not report that the patient had issues with urinating. The provider recommended following up with urology and nystatin-triamcinolone cream. The patients parent has requested authorization and coverage for circumcision. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue is whether circumcision is medically necessary for the treatment of this patient. Circumcision in the absence of pathologic phimosis that is unresponsive to gentle retraction or retraction assisted by betamethasone and or clobetasol topically, represents a cosmetic choice when unaccompanied by recurrent infection. Normal hygiene achieved by local care of the uncircumcised phallus with retraction at or about puberty is equivalent to circumcision in achieving health parameters. Medical benefits of circumcision do not warrant routine circumcision based upon current peer-reviewed literature. In this case, there is no documentation of recurrent infection. Therefore, the requested circumcision is not medically necessary for the treatment of the patients 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 urology with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant. A review of the patients records indicated the possibility of a diagnosis of an intracranial aneurysm, which is common in patients with ADPKD. The risk of bleeding from such an aneurysm is significant. Therefore, any anticoagulation in patients with ADPKD must be undertaken cautiously. Studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Findings:  Two out of three physician reviewers found that studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Final Result: The reviewers determined that the requested tests were 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 nephrology, 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 enrollee requested authorization and coverage for a virtual colonoscopy. The Health Plan has denied the request as not medically necessary for treatment of the enrollees medical condition. The American College of Radiology (ACR) guidelines for virtual colonoscopy, also known as computed tomography (CT) colonography, in adults state that it is indicated for diagnostic examination in symptomatic patients, particularly in the setting of an incomplete colonoscopy, including those with gastrointestinal bleeding. The guidelines also state that CT colonography is indicated for patients who may be at increased risk for complications during optical colonoscopy due to advanced age, anticoagulant therapy, sedation risk, or prior incomplete colonoscopy. Medical literature concluded that CT colonography is sensitive in patients with lower gastrointestinal bleeding and is a good alternative to conventional colonoscopy. In addition, the U.S. Preventive Services Task Force supports CT colonography as a colorectal cancer screening test, and cites the American College of Gastroenterology recommendation. In this case, the patient has lower gastrointestinal bleeding, is on antithrombotic medication, and is overdue for colorectal cancer screening.Final Result: The reviewer determined that the requested test is medically necessary for evaluation 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) scan of the heart. Findings: Three physician reviewers found that this patient presented with some coronary risk and no documented symptoms or findings concerning for coronary ischemia. In this circumstance, guidelines for the evaluation and management of cardiac risk 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 coronary calcium scoring and coronary computed tomography (CT) scanning. Treatment change or addition based on the results of screening with specialized tests, including screening coronary CT scanning, has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT scan of the heart was not likely to have been superior over other methods of evaluating this patient.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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

The patient has requested reimbursement for the removal of implants and lift that was completed. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of the patient and were not reconstructive in nature. The California Health and Safety Code requires health insurers to cover reconstructive surgeries. This is defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to either improve function or create a normal appearance to the extent possible. The medical records support that the bilateral removal and capsulectomy that were completed were medical necessary and considered reconstructive in nature. With regard to the requested breast lift (mastopexy), the records failed to support that the lift was medically necessary and reconstructive in nature. Final Result: The reviewer determined that some of the requested services were medically necessary for treatment of the patients medical condition and some of the services were not medically necessary. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage of transcranial magnetic stimulation (TMS). The Health Plan denied the request as not medically necessary.In its approval of TMS, the U.S. Food and Drug Administration (FDA) noted that 38 percent of patients responded to treatment with TMS with a greater than 30 percent reduction in Yale-Brown Obsessive Compulsive Scale score, whereas 11 percent of patients responded when using the sham treatment. In medical literature, Trevizol and colleagues concluded that TMS was superior to sham stimulation for the amelioration of OCD symptoms. Overall, the data shows that TMS is an effective treatment for patients with treatment resistant OCD. This patient has failed multiple psychotherapeutic agents, CBT and PHP focused on exposure and response prevention therapy for OCD. This suggests that his OCD is treatment resistant and he is a candidate for treatment with TMS. Accordingly, the requested transcranial magnetic stimulation is medically necessary for treatment of the patients behavioral health 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for the HillRom Vest Airway Clearance System being used. The Health Plan has denied this request, indicating that the device at issue is investigational for the treatment of the patients medical condition. The records noted a history of cystic fibrosis, which is complicated by elevated liver enzymes and pancreatic insufficiency. The records noted an acute increase in pulmonary secretions.Findings:  Three physician reviewers found that According to the Cystic Fibrosis Pulmonary Guidelines from the Cystic Fibrosis Foundation, airway clearance therapy is recommended for all pediatric patients with cystic fibrosis (CF). According to researchers, the Cystic Fibrosis Pulmonary Guidelines further indicate that no airway clearance therapy has been demonstrated to be superior to others, so the prescription of therapy should be individualized. Clearance of airway secretions has been a primary therapy for those with CF. This patient has had been using the positive expiratory pressure (PEP) without good results.Final Result: The reviewers determined that the requested device was and is 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: Two out of three physician reviewers are board certified in pediatrics with sub-specialty certification in pediatric critical care, and are actively practicing. One out of three physician reviewers is board certified in internal medicine with sub-specialty certification in pulmonary disease, and 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 is a 65-year-old female with a history of breast cancer and chemotherapy treatment. Findings:  The physician reviewer found that ecords document a diagnosis of onychomycosis and tinea pedis. On 3/6/19, the patient reported previously using a fungal cream for one month, which did not improve her toenails. The patients provider recommended laser treatments and a fungal cream for the toenails. There is no documentation of contraindications of other medications due to past history of chemotherapy. The patient has requested authorization and coverage for toenail laser treatments. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient and are not reconstructive in nature.The submitted documentation fails to demonstrate the medical necessity of the requested toenail laser treatments. There is no indication that the patient has open lesions or ingrowing toenails causing infection from onychomycosis. There was also no documentation of which topical medications were prescribed for the patients onychomycosis. Although neodymium doped:yttrium aluminum garnet (Nd:YAG) and diode lasers have emerged as treatment options for onychomycosis, data on the efficacy of these interventions are limited, and the mechanisms of action and optimal regimens for these treatments remain unclear. Until more robust data supporting the efficacy of laser therapy for onychomycosis are available, we cannot recommend the routine use of this modalityTherefore, toenail laser treatments are not medically necessary for this patient. Onychomycosis does not constitute an abnormal structure of the body. There is no indication that the patient has difficulty ambulating or diminished function due to onychomycosis. There is also no documentation of pain. Onychomycosis is not a result of a congenital defect, a developmental abnormality, trauma, tumors or disease. However, Onychomycosis is a fungal injection. The requested toenail laser treatments are not likely to improve function or create a normal appearance to the extent possible. Therefore, the requested toenail laser treatments are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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 patient has requested authorization and coverage for orthotic inserts. Findings:  The physician reviewer found that orthotic inserts are not arch supports, but custom appliances crafted from plaster impressions, or computerized analysis of the feet. Each orthotic device is unique to the patient and are fabricated to address specific pedal deformities and abnormal mechanics of the feet and lower extremities that contribute to the patients podiatric complaints. Custom orthotic inserts are prescribed for a multitude of foot and lower extremity pathology and can help delay or prevent the need for surgery or be used post-operatively to maintain surgical correction and allow for improved foot mechanics. This patients MRI demonstrated an osteochondral lesion of the lateral dome of the talus, chronic sprains of the anterior talofibular and tibiofibular ligaments, as well as tendinitis of the distal anterior tibial tendon on the right. There was also the presence of osteoarthritis and degenerative changes in the ankle. The patient has already had surgery to release the right posterior tibial nerve which was complicated with a post-operative infection and resultant wound. At this point, custom orthotic inserts may best serve the patient. Repeat surgery could result in painful scar tissue, post-operative infection and continued pain. There is potential for healing and controlling pain and swelling associated with these issues with the use of custom orthotic inserts. Tarsal tunnel syndrome is often associated with abnormal pronatory forces, and so an orthotic insert can be used to control the abnormal foot mechanics, and in turn decrease or eliminate pain and improve function. The patient has also been diagnosed with bilateral pes valgus and right posterior tibial tendinitis. Custom orthotic inserts can also address the abnormal pronation issues associated with these podiatric complaints. By controlling the abnormal pronatory forces, the associated pain and swelling could be greatly reduced or alleviated and function improved. Given these findings, the requested orthotic inserts are medically necessary for treatment of this patients medical condition. 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 authorization and coverage for 12 months of treatment at Sunrise Residential Treatment Center for dialectical behavior therapy. Findings:  The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. The patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, 12 months of treatment at Sunrise Residential Treatment Center for dialectical behavior therapy is 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 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 reimbursement for septoplasty of the nose with replacement with grafts and ablation of the soft tissue of the inferior turbinates. The submitted documentation supports the medical necessity of the services at issue. The records documented deviated nasal septum and hypertrophic bilateral inferior turbinates. The patient had failed a trial of conservative therapy with nasal sprays to improve breathing through the nasal airway. The operative report indicated that the services at issue were performed to achieve a functional improvement in airflow. The medical evidence supports the services at issue in this clinical setting. Therefore, septoplasty of the nose with replacement with grafts and ablation of the soft tissue of the inferior turbinates were medically necessary for the treatment of this patient. In this case, the records document that the patients septum was significantly deviated and the turbinates were enlarged. This constitutes an abnormal structure of the body. The cause of the abnormal structure of the body was likely either developmental or a response to allergens. The services at issue were performed to improve function. Thus, septoplasty of the nose with replacement with grafts and ablation of the soft tissue of the inferior turbinates were reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery with expertise in facial plastic and reconstructive 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.