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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided for treatment of an emergency medical condition.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. The urgent care services provided were not necessary for treatment of an emergency medical condition. In this case, the patient presented to an urgent care facility with reports of having a rash for the past three months. He denied any chest pain, difficulty breathing, or sore throat. The patients airway was patent. His lungs were clear. The patient also reported night sweats with pain at a prior site of a leg osteomyelitis. He denied fever. His vital signs were normal. His leg was not tender or erythematous. X-rays were consistent with old bone scar. Laboratory testing was unrevealing. The patients symptoms were not sudden or acute. He was not experiencing any airway compromise. There were no signs of acute infectious illness or sepsis. This patients symptoms were 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 reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 partial hospitalization program (PHP) services for treatment of the enrollees polysubstance abuse, depression, and anxiety. Findings:  The physician reviewer found that the patient showed what appeared to be mild to moderate post-acute withdrawal symptoms. She was not suicidal or homicidal, and there were no emotional, behavioral, cognitive, or psychotic issues indicating a need for PHP level of care. She was medically stable to the extent that her hypertension did not require management in PHP. The standard of practice for hypertension management is in the outpatient setting. She was psychiatrically stable and she was motivated, completing assignments, and otherwise engaged in her treatment. She had coping skills and was aware of triggers. She was aware of relapse risk. She had multiple treatments in the recent past, and was familiar with the process. She no longer required the rigors of PHP level of care and could have been stepped down to IOP level of care to continue her recovery, along with the support of a 12-step home group and counseling. Thus, the PHP services provided were not medically necessary for treatment of the patients medical condition.  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 psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage reduction mammoplasty for treatment of the enrollee's mammary hypertrophy.  Findings:  The physician reviewer found that the request for reduction mammaplasty is medically necessary for treatment of the patients medical condition. According to the guidelines from the American Society of Plastic Surgeon (ASPS), reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. In this case, the patient presents with well-documented, chronic back, neck and shoulder pain, shoulder grooving and headaches due to the weight of the breasts. This has significantly impacted her activities of daily living. Multiple medical evaluations provide confirmatory evidence of these findings. In addition, based on the overall clinical documentation, the patient has failed reasonable conservative management. Mammary hypertrophy is causing functional problems and would likely benefit significantly from reduction surgery. In sum, breast reduction is medically necessary for this patient and is consistent with standard of care. Moreover, further conservative treatment would not likely improve her functional deficit. Therefore, based on the documentation submitted for review, the request for reduction mammaplasty is medically necessary.Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein ablation for treatment of her varicose veins.  Findings:  Three physician reviewers found that the hemodynamic significance of the calf perforating veins continues to be controversial. There is a bidirectional flow within calf perforators in healthy patients enabling a quick equilibration of pressure changes produced during calf muscle contractions and relaxations. In cases with saphenous reflux, the bidirectional flow within calf perforators has a distinct inward vector directed to the deep veins. In primary varicose veins, calf perforators cannot become the source of reflux because they are situated at the lower pole of the ambulatory pressure gradient, which occurs between thigh and lower leg veins during ambulation. The size of the calf perforators is determined by the amount of saphenous reflux. When the saphenous reflux is abolished by ablation or high ligation, the enlarged calf perforators generally diminish. Currently, there are insufficient level 1 or level 2 studies in the literature to demonstrate that ablation of perforators is appropriate and no evidence to support perforator surgery in the absence of stage 5 and 6 chronic venous disease. Given these findings, the requested vein ablation of the GSV and perforator are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Results:  The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in surgery with sub-specialty certification in vascular surgery and is actively practicing. The reviewer 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 and prospective authorization and coverage for 136.95 total hours (to reach 35 hours per week) of direct one-on-one applied behavioral analysis (ABA) therapy and 5.8 total hours (to reach 15 hours per month) of supervision by Board Certified Behavior Analysis (BCBA) provided from for treatment of the enrollees autism. Findings:  The physician reviewer found that the request for 136.95 total hours (to reach 35 hours per week) of direct one-on-one ABA therapy and 5.8 total hours (to reach 15 hours per month) of supervision by BCBA provided was not and is not medically necessary for treatment of the patients medical condition. The records submitted for review document that the patient is making progress with the current amount of ABA being provided. There is no documentation of aggressive or other maladaptive behaviors that might warrant intensification of ABA services, and there is no indication that maintaining the current amount of direct ABA therapy would result in loss of skills. In addition, the Health Plans authorization of caregiver training will assist the parents in reinforcement of skills acquired in ABA therapy sessions. As such, the request for an increase in ABA hours is not clinically indicated for this patient.  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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 left-sided L3, L4 and L5 radiofrequency ablation.  Findings:  Three physician reviewers found the submitted documentation fails to demonstrate the superior efficacy of the requested services. This patient has multilevel degenerative disc disease with radiculopathy and scoliosis. Performing radiofrequency lesioning in the presence of an extruded disc with radiculopathy, instead of epidural steroid injections or surgery, is not the standard approach. The medical evidence supports surgery after failed conservative therapy. All told, the requested for left-sided L3, L4 and L5 radiofrequency ablation is not likely to be superior over other treatment options.  Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral occipital nerve block and trigger point injections performed for treatment of her intractable chronic migraine.  Findings:  Three reviewers found that the records do not indicate the presence of occipital neuralgia as documented by physical examination findings. Occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Cuadrado and colleagues noted there was no long-term improvement of headache of chronic migraine type with use of occipital nerve block.  The study by Dilli and colleagues noted greater occipital nerve block do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo.  The medical records do not indicate occipital nerve block and trigger point injections were indicated for the treatment of this patients migraine headache condition. Thus, the superior efficacy of bilateral occipital nerve block and trigger point injections performed  has not been demonstrated.  Final Result:  Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in neurology 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 authorization and coverage for Botox injection for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. While Botox has been demonstrated to have efficacy in treating chronic headache and chronic migraine in double-blinded studies, it is not considered an initial platform therapy.  Botox is not more likely to improve this patients headache activity as compared to standard treatments including, but not limited to, beta blockers, tricyclic antidepressants, anticonvulsants or serotonin-norepinephrine reuptake inhibitor (SNRI) class of medications.  Therefore, the requested Botox injection 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 neurology 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 substance abuse residential treatment provided for his alcohol dependence.  Findings:  The physician reviewer found that It appears that the patient underwent detoxification of an indeterminate length. It is unknown what happened between detoxification and his presentation, in a sober state, for residential admission. There are no Clinical Institute of Withdrawal Assessment (CIWA) scores provided for review. His vital signs on admission were stable, and there were no further vital signs in records provided. In addition, there were no physician progress notes or nursing progress notes. Moreover, there were no consistent mental status evaluations. Despite the patient reporting anxiety and depressive symptoms on admission, the patient was not seen by a psychiatrist and not placed on medications.  Overall, the patient was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive factors requiring residential supervision. The patient was motivated, he had sober support, and a safe home environment. He was on Naltrexone and had acquired a sponsor. Given these findings, this patient did not require 24-hour monitoring and could have been treated at IOP level of care, along with AA meetings and the support of his sponsor. Thus, the substance abuse residential treatment provided was not medically necessary for treatment of this patients alcohol dependence.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 psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollee's hepatitis C virus.  Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The guidelines recommend treatment based on prior therapy. The guidelines state that non-cirrhotic genotype 1a patients who have failed peg-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on the C-EDGE TE clinical trial results showing a 94% cure rate when NS5A resistance is absent (Kwo, et al).  Although the patient may have failed a different regimen three to four years ago, failure of such a regimen would not be relevant to the efficacy of Zepatier, a combined NS5A and NS3/4 inhibitor, when NS5A resistance testing is negative. Moreover, the AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication 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 internal medicine with sub-specialty 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 computerized axial tomography scan that was performed for evaluation of his hyperlipidemia.  Findings:  Three physician reviewers found that based on the records provided, this patient presented with no documented increased coronary risk, no documented symptoms concerning for coronary ischemia, and no ischemia on recent stress testing. In addition, the patients most recent lipid values while off lipid medication are not significantly elevated and his HDL is protectively high. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia 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 CT scanning and coronary calcium scoring. Treatment change or addition based on the results of screening with coronary CT scanning/calcium scoring has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Given these findings, the computerized axial tomography scan that was performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Three reviewers determined that the service at issue was 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. Final Result: Three reviewers determined that the service at issue was 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of his behavioral health conditions.Findings:  The physician reviewer found that with records to the patients recovery, the records support a score of 2 regarding environmental stress. The patient had a mildly stressful environment.  He reported that he did well socially and made friends easily. His friends are supportive. He has a good relationship with his parents. Stress from the home came mainly from expectations for performance at school and at home which were not being met. In terms of environment support, the records support a score of 2.  The patient had a supportive environment.  Both parents are supportive and would participate in care if requested to do so. Regarding significant response to treatment, the records support a score of 2. The records noted that the patient had improved significantly. Regarding acceptance and engagement, the patient scored 2. At the initiation of treatment, the patient was obstructive with treatment. Subsequently, the patient was able to develop positive relationships with his clinicians and care providers. Overall, the patient has a composite score of 15.  Based on these criteria, the patient could have been discharged to a less restrictive environment as an outpatient. All told, residential treatment services provided 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 patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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.