Persius/hicric huggingface dataset:
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 a custom lightweight wheelchair with a fabric cushion. The submitted documentation does not support that the requested durable medical equipment is medically necessary. Pediatric patients with Ehlers-Danlos may, at times, require assistive devices for ambulation; however, the need for a wheelchair would be very unusual for this reason. If a wheelchair were indicated for any patient, a detailed physician history/examination and physical therapy/wheelchair seating evaluation would be essential.In this case, the patient had a high end mobility assessment performed that noted that the patient was a functional ambulator and that she would not be bed or chair confined without the use of a wheelchair. The records reflect that the patient does not utilize her current wheelchair 90 percent of the time. She has reported a preference for trying to ambulate without any assistive devices. She is noted to be actively participating in extracurricular activities. The available records do not document any musculoskeletal or neurological exam to suggest an impairment requiring a wheelchair. Under these circumstances, the requested custom lightweight wheelchair with a fabric cushion is not medically necessary to treat the patients medical condition.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.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommend that RTC or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting.In this case, the patient had been treated in the ER for alcohol related problems three of the five days prior to admission, including at least one admission for life-threatening severe alcohol intoxication. The patients withdrawal symptoms included tremors, anxiety, chest pain, insomnia, sweating, unsteady gait, and psychomotor agitation. His prior rehabilitation services, including IOP and RTC services, were not sufficient as evidenced by yearly relapse. This patient required a safe and stable living environment in order to develop recovery skills. The medical records support an ASAM Level III treatment score, indicating he qualified for a level of care similar to what he received at the facility for the dates of service in question. The medical records support that the severity of the patients illness, including admissions for life-threatening alcohol intoxication and residential treatment, was in accordance with generally accepted standards of medical practice. Accordingly, the residential treatment center (RTC) services were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting (Lee D., et al).In this case, the severity of the patients illness includes: continued substance use despite severe consequences; a history of anxiety, depression, and hopelessness; and multiple relapses despite extensive outpatient services through more than one thousand 12-step program meetings. The patient required a safe and stable living environment to develop recovery skills. Medical records support an ASAM Level III treatment score, indicating that the patient qualified for a level of care similar to what she received at the facility for the dates of service in question. The purpose of detoxification is to make a patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help a patient maintain sobriety and reduce the risk of relapse. The RTC services provided to the patient were in accordance with generally accepted standards of medical practice. Therefore, the residential treatment center (RTC) services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Braftovi 75 mg, four capsules daily, in conjunction with Mektovi and Erbitux.Findings:  Two of the three physician reviewers found encorafenib (Braftovi) is not U.S. Food and Drug Administration (FDA) approved for the treatment of colon cancer, and it is not supported by major drug compendia. Vemurafenib is recommended in combination with irinotecan plus either cetuximab or panitumumab as a subsequent treatment option for patients with BRAF V600E mutation-positive tumors who were not previously treated with an epidermal growth factor receptor (EGFR) inhibitor, and this would be considered the standard of care for this patient. Braftovi with Mektovi and Erbitux is the subject of ongoing clinical trials. In sum, Braftovi 75 mg, four capsules daily, in conjunction with Mektovi and Erbitux, is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication regimen 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

An enrollee has requested reimbursement for intravenous immune globulin (IVIG) and prospective authorization and coverage for intravenous immune globulin (IVIG) to be received monthly going forward.Findings:  Three physician reviewers found that there is limited high-quality data on the management of recurrent pregnancy loss. Currently, therapeutic recommendations are largely based upon clinical experience and data from observational studies. In this patients case, the records document recurrent pregnancy loss, and her provider has recommended intravenous immune globulin (IVIG) therapy. Systematic reviews have not demonstrated a beneficial effect of immunotherapy for the treatment of recurrent pregnancy loss.  Colleagues performed a systematic review of 20 trials, and the authors noted that immunotherapy did not result in a statistically significant improvement in live births compared to untreated controls. Treatment with intravenous immune globulin was included in this study. Therefore, IVIG was not likely to have been superior over other available treatment options. Additionally, the superior efficacy of future IVIG to be received monthly going forward has not been established.Final Result: The reviewers determined that the services at issue were not and 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: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for bilateral occipital and trigger point nerve blocks. In this case, the patients pain complaints are corroborated by physical examination findings. In addition, the patient has failed a number of conservative measures including physical therapy and medical management. The provider charted the patients improvement in function with prior occipital nerve blocks to substantiate an indication for repeat injection therapy. Furthermore, the literature demonstrates that occipital nerve blocks have been shown to be low risk and efficacious for the treatment of occipital neuralgia. Given these findings, the requested bilateral occipital and trigger point nerve blocks are likely to be more beneficial for the treatment of the patients medication condition than any available standard therapy.One reviewer found that the requested bilateral occipital and trigger point nerve blocks are not likely to be more beneficial for the treatment of the patients medication condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  One Reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 patient has requested authorization and coverage for Humalog 100 units/mL Kwikpen and Lantus 100 units/mL vials.  Findings:  The physician reviewer found that Humalog, Admelog is a lispro insulin that has been developed as a similar product to Humalog 100 units/mL. However, a patient can experience different results with the two medications. This patients records indicate that she tried Admelog with adverse or inconsistent results that have required medical attention. Thus, the Humalog 100 units/mL Kwikpen is supported as medically necessary for treatment of this patients diabetes. With regard to the request for Lantus vials, Basaglar is not recognized as interchangeable by the U.S. Food and Drug Administration (FDA). In addition, Dolinar and colleagues noted that Basaglar is not considered to be identical because it uses a different manufacturing process and excipients. Thus, it is not substitutable for Lantus. Given this patients concern for confusing her basal and meal insulin pens as she has in the past, it is reasonable to replace one pen with one vial medication. Having the meal insulin as a pen and the basal insulin as a vial, will avoid patient confusion of insulin and prevent a dangerous event that can lead to hypoglycemia. Accordingly, Lantus 100 units/mL vials and Humalog 100 units/mL Kwikpen are medically necessary for management of this patients diabetes.Final Result: The reviewer determined that the requested medications 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 sub-specialty certification in endocrinology, diabetes and metabolism 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 authorization and coverage for hyaluronan injections for the right knee. According to the current practice guidelines for knee arthritis from the American Academy of Orthopaedic Surgeons (AAOS), hyaluronic acid is no longer a recommended treatment for knee arthritis. Fourteen hyaluronic acid (HA) studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet the minimum clinically important improvement (MCII) thresholds. It was conceded that there might be some subgroup of responders who could be helped by HA, but that subgroup has not yet been identified. In this case, there is no rationale presented in the submitted clinical documentation to support an approach that is contrary to AAOS guidelines. Accordingly, the requested hyaluronan injections are not medically necessary for 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 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: A patient requested authorization and coverage for mefenamic acid (Ponstel). The American College of Obstetricians and Gynecologists (ACOG) recommend treatment of fibroid associated pelvic pain with non-steroidal anti-inflammatory drugs (NSAIDs). The ACOG practice bulletin noted that NSAIDs are effective in reducing dysmenorrhea. Ponstel is a member of the fenamate group of NSAIDs. Studies show Ponstel has analgesic, anti-inflammatory, and antipyretic properties. Per its current U.S. Food and Drug Administration (FDA) indications for use, Ponstel is noted to be a potent inhibitor of prostaglandin synthesis. In the case of this patient, the effectiveness and tolerability of Ponstel has been demonstrated in the medical records provided for review. Specifically, the records indicate that the patients pelvic pain has been effectively managed with this medication. Accordingly, the requested Ponstel is medically necessary for continued treatment of this patients gynecologic related pain.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The submitted documentation does not support that the requested services are medically necessary. The literature supports that in the case of hypertrophic scarring, the timing of surgical treatment is an important consideration in the treatment protocol of scar revision strategy. Hypertrophic scars may mature over at least a one-year period and can show significant flattening and softening without any physical manipulation. In this case, the patient has scar hypertrophy in the lateral breast scars six months after reduction mammoplasty. There is no indication for early excision of hypertrophic scars to prevent further hypertrophy. There has been an insufficient amount of time for scar softening to occur. Under these circumstances, the requested scar revision is not medically necessary for treatment of the patients medical condition at this time.Furthermore, the submitted documentation does not support that the requested services constitute reconstructive surgery. Under California law, reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or create a normal appearance, to the extent possible. If the surgery is intended to create a normal appearance, it must offer more than a minimal improvement in appearance. California law mandates that health plans must cover reconstructive surgery. In this case, scarring after breast reduction surgery is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. The patient has scar hypertrophy in the lateral breast scars six months after reduction mammoplasty. Scarring after breast reduction surgery does not constitute a significant abnormal structure of the body. Hypertrophic scars may mature over at least a one-year period and can show significant flattening and softening without any physical manipulation. The records state the patient has difficulty sleeping on her left side due to discomfort but do not support deficits in function. Accordingly, the requested scar revision is not reconstructive in nature.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a three-wheeled mobility scooter and trunk lift. Findings:  The physician reviewer found that the submitted records do not support that the requested durable medical equipment is medically necessary at this time. The records indicate that the patient has multiple chronic medical conditions, but her primary mobility-related issue is back pain with intolerance of long periods of standing and ambulating for long distances. Otherwise, the patient is neurologically intact. The records do not establish that the patient has impairments that would preclude the use of a cane or walker to accomplish her mobility-related activities of daily living. The submitted documentation does not include objective findings such as examination notes describing gait, mobility deficiencies, or medication management due to pain. In addition, the records indicate that the patient has health conditions such as obesity and hypertension that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device would encourage. Under these circumstances, the requested three-wheeled mobility scooter and trunk lift are not medically necessary for the patients medical condition at this time.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.