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 reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient was reported as making progress. The patients parents are supportive of the patient and are involved in family counseling. The patient denied any suicidal or homicidal ideation or psychosis. The patient was noted to be making progress in her treatment goals. The patient was able to attend to her activities of daily living. The patient was able to be treated in a less restrictive environment attending community 12-step programs and having sober supports. Therefore, while the patient continues to require treatment for her behavioral health condition, treatment could have been accomplished in a less restrictive environment such as a routine outpatient environment. As such, the services at issue have not been demonstrated as medically necessary for the treatment of this patients medical condition.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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections in both knees. Medical literature concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in a meta-analysis of 137 studies with 33,243 patients. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. A study found that a systematic review of overlapping meta-analyses (total 20,049 patients) comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines also indicate that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with recurrent bilateral knee pain. Significant functional limitations are noted in weight bearing tolerance and activities of daily living. Clinical examination findings have been consistent with bone-on-bone bilateral knee osteoarthritis. Reasonable conservative treatments have failed to provide adequate symptom relief. The patient reported that several prior Synvisc One injections provided up to six months of significant pain reduction and functional restoration. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given these findings, the requested Synvisc One injections in both knees are supported as 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.
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 for an adaptive car seating system. The submitted documentation supports the medical necessity of the requested equipment. This patient requires a device to offer proper support while riding in a vehicle. She is immobile and requires assistance. The patient is unable to correct positioning on her own. She needs to sit upright in a vehicle in the proper position. The requested equipment is indicated because she cannot sit in the vehicle in the correct and safe position without it. Many of the patients activities of daily living occur outside the home. Thus, the adaptive car seating system will assist in allowing the patient to complete her activities of daily living. All told, the requested adaptive car seating system is medically necessary for the treatment of this patient. 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. It is considered to be one of the most common neurological immunologic diseases. Multifocal inflammation of the central nervous system characterizes the disease and causes impaired nerve conduction, which is what causes the many different symptoms of multiple sclerosis. Multiple sclerosis is not a curable pathology. However, there are several therapies that can manage the disease. The formulary alternatives Copaxone, Extavia, and Gilenya have all been shown to be effective. Additionally, there is limited evidence of head-to-head comparisons indicating superiority of Tecfidera compared to the formulary options. All medications are associated with possible adverse reactions.  Tecfidera has been linked with progressive multifocal leukoencephalopathy, a potentially life threatening and severely debilitating complication. Severe flushing has also been associated with Tecfidera, which can possibly mimic and/or precipitate an anxiety attack. Considering the available evidence, the formulary options are appropriate. Therefore, Tecfidera is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Spinraza. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees spinal muscular atrophy type III.Findings:  The request for Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Recent clinical studies have shown Spinraza to be an effective treatment for SMA.  Per the medical literature, it is the only drug with U.S. Food and Drug Administration (FDA) approval for treatment of SMA. SMA is an autosomal recessive degenerative neuromuscular disorder characterized by loss of spinal motor neurons leading to muscle weakness. In a published study of Spinraza for the treatment of SMA researchers stated that the studies show improvement in motor function across SMA of all types, including SMA type 3.  Best motor response was observed with early treatment and pre-symptomatic treatment prevented disease manifestations. Maharashi and colleagues note major evidence of Spinraza efficacy came from a sham controlled phase 3 clinical study ENDEAR. According to the literature, all the patients were transitioned to receive Spinraza in an ongoing open label, phase 3 study, SHINE. Therefore, Spinraza is likely to be more efficacious than the available modalities for the treatment of this patients SMA, type III.Final Result: Two of the three reviewers determined that requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in neurology and are 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: An enrollee has requested authorization and coverage for mastoplexy and fat grafting. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees medical condition.There is support in the medical literature for the services at issue in this clinical setting. The patient is documented to have undergone medically necessary bilateral mastectomies followed by typical breast reconstruction. Based on the most recent evaluation, the patient has evidence of complications and deformities related to her medically necessary breast reconstruction. The patient has evidence of common complications associated with reconstructive breast surgery. Therefore, the recommended procedures for revision are consistent with standard procedures and standard of care. As such, mastoplexy and fat grafting are medically necessary for the treatment of this patients medical condition.With regards to whether mastoplexy and fat grafting are reconstructive in nature, the documentation supports that the requested services are reconstructive in nature. The patients bilateral mastectomies produced a severely abnormal appearance of the chest and breasts. The patient is documented to have continued breast deformities. The recommended surgical plan is aimed to produce relatively normal appearing breasts and would likely provide more than a minimal improvement in the patients appearance. For these reasons, mastoplexy and fat grafting are reconstructive in nature as defined by California law.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  A 49-year-female enrollee is requesting reimbursement for dental services on the basis that the services were emergent in nature. Review of the submitted documentation does not establish the medical necessity of full mouth reconstruction with porcelain crowns and veneers. The submitted records do not demonstrate the patient had severe maxillofacial injuries. Additionally, full mouth reconstruction is generally an elective procedure that is not typically provided on an emergent basis. Full mouth reconstruction is a complex procedure and there are a range of treatment options available to achieve an esthetic smile while maintaining a healthy oral environment. There are no notes from the patients dentist to indicate other options were offered. Full-mouth reconstruction involves full arch preparations, impressions, provisional restorations and master casts; such procedures require planning and are performed over a somewhat lengthy period of time and do not constitute emergency medical services to treat an acute condition.Final Result: The reviewer determined that 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 oral and maxillofacial 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: An enrollee has requested authorization and coverage for facial feminization surgeries and vocal feminization surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature.Findings: Overall, facial feminization surgeries and vocal feminization surgery are medically necessary for treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients facial features constitute an abnormal body structure. The requests appear to be consistent with addressing gender related abnormalities. The record supports that this patients facial features constitute an abnormal body structure for the female gender. In the same way that genitalia and breasts are abnormal structures in a patient who is diagnosed with gender dysphoria, these facial structures are inconsistent with this patients gender identity.  Masculinized facial features due to the effects of testosterone are also aberrant in the same manner. This patients facial features and masculine voice are considered a congenital defect since the patient is a female and the masculinized features are a congenital abnormality. Furthermore, the requested surgeries would create a normal appearance to the extent possible and are likely to result in more than a minimal improvement in the patients appearance. In addition, improvement in this patients mental health and functioning are both secondary benefits. Therefore, the requested facial feminization surgeries and vocal feminization surgery satisfy the criteria for reconstructive surgeries as defined in California law. Final Result: The reviewer determined that that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery with expertise in transgender 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: A enrollee has requested authorization and coverage for three months of weekly one hour individual therapy sessions that include medication management and three months of one hour group therapy sessions, five times a week. Findings:  The physician reviewer found that the requested services are not medically necessary based on the clinical documentation and current practice standards. The records indicate that the patient has been stable on his psychotropic medications and has access to psychiatric care. Further, he has been approved for weekly psychotherapy visits, which are recommended. The records document that the patients most recent clinic visit was six months ago, save for a few discussions via telephone. Thus, the patients current clinical status, symptom inventory, degree of psychosocial stressors and extent of psychiatric, substance use and medical comorbidity, if any, are unknown at this time. Without this information, there is a lack of evidence supporting the requested services. Typically, in providing clinical and consultative services, psychiatrists function as valuable members of a health care team, and are not a sole provider. In this case, the patient has access to weekly visits with a therapist. The patient has been stable on trazodone, paroxetine and lorazepam for some time. There is no indication of poor tolerability, lack of efficacy, misuse or side effect. Under these circumstances, weekly psychiatric visits are not medically necessary. The patient should continue weekly psychotherapy and consider self-help groups and wellness-based activities in the community. Given these findings, the requested three months of weekly one hour individual therapy sessions that include medication management and three months of one hour group therapy sessions, five times a week are not medically necessary for treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for levofloxacin and azithromycin daily intravenous (IV) infusions. The Health Plan has denied this request indicating that the medications at issue were not and are not medically necessary for treatment of the enrollee, who has a history of Lyme disease. This patient was diagnosed with Lyme disease per the submitted clinical documentation.  The provider recommended treatment for at least six weeks or possibly longer. However, the standard duration of therapy for Lyme disease is two weeks of IV therapy with an additional four weeks for patients with severe cases. In this patients case, the patient has already been treated with several weeks of IV therapy. Moreover, guidelines to suggest that additional treatment with azithromycin and levofloxacin is beneficial are lacking. Therefore, the proposed duration and regimen are not medically indicated for treatment of the patients medical condition. As such, levofloxacin and azithromycin daily IV infusions were not and are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the medications 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 internal medicine with sub-specialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 100 mg per week of testosterone cypionate (Depo-testosterone) and if not 75 mg per week. Findings:  The physician reviewer found that there is support in the medical literature for a portion of the requested medication dosage in this clinical setting. Specifically, testosterone cypionate (Depo-testosterone) is medically necessary. In 2016, the patient was noted to have an elevated hematocrit. However, it is unclear if this was calculated using the male reference range values. Based on the male reference range values, his hematocrit could be considered within the normal range. The standard typical doses for transgender or cisgender male with regards to testosterone intramuscular is 100 mg a week. Measuring testosterone level can be difficult as there are wide ranges and the peak and nadir levels. Typical normal values of testosterone is between 32 ng/dL through 1000 ng/dL. The patient states that in the past when he took a higher does, he felt better emotionally and had less abdominal cramping. As such, the patient can start at 75 mg per week. Part of transgender treatment is individualizing care based on patients goals in the context of informed consent as to the risks and benefits. The standard practice is to take into account the individuals moods, the desire for virilization, fertility concerns as well as other concerns. The medical literature and guidelines supports trying higher doses to observe its affect on mood and/or abdominal cramping. Therefore, it has been demonstrated that 75 mg per week of testosterone cyplonate (Depo-testosterone) is medically necessary.Final Result: The reviewer determined that a portion of the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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.