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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. This patient presented with severe incapacitating low back pain radiating into the right lower extremity to the calf. Clinical examination demonstrated significant motor defects consistent with imaging evidence of a large recurrent L4/5 disc bulge with extrusion resulting in severe spinal stenosis and L4 and L5 nerve root compression. Reasonable conservative treatment was attempted, including oral steroids, anti-inflammatory medications, and activity modification. He was recommended for L4/5 revision microdiscectomy and decompression and underwent surgery. Given the severity of pain and progressive neurologic deficits, the surgical intervention would be considered emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). The services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. Based on the available documentation, this patient does not meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for postpartum depression because the onset of her symptoms started more than four weeks following the birth of her child. She did struggle with anxiety and sleep deprivation related to her childs difficulty sleeping. However, the records do not document that the patient was at serious risk for suicide, self-harm or harm to others. She was provided with timely therapeutic intervention from several resources and she did not meet the criteria for emergency care. Accordingly, the emergency services provided were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services at issue were not necessary for treatment of a psychiatric 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 for skilled nursing facility services. In this case, the medical needs of the patient do not support that the services in issue were medically necessary. The patient had reached a level of function that did not require daily inpatient skilled therapy, and she did not require continued daily skilled nursing services. The requested extension of skilled nursing facility care was not based on medical instability, rehabilitation needs or skilled nursing needs. Inconvenience to the patients family is not a medically necessary reason for staying within a skilled nursing facility. The ability to perform car transfers is not medically necessary prior to discharge home for a patient who is able to toilet, to transfer with standby assistance, and to walk 200 feet. Accordingly, skilled nursing facility services were not medically necessary to treat the patients medical condition during the period in issue.Final Result: The reviewer determined that the services in 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 internal medicine, with subspecialty certification in hospice and palliative 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 authorization and coverage for bariatric gastric sleeve surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) noted that requiring a specified amount of weight loss or type of diet program for a specified number of months has not been demonstrated to improve perioperative outcome. The records provided for review document that this patient has failed non-surgical efforts at weight loss. However, the patients records do not include adequate documentation to support the medical necessity of the requested surgical intervention. The patients records do not include a thorough multidisciplinary evaluation to demonstrate that the patient is an appropriate candidate for bariatric surgery. Given the absence of a multidisciplinary evaluation, the requested bariatric gastric sleeve surgery is 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 surgery with expertise in bariatric 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 reimbursement for Residential Treatment Center (RTC) services. In this case, the medical needs of the enrollee do not support that the services in issue were medically necessary. On admission, the patient indicated that she was not suicidal, and she gave a reason for not being suicidal. The patients mood rapidly improved after changes in medication. As of the date that the services in issue commenced, the patient appeared to be stable and to be able to cooperate and participate in therapy. The submitted documentation reflects that the patient could be treated at a less restrictive level such as a partial hospitalization program or an intensive outpatient program. While there is mention that the patient had a complex combination of medications that required medical observation, there is no indication of frequent psychiatric evaluation. Accordingly, Residential Treatment Center services were not medically necessary to treat the enrollees medical condition during the period in issue.Final Result: The reviewer determined that the services in 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 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 laboratory services. Findings:  Two of three physician reviewers found stomatitis is a general term for an inflamed and sore mouth. This condition can be caused by a number of medical conditions, including infections. Infections can include candidiasis, viruses or bacteria. In this case, the patient was diagnosed with stomatitis as the likely reason for her symptoms of loss of taste. Physical examination showed superficial depapillation and white coating on the tongue, which is consistent with a diagnosis of thrush or candidal infection.  The diagnosis of oropharyngeal candidiasis is usually suspected clinically and is readily confirmed by scraping the lesions with a tongue depressor and performing a Gram stain or potassium hydroxide preparation on the scrapings. Although a culture can be performed, it is rarely indicated unless the disease is difficult to treat or recurs. The medical evidence does not support the services at issue in this clinical setting. In sum, laboratory services were not likely to have been of greater benefit than 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 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: An enrollee has requested reimbursement for Supartz FX 10 mg/mL intra-articular injections provided in each knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is an effective option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. This patient has experienced excellent relief with hyaluronic acid injections. Thus, the Supartz FX 10 mg/mL intra-articular injections provided in each knee medically necessary for treatment of this 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the serological antibody blood test. Confirmation of eradication should be performed in patients treated for H. pylori due to increasing antibiotic resistance. Based on the current medical guidelines, eradication can be confirmed with a urea breath test, stool antigen testing, or endoscopy-based testing. The choice of test depends on the need for an upper endoscopy. Tests to confirm eradication should be performed at least four weeks after completion of antibiotic treatment. However, there is a lack of data supporting a role for serologic testing to confirm eradication, as patients may continue to have antibodies after eradication, and this leads to false positive results. Accordingly, the serological antibody blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the serological antibody blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene mutation test prothrombin G20210A (Factor II). Findings:  Three physician reviewers found that this testing is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. DVT and pulmonary embolism may be caused by hereditary thrombophilias. The increased risk is worth knowing, especially in situations of estrogen therapy, prolonged immobility such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions. There are also known interactions between drugs and other variables and gene mutations in Factor V or II. For example, there is a known interaction between estrogens and the Factor V mutation. There is extensive literature supporting the testing that was done in this case. The Factor V mutation, also known as Factor V Leiden, definitely has the potential to induce hypercoagulopathy if the right environment were provided, such as a long airplane flight or automobile trip as in this specific case. Colleagues have found that the Prothrombin G20210A mutation adds to this risk, such that compound heterozygous patients can have up to 20-fold increased odds of developing DVT. The prothrombin G20210A (Factor II) gene mutation test was medically appropriate and necessary, and would directly alter treatment or prevention recommendations. Therefore, the services in issue were likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services in issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in hematology, 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 reimbursement for magnetic resonance imaging (MRI). The submitted documentation fails to demonstrate the medical necessity of the services at issue. MRI can be utilized in the evaluation and diagnosis of bony and soft tissue metastases in the setting of prostate cancer due to its high spatial resolution and contrast. Per the American College of Radiology, whole body MRI may be appropriate in post-treatment follow-up of prostate cancer. Specifically, it may be complementary to prostate-specific PET examinations. However, in this patients case, the records do not establish the medical necessity of the services at issue. Although some more recent records were provided, the most recent clinical note specifically regarding treatment strategy is dated 2015. Documentation regarding the providers rationale for ordering the MRI is lacking. Therefore, the submitted records did not establish that the MRI was medically indicated. All told, the MRI was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 representative of a 46-year-old female enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care. The documentation does not support the medical necessity of skilled nursing services for treatment of this patients medical condition from August of 2018 forward. The current medical literature states that there are rehabilitation interventions for patients with disorders of consciousness, which are established in clinical practice and supported by expert opinion, that do not need to be provided in the skilled nursing facility setting. The patient requires gastrostomy and tracheostomy care. However, the patient is medically stable and these services do not need to be performed by a trained medical provider in a skilled nursing facility. Moreover, the patient does not require therapy services with the specialized skill, knowledge and judgment of a qualified therapist. The patient has been receiving therapy, but progress has been limited due to cognition and limitations in function. The records indicate that overall, the patients exercises do not require the services of a skilled therapist. Given these findings, the skilled nursing care provided was not and is not medically necessary for 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: The parent of an enrollee has requested authorization and coverage for speech therapy services. Based on the available documentation of the patient's lack of progress, and in line with multiple professional recommendations, the continuation of speech therapy is not medically necessary at this time. Any progress made over two years of speech therapy would manifest in the standardized test scores. In this case, scores were lower at the second testing almost two years after initial testing, indicating that progress had not been made. The National Autism Center highlights ABA therapy as the most effective evidence-based treatment for autism. In this case, the patient appears to have made several gains through this service format. According to researchers, speech therapy is not medically necessary as the speech therapy in this case is not meeting the essential health needs of the patient. Therefore, the requested speech therapy services 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 psychology, is a board certified behavioral analyst, 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 hearing aids with masking sounds. Recent literature explains that tinnitus is the perception of phantom sound in the absence of a corresponding external source. It is a highly prevalent disorder, and most cases are caused by cochlear injury that leads to peripheral deafferentation, which results in adaptive changes in the CNS. Tinnitus is a heterogeneous disorder, tinnitus sound can differ between individuals, it can result from many different types of injury and its effect can vary from a minor annoyance to catastrophic impact on daily life. Current tinnitus management options include hearing aids, sound generators, cognitive behavioral therapy (CBT), music therapy, tinnitus retraining therapy (TRT), relaxation therapy, or may involve pharmacotherapy for associated problems such as insomnia, anxiety, or depression. Masking can be used to totally or partially reduce the audibility of tinnitus by covering it with another sound. An increased benefit derived from maskers has been demonstrated in patients with tinnitus. In this patient with sensorineural hearing loss and tinnitus, hearing aids with masking is medically necessary. Final Result: The physician reviewer determined that the requested devices are medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in otolaryngology 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.