Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for vision therapy. Current concepts in convergence insufficiency describe this as a condition in which an individual has difficulty with reading at near because of their inability to bring their eyes close together. Colleagues have noted that convergence insufficiency can develop following head trauma. While the standard treatment for patients with convergence insufficiency would be to start with home-based exercises including pencil push-ups, studies such as the Comparison of Three Vision Therapy Approaches by colleagues have shown that it is not unreasonable to start office-based vision therapy, which has also been shown to be effective. In this case, the patients initial examination clearly documented objective evidence of convergence insufficiency. The patients near point of convergence was at and exophoria was also noted. The submitted records of the patients subsequent vision therapy sessions document subjective and objective evidence that supports the diagnosis of convergence insufficiency and, therefore, supported the medical necessity of the first twelve (12) vision therapy sessions. Following these initial twelve (12) vision therapy sessions, however, the records do not document subjective or objective findings that support that continued vision therapy was medically necessary. After the first twelve (12) vision therapy sessions, there was no documentation of objective findings to support the presence of point of convergence. Accordingly, vision therapy was medically necessary to treat the patients medical condition, and vision therapy was not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that some of the services at issue were medically necessary for treatment of the patients medical condition. Specifically, the reviewer has determined that the first twelve (12) vision therapy sessions were medically necessary. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 a continuous passive motion (CPM) device and for physical therapy. The medical literature and submitted documentation do not support the medical necessity of the continuous passive motion (CPM) device in this case. There is no demonstrated benefit of continuous passive motion used in the home setting following hip arthroscopy for any indication with regards to functional or health outcomes. In this case, the patient underwent left hip arthroscopy surgery but did not receive the hip CPM device until nine days later. There is no clear documentation related to the patients left hip range of motion postoperatively or whether, and how specifically, the CPM device was employed. Under these circumstances, the CPM device was not medically necessary for treatment of the enrollees medical condition.The submitted documentation does not support the medical necessity of the physical therapy provided to the patient. There may be a role for vestibular rehabilitation, and rehabilitation for concussion injuries and benign musculoskeletal spinal conditions in the short-term following multi-trauma. However, there is no proven role for these interventions in the long-term, especially for formal manual therapy interventions. In this case, at the start of physical therapy, the patient was more than 10 months distant from the motor vehicle accident that caused her injuries. There was no basis for ongoing therapy on an empiric basis for the patients conditions. There were no indications that she had impairments that would have precluded a fully independent program as of that time. There were also no objective indications of benefit for ongoing therapy as of that time. Although the patient continued to have symptoms, no marginal difference in clinical course or outcomes would have been reasonably expected with ongoing therapies versus an independent program at that time. Additionally, despite the therapies that were rendered, the patient continued to have persistent significant symptoms, without noted improvement in her condition that could be reasonably attributable to the interventions. Accordingly, the physical therapy provided to the patient was not medically necessary for treatment of the enrollees 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for denosumab injections. The submitted documentation does not support the medical necessity of the services at issue or the requested services. Current guidelines recommend oral bisphosphonates as initial therapy. Reclast or zoledronic acid (IV bisphosphonate) are preferred if oral bisphosphonates cannot be tolerated. Prolia is a recommended alternative, and it is relatively safe; but there are no long-term safety data at this time, as opposed to bisphosphates, which have been used for years. Prolia has the risks of hypocalcemia, osteonecrosis of the jaw, atypical femur fractures and serious infections. Denosumab is an alternative to IV zoledronic acid for women at high risk for fracture, difficulty with the dosing requirements of oral bisphosphonates, and who prefer to avoid intravenous bisphosphonates due to side effects or who have chronic kidney disease.In this case, the medical records indicate that the patient has a history of normal kidney function and no pending dental issues or plans for major dental work. There is no history of gastrointestinal issues or of an inability to take oral bisphosphonates. Irritable bowel syndrome is not a contraindication to oral bisphosphonates. Therefore, the submitted documentation does not reflect any contraindication to a trial of another oral bisphosphonate or Reclast, which would be preferred, given the patients normal renal function and these medications efficacy and long-term safety profile. Under these circumstances, the denosumab injection administered to the patient, and denosumab injections every 6 months moving forward, were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue and the requested services 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 subspecialty certification in rheumatology, 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 anterior/posterior lumbar fusion surgery. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document obesity, chronic back pain and ill-defined lower extremity symptoms which are not consistent with lumbar radiculopathy. The records do not document vascular studies to rule out vascular claudication. He has not failed conservative management. There is a lack of correlation of his imaging with his clinical condition. He had an abnormal MRI with stenosis, but there was no evidence of nerve root compression. The current medical evidence does not support the requested services in this clinical setting. Therefore, the requested anterior/posterior lumbar fusion surgery 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 neurological 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of liver mass.  Findings:  The physician reviewer found that radiofrequency ablation is commonly used for metastatic liver tumors which are not responsive to systemic chemotherapy. The survival of patients with metastatic breast cancer is variable, and local resection of metastases is standard of care in some instances. Targeted resection of metastases in select patients is a standard therapeutic approach and can confer a long-term survival advantage. The medical evidence supports the requested services in this patients case. Thus, the requested radiofrequency ablation of liver mass is likely to be of greater benefit than other treatment options. Final Result: Three physician 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: 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting coverage for Emergency Room (ER) services. The Health Plan denied the request as the services provided were not emergency medical services.Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.In this case, the patient did not have an emergency medical condition. She did not have severe acute symptoms that placed her health in serious jeopardy. The patients condition also did not put her at risk for serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The patients symptoms had been present for two weeks. She had stable vital signs and was noted to be in no distress. Her examination was typical of arthritis without additional evidence of any serious complication, infection, or other medical emergency. The patients condition could have been treated appropriately and safely in a lower acuity setting such as an urgent care or primary care clinic. Since the patient did not have an emergency medical condition, the services provided were not emergency medical services.Final Result: The reviewer determined that the requested services at issue were not emergency medical services. 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: The enrollee has requested authorization and coverage for nipple sparing, skin saving, total mastectomy without sentinel node resection. The current peer-reviewed medical literature states that sentinel lymph node biopsy (SLNB) is medically necessary for patients with ductal carcinoma in situ (DCIS) who are undergoing mastectomy. With regard to nipple sparing mastectomy (NSM), researchers reported that they disregard the tumor-to-nipple distance as long as the subareolar/nipple margin is pathologically negative. Researchers acknowledged that the decision to save the nipple is treated like a lumpectomy margin, with the presence of positive margins supporting further excision. In this case, sparing the nipple/areolar complex is not medically necessary. The Health Plan has approved total mastectomy with sentinel lymph node resection and skin sparing with subsequent breast and nipple reconstruction, which is appropriate in this clinical setting. Furthermore, the requested NSM is not reconstructive in nature. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to either improve function, or to create a normal appearance, to the extent possible. In this case, DCIS is a malignant condition and an abnormal structure of the body caused by tumor. The purpose of breast reconstruction is to create a normal appearance, to the extent possible. However, skin sparing mastectomy, both with and without nipple sparing, will not improve function or provide a more than minimal improvement in the patients appearance. Accordingly, the requested NSM is not reconstructive in nature 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Mavyret 100/40mg as three tablets daily for eight weeks. According to the most recent 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype three patients should be treated with Mavyret as three tablets daily for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95 percent cure rate with eight weeks of treatment. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret as three tablets daily for eight weeks is supported as 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a male who has requested acupuncture treatments for the treatment of cervical spondylosis. The Health Plan has denied this request indicating that the treatments are not medically necessary for treatment of the patients cervical spondylosis. At issue in this case is whether the requested acupuncture treatments are medically necessary to treat the patients medical condition. The patient has had sufficient acupuncture treatment with previous sessions. He has not made any increased or sustained improvement after the previous acupuncture treatment, per the records. There is no indication that he is expected to make further sustained improvement through more acupuncture treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is limited evidence on the long-term effectiveness in this clinical setting. Additionally, studies show that acupuncture is not more clinically significant than sham-acupuncture or placebo for neck pain. Moreover, there is no evidence that the patient has tried or has been referred for proper medical management for his pain with treatments such as physical therapy, pain management, or cortisone injections. Therefore, the acupuncture treatments are not medically necessary.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 chiropractic and oriental 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure.Findings:  Three physician reviewers found that this patient was diagnosed with progressive keratoconus. The records document decreased visual activity which interferes with activities of daily living. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen over time. Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant. This procedure has the potential for significant complications. Corneal collagen cross-linking has been studied extensively and is considered the standard of care for patients with progressive keratoconus. As compared to corneal transplant, corneal collagen cross-linking involves less risk. Therefore, corneal collagen cross-linking procedure was likely to have been superior over other treatment options. Final Result: The reviewers determined that the services at 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 ophthalmology 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 magnetic resonance imaging (MRI) of the knee. The submitted documentation does not support the medical necessity of the requested service at this time. An MRI is the procedure of choice following negative knee x-rays to evaluate for possible internal derangement of the knee including suspected meniscal and/or medial collateral ligamentous disruption. Medial collateral ligamentous injuries on MRI have remarkable correlation with arthroscopic findings. In this case, the requesting provider has not documented any objective findings regarding the patients right knee. There are no specific maneuvers mentioned, such as anterior drawer sign, which would elevate the suspicion of internal derangement. There is also no documented point tenderness or impression of joint effusion. Under these circumstances, the requested MRI of the knee is not medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 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.