Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for occupational therapy sensory integration services. With its focus on developing motor planning skills and problem solving skills, teaching self-help skills, and developing spatial awareness, occupational therapy is well suited to affect positive change in this patient. Combining sensory integration techniques with other occupational therapy approaches is also appropriate. According to the most recent recommendations from the American Academy of Pediatrics (AAP), sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders  occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. For these reasons, the requested occupational therapy sensory integration services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested occupational therapy sensory integration services are not likely to be more beneficial for treatment of the patients medical 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 pediatrics with sub-specialty certification in pediatric critical care and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics and is actively practicing.  One Reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral pediatrics 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem solution (sodium oxybate).  The submitted documentation fails to demonstrate the medical necessity of the requested medication. This enrollee reported sleep issues and mood symptoms. The progress notes do not indicate the patient has a diagnosis of narcolepsy. The requested medication is approved by the U.S. Food and Drug Administration (FDA) for narcolepsy.  There is a lack of support for the requested medication in this clinical setting. Therefore, Xyrem solution (sodium oxybate) is not medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-UM test. Findings:  The physician reviewers found that the DecisionDx-UM test evaluates the genetic profile of an individual patients uveal melanoma tumor sample to determine the patients risk for metastasis. The DecisionDx-UM test stratifies a tumor to low risk and high risk for metastasis and is considered the current standard of care. Although it does not change the prognosis, it does provide prognostic information that is clinically useful. As this testing is within the standard of care for patients with uveal melanoma, the DecisionDx-UM test rendered was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-UM test rendered was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for group speech therapy. Based on this patients language scores, he is likely to benefit from one hour per week of individual speech therapy plus the addition of group speech therapy. He is currently being treated with ABA therapy and a social skills group therapy. He also receives speech therapy for one hour per week and occupational therapy for one hour per week. Based on his scores on language skills, he has delays in pragmatic language, overall listening comprehension, and oral expression. He requires individual speech therapy to address the listening comprehension and oral expression. He also has very low pragmatic skills testing at 4%, so he requires pragmatic language interventions, which are usually provided through group speech therapy (Adams, et al). All told, the requested group speech therapy for one hour per week is medically necessary for 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. Credentials/Qualifications: The reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne genetic testing. Findings:  Two of the three physician reviewers found that FoundationOne assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the provider as to which chemotherapeutic drug would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of such analyses.  A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. Therefore, FoundationOne genetic testing was 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 45-year-old male enrollee has requested authorization and coverage for a fistula laser tract closure (FiLAC) surgery for treatment of the enrollees fistula-in-ano.  Findings:  The physician reviewer found that Fistulas in patients with Crohns disease can be difficult to close and there are instances where patients live with the seton. Seton removal does not generally result in fistula healing, especially if the fistula tract has been present a long time and the tract is likely epithelialized. One option that was discussed with this patient is endorectal advancement flap which is a procedure recommended for management of fistula-in-ano in the clinical practice guideline from the American Society of Colon and Rectal Surgeons.  There is no mention of the FiLAC procedure in this clinical practice guideline for management of fistula-in-ano. Adegbola and colleagues noted that there is a paucity of robust data with long-term outcomes. Overall, the benefits of this procedure have not been demonstrated to provide improved health outcomes in this clinical setting. All told, the requested FiLAC procedure is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in colorectal 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 intensity modulated radiotherapy. The submitted records do not support the use of intensity modulated radiotherapy technique in the treatment of this patients bone metastases. The standard treatment is with three-dimensional conformal radiation therapy. Intensity modulated radiotherapy is indicated when patients are undergoing re-irradiation to the same site in the palliative setting. However, this patient has not undergone prior radiation to the spine or chest. Currently, researchers have not established that treatment with intensity modulated technique offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for uncomplicated bone metastases. Thus, intensity modulated radiotherapy was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services. TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. Researchers noted that TMS has been demonstrated to provide clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. According to the validated rating scales in this case, the patient had improved with the initial course of TMS. Currently, for patients who respond well to TMS, clinical improvement is usually maintained with psychotherapy and psychotropic medication. Further, it does not appear that standard treatment modalities had been exhausted. Psychotherapy remains a first-line intervention for depression and there are other trusted, evidence-based interventions, such as interpersonal therapy and psychodynamic psychotherapy. Additionally, there is no mention of intermediate treatment settings such as intensive outpatient services or partial hospitalization programming. Finally, there is no discussion of or contraindication to electroconvulsive therapy, which remains the proven non-pharmacologic intervention in the treatment of depression to which other stimulatory techniques are measured. Therefore, the TMS services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the TMS services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the TMS services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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 the electric scooter. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees chronic low back pain. Findings: The documentation provided does not support the medical necessity for the requested equipment in this clinical setting. The records indicated a musculoskeletal examination that was within normal limits. The patients COPD is managed with bronchodilators, steroids and supplemental oxygen as needed. However, the records do not indicate that the patient has neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using assistive devices or an optimally configured manual wheelchair to accomplish her mobility related activities of daily living. Physical activity, moreover, is generally appropriate and encouraged for conditions such as COPD and for general musculoskeletal health. Therefore, the request for an electric scooter is not medically necessary for the treatment of this 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a female with a history of mandibular anterior pain. She did undergo treatment of teeth in the area. However, as the lesion persisted, she was referred to an oral surgeon for evaluation who found her to have a large radiolucent lesion which crossed the midline and extended in the area from teeth numbers 21 and 28. Given this finding, a biopsy of the area was recommended and this was performed. The lesion was found to be consistent with a central giant cell granuloma. She was referred to otolaryngology for further treatment. The patient has requested reimbursement for emergency services provided. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. At issue in this case is whether the enrollee received emergency medical services on the date(s) of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The patient did have a lesion within her mandible and was symptomatic. Given the presence of the lesion, immediate biopsy of the lesion was indicated. The importance of early biopsy is imperative as aggressive pathology needs to be ruled out. The biopsy would then guide management of this lesion after histological evaluation. Given that the patient was symptomatic, performance of the procedure on an immediate basis was warranted. The emergency services provided were necessary for treatment of an emergency medical condition. Thus, the patient did receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did receive emergency medical services for treatment of an emergency medical condition. Therefore, the Health Plans denial should be overturned. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services on the basis that the services were emergent in nature. Review of the submitted documentation demonstrates the patient had elective surgery for sinonasal issues. She underwent frontal sinus surgery to treat recurrent sinusitis, open septoplasty, valve repair and turbinate reduction surgery to treat nasal obstruction, and tip plasty for cosmesis. None of these procedures were performed on an emergent basis. Each procedure was performed for chronic issues and done on an elective basis. In situations of excessive nasal bleeding or impending ocular or intracranial complication from sinusitis, sinonasal surgery can be performed on an emergent basis. However, these criteria were not met in this case. As such, the patient was not experiencing an emergency medical condition on the date of service at issue. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrocodone-acetaminophen 10-325 mg, four pills per day at 120 pills for a 30-day supply. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the patients chronic pain. The submitted documentation does not support the medical necessity of the requested medication quantity. The Centers for Disease Control guidelines do not support the chronic use of opiates for non-malignant disease. There is no documentation of hormonal therapy or of surgical intervention for this patients pain. The dosage of gabapentin is sub-therapeutic. The current guidelines do not support the use of chronic opiate therapy for endometriosis. Therefore, hydrocodone-acetaminophen 10-325 mg, four pills per day at 120 pills for a 30-day supply is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication quantity 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 anesthesiology with sub-specialty certification in pain 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 ambulatory event heart monitor.Findings:  Two of the three physician reviewers found that this patient has significant ischemic heart disease. He has had recurrent symptoms of dizziness and near syncope which required hospital admission. He has a history of multiple embolic events. Given the underlying heart disease, the recurrent symptoms necessitating admission and the prior multiple embolic events, the likelihood of a significant rhythm disturbance, like atrial fibrillation or bradycardia, is relatively high. In the absence of any findings on the external event monitor and in the setting of recurrent symptoms requiring readmission to the hospital, evaluation with an implantable loop recorder was a reasonable next clinical step. There is sufficient support for the device at issue in this setting. Therefore, ambulatory event heart monitor was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the device at issue was likely to be more beneficial for evaluation 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 cardiovascular disease 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.