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 emergency medical services on an emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with ongoing palpitations for five hours. The patient was hypertensive on arrival in the emergency department. Although the patients EKG did not show any acute ischemic changes, her telemetry monitoring did document occasional PVCs. Palpitations may be benign, or may be unstable or have the potential to become unstable. Palpitations may also be the only symptoms of an ischemic event such as a myocardial infarction. Once an acute ischemic event was ruled out with a normal serum troponin, the patient was discharged home. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross linking for treatment of the enrollees keratoconus. Findings: Two of the three physician reviewers found that the records show that she has previously undergone collagen cross linking in the right eye (her worse eye) and in the left eye more recently. The patient has requested reimbursement for the recent treatment to her left eye. The Health Plan denied the reimbursement for the corneal collagen cross linking noting that the procedure at issue was investigational for treatment of this patient. The clinical data supports the efficacy of this procedure for patients who are diagnosed with keratoconus. Collagen cross linking was approved by the U.S. Food and Drug Administration for progressive keratoconus. The medical literature has shown that this procedure can halt progression of this eye condition. The submitted documentation noted that this patient was previously treated with collagen cross linking in her right eye. The documentation also appears to indicate that keratoconus was progressive in her left eye. The keratometry readings support this condition where the readings increased from 44.15/46.94 to 45.4/49.2. Therefore, these changes in her results demonstrate a progression of keratoconus in the left eye. Final Result: The reviewers determined that the procedure 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: 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided on an emergent basis or urgent basis. Findings: The physician reviewer found that the issue in this case is whether the enrollee received emergency medical services on the date 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with the sudden onset of dizziness and vomiting. He has history of hypercholesterolemia, which is a significant risk factor for atherosclerosis. His blood pressure was elevated on arrival. The combination of these factors placed him at risk for an acute stroke, prompting a CT scan of the brain. Such symptoms may also be characteristic of acute coronary syndrome, despite the absence of chest pain. Therefore, an EKG and cardiac biomarkers were obtained. Given the patients age, sudden onset of dizziness with vomiting and a history of hypercholesterolemia, the services at issue were necessary for an emergency medical condition. Final Result: The reviewers 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that the patient presented on intake as sober with no signs of withdrawals. Although the patient showed no behavioral aberrations and was cognitively intact, the patient's drinking impacted negatively upon his marriage. The patient was motivated to change. The patient had extended periods of sobriety, but relapsed. The patient has previously been treated with one IOP treatment and limited Alcoholics Anonymous experience. The patient has a history of opiate addiction. Based on the documentation submitted for review, IOP services are medically necessary in this clinical setting to educate the patient regarding the nature of addiction, development of coping skills, and relapse prevention. The patient requires a more structured and intense setting for treatment than outpatient services can provide. 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 physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 substance abuse intensive outpatient program (IOP) treatment services. Findings:  The physician reviewer found that there were no emotional, behavioral, cognitive, or impulsive issues that would prevent treatment at the outpatient level of care. The patient is not gravely disabled and has been motivated and engaged in treatment. The patient's home environment is supportive and without alcohol present. The patient's post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and sleep disturbance did not require monitoring or treatment at IOP level of care. The patient was appropriate for step down to outpatient counseling. 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 with sub-specialty certification in addiction 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Rituxan (rituximab). Findings:  The physician reviewer found that Rituximab is an effective and accepted therapy for membranous nephropathy.  In the trial by Ruggenenti and colleagues, 100 patients with idiopathic membranous nephropathy with persistent nephrotic syndrome were treated with rituximab.  The authors noted that 65 patients achieved remission with therapy, and a large number who did not reach remission status had clinical improvement. The long-term effects of steroids are well-known. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cardiac stress test for evaluation of his chronic pain and orthostatic dizziness. Findings:  The physician reviewer found that based on the records provided for review, this patient presents with no documented coronary risk factors, no symptoms concerning for angina, no cardiac physical examination abnormalities and no coronary ischemia on prior stress testing about two years ago. In this circumstance, further evaluation with repeat stress testing is not considered standard accepted practice in the medical community. Current guidelines for both stress echocardiography and nuclear stress testing that are endorsed by several national organizations also do not consider stress testing appropriate in this clinical setting. Final Result: The reviewer determined that the requested diagnostic procedure is 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 internal medicine with sub-specialty certification in cardiovascular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve ablation for treatment of her chronic headache. Findings:  Two physician reviewers found that he patient is a 53-year-old female with a history of chronic headaches, vertigo, and prior cervical fusion from C5-6 and C6-7. The patient reported that she has previously been diagnosed with occipital neuralgia, with severe headaches encompassing the whole head, with sensitivity and vomiting. The symptoms had persisted despite C5-7 fusion. Occipital decompression had reportedly helped left sided pain but then caused right sided pain. She described severe headache, nausea, and vertigo. The patient reported that she has been hospitalized for pain control. The patient reported that occipital nerve blocks, while hospitalized, were transiently beneficial. She has had a variety of medications including Imitrex and Lyrica. An examination described non-tender cervical spine, pain on palpation of the muscles in the cervical spine, numbness down the medial sides of the hands, and ataxia. She has had bilateral occipital decompression, but continues to have severe headaches with light sensitivity. Facet injection with Botox was reportedly partially beneficial. There are no records to indicate that she has been evaluated by a neurologic headache specialist. The patient has requested coverage for occipital nerve ablation. The Health Plan denied the requested services as investigational for the treatment of this patient. There is very little evidence based literature to support the long term efficacy of occipital nerve ablation in this clinical setting. This patient has reportedly had severe headaches with nausea and light sensitivity, and she has been prescribed Imitrex. These features support a diagnosis of chronic migraine. Botox injections is the treatment option approved by the U.S. Food and Drug Administration for treatment of chronic migraine. There is a need for high-quality randomized controlled trials supporting the long term efficacy of occipital nerve ablation for chronic headaches.  Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in neurology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right bipolar ablation. Findings:  The physician reviewer found that based on the medical evidence regarding radiofrequency ablation of the sacroiliac joint, there is wide variation in reported efficacy and lack of uniformity in how the procedure is conducted. A study characterized the evidence supporting radiofrequency ablation of the sacroiliac joint nerves as limited, with large numbers of case series with large false positive results and limited efficacy.  Another study conducted a systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions and found limited effectiveness.  In sum, the superior efficacy of the requested right bipolar ablation has not been established.Final Result: The reviewers  2 of 3 determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer s are board certified in anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a standing frame device provided.Findings:  The physician reviewer found that the current medical evidence supports the device at issue in this clinical setting. This patient has impaired mobility due to a cervical spinal cord injury.  A study noted sitting for more than eight hours per day has been shown to increase mortality while standing is a healthier alternative that can positively affect mortality in adults. Researchers found that standing has a positive impact on range of motion, activities of daily living, bladder function, and skin. The literature shows that a standing frame has positive effects on the health of those with spinal cord injury. All told, the standing frame device provided was likely to have been more efficacious than other treatment options. Final Result: The reviewers determined that the device at issue was 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 are board certified in physical medicine and rehabilitation and are actively practicing. The reviewers are 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: The parent of an enrollee has requested authorization and coverage for Botox injections. Findings:  The physician reviewer found that Botox is a muscle relaxant which has been found to have analgesic effects in patients with a variety of pain syndromes. Data from clinical trials confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine, the most severe and debilitating type of migraine, in adults. The peer-reviewed literature demonstrates that Botox injections for the treatment of chronic daily headache and migraine are effective for children. Its effective use, safety and tolerability have been demonstrated in several pediatric studies. This study described10 patients ages 11-17 with chronic daily headache refractory to treatment that were given Botox injections. The patients had failed to respond to an average of eight prior medications. In the study group, four patients treated with Botox had meaningful relief of their headache with improvement in their quality of life and two patients had a decrease in their headache frequency. Another study performed a retrospective review of all patients who received Botox for chronic migraine in a large pediatric headache center. The authors recommended Botox injections for pediatric patients with chronic headache if they fail two or more preventive medications. Their study showed a major change in the frequency of the headache with a statistical difference in the improvement of headache days per month. In this case, the patient has tried several therapeutic trials, including a tricyclic antidepressant medication, sertraline, biofeedback, acupuncture and massage without headache relief. As such, the request for Botox injections has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in pediatrics and neurology with special qualification in child 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: 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 skilled nursing facility services provided. Findings:  The physician reviewer found that the patient had a baseline of being non-ambulatory for many years. Although the medical literature generally supports subacute or skilled nursing facility level inpatient rehabilitation in a variety of clinical settings including cardiomyopathy, the medical literature does not support the necessity of this intervention indefinitely in the absence of expected functional progress.  Moreover, the documentation does not indicate that the patient has any other ongoing skilled nursing or medical needs requiring inpatient hospital level care.  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 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.