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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Gallium-68 Dotatate positron emission tomography (PET) scan. The American College of Radiology (ACR) has recognized the use of Gallium-68 Dotatate PET in patients with suspected neuroendocrine tumors. Overall, this imaging technology has been demonstrated to be the most comprehensive physiologic test to detect neuroendocrine tumors, especially when conventional imaging is negative. The basis for the advantage of Gallium imaging is the positive binding of the compound with somatostatin receptors which are the basis of neuroendocrine tissue. In order to further evaluate this patients symptoms, when compared to standard alternatives including fluorodeoxyglucose (FDG) PET, the requested Gallium-68 Dotatate PET is likely to be more beneficial for evaluation of this patients medical condition. One reviewer found that the Gallium-68 Dotatate PET is not likely to be more beneficial for evaluation of this patients medical condition.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injections and stem cell injections.Findings:  Two of the three physician reviewers found that there is a lack of support for the requested services in this clinical setting. The records document plantar plate tears and osteoarthritic changes to the first metatarsophalangeal joint. Currently, most of the studies on platelet-rich plasma and stem cell injections have been performed for the treatment of lateral epicondylitis. At this time, platelet-rich plasma injections and stem cell injections are not considered standard of care in this patients case. The standard of care treatments for plantar plate tears include immobilization, non-weight-bearing, physical therapy, and surgical plantar plate repair. Therefore, the requested platelet-rich plasma injections and stem cell injections are not likely to be superior over other treatment options. 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: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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 an enrollee has requested authorization and coverage for a chest brace. The medical literature and submitted documentation support the medical necessity of the requested device. Literature and research support the provision of a brace as the standard of care for most carinatum defects. Their conclusions resulted in the hospitals use of this approach as a first-line treatment, with surgery reserved for patients who are either noncompliant or for those who had failed the nonoperative modality. After this research was published, most childrens hospitals adopted the practice of offering bracing as the first line of treatment, with surgery reserved for those who failed bracing or preferred the surgical approach. Patients with pectus carinatum are at risk for a disturbed body image and reduced quality of life, and chest bracing has been shown to improve the psychosocial outcome of these patients. The long-term outcomes of bracing have now been shown to be more than adequate.In this case, forcing the patient to have surgery rather than a brace would be outside of the standard of care for most pediatric surgeons, and the provider in this case recommended a chest brace and never mentioned surgery as an option in his clinic note. The submitted records document subjective and objective findings of an asymmetric pectus carinatum that is correctable with manual pressure. There was no prior failed trial of bracing or issues with non-compliance. Under these circumstances, a chest brace is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested device 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 surgery, with subspecialty certification in pediatric 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 authorization and coverage for physical therapy services. Findings:  The physician reviewer found that the patient has had chronic symptoms affecting the upper limbs, with no clearly demonstrated pathology or etiology. Evaluations at her primary care provider's office have been incomplete, with no documentation of an examination of the limbs. The reported diagnoses appear to be based on subjective complaints. A workup with neurology was reported to have no significant findings. The records indicate the patient reported being told that she had arthritis. Physical therapy, in this case, has focused on the administration of passive interventions such as manual therapy and ultrasound. These interventions provided no proven health or functional benefit in the setting of this clinical scenario.  There is no expectation of marginal benefit of ongoing formal physical therapy in this case above what would be achieved with a compliantly followed exercise, stretching and self-applied palliative modality program. There are no objective physical examination findings to support continued treatment with physical therapy. There were no significant findings reported by neurology. Therefore, the requested physical therapy is not medically necessary to treat the 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 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: 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 Malarone. The current diagnostic strategy for Babesiosis includes blood smear evaluation and specialized nuclear acid testing. The records provided for review do not include evidence that testing was needed in this patients evaluation and treatment. In addition, the treatment for Babesia is atovaquone and azithromycin. Currently, there is inadequate data in the peer-reviewed medical literature to support an indication of Malarone in this clinical setting. Overall, there is a paucity of evidence significant evidence for the standard treatment of Babesiosis with Malarone. For these reasons, Malarone was not and is not more likely to be beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that Malarone was not and is not more likely to be beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in infectious 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hybrid (endoscopic) Maze procedure. Available clinical trial data has demonstrated that the hybrid Maze procedure achieves high success rates in the therapy of atrial fibrillation and is less invasive than alternative approaches. Although the available reports are limited, the current literature supports the use of the hybrid Maze procedure for treatment of patients with atrial fibrillation. The documentation indicates that this patient has atrial fibrillation that is described as severe. Despite prior ablation, the patient reports worsening symptoms with verified episodes lasting at least 12 hours every few days. Therefore, the requested hybrid (endoscopic) Maze procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the requested hybrid (endoscopic) Maze procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested hybrid (endoscopic) Maze procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and are actively practicing. Physician reviewer 3 is board certified in surgery with subspecialty certification in thoracic surgery 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

An enrollee has requested reimbursement for the Testopel Pellets 75 mg provided, and prospective authorization and coverage for Testopel Pellets 75 mg (quantity 4 per year). Patients treated with testosterone require monitoring of serum levels and symptom management to assure the lowest effective dose is used to achieve treatment goals. However, based on the current medical literature, there is a paucity of data demonstrating that one formulation of testosterone supplementation is more effective than other preparations. Moreover, there is a lack of long-term studies that suggest a benefit with Testopel treatment over standard available therapies. Thus, the Testopel Pellets 75 mg provided, and future Testopel Pellets 75 mg (quantity 4 per year), were not and are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the Testopel Pellets 75 mg provided, and future Testopel Pellets 75 mg (quantity 4 per year), were not and are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Testopel Pellets 75 mg provided, and future Testopel Pellets 75 mg (quantity 4 per year), were not and are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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 authorization and coverage for Euflexxa injections in the left knee. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees.There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Reviewer found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa injections in the left knee are medically necessary for the treatment of this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for acute inpatient psychiatric services. At issue is whether the acute inpatient psychiatric services provided were psychiatric emergency medical services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder.In this case, the submitted treatment records reflect that the patient presented as an immediate risk for self-harm. The patient had suicidal ideation requiring treatment in a secure facility with close psychiatric monitoring and intervention. The treatment provided was effective in relieving the patients symptoms and was personalized to produce improvement. Appropriate evaluation and intervention with both medication and individualized treatment was provided. The patient's history, presenting symptoms, and current behavior comprised most of the risk factors for repeated suicide attempts. The patient had a psychiatric emergency medical condition during the psychiatric inpatient admission at issue. Therefore, the services provided were psychiatric emergency medical services as defined by California law.Final Result: The reviewer determined that the services at issue were psychiatric emergency medical services as defined by California law. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of enrollee has requested reimbursement for the intensive outpatient program (IOP) services provided. The Health Plan has denied the request as not medically necessary for the patients behavioral health condition. At issue in this case is whether the IOP were medically necessary for the treatment of the enrollees behavioral health condition.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.  Regarding the six CALOCUS dimensions, the patient has a significant risk of harm, cutting on herself and her history of verbal aggression and impulsivity (score = 3). Regarding functional status, she has moderate impairment of function in that she is failing in school and has daily emotional instability (score = 3). There are no comorbidities noted (score = 1). The patient has a moderately stressful recovery environment due to the impending relocation and her fear of relationships becoming emotionally distant (score = 3). Her parents were involved and supportive (score = 2). The patient has had only an equivocal response to treatment, which is manifested by her expressed ambivalence toward her attacker, persistent emotional instability, and her impulses to put herself into risky situations (score = 3). The patient appears to display an obstructive engagement with her treatment with rationalization and denial (score = 3). The patients parents appear to take a constructive position in support of treatment with active engagement in therapy (score = 2). For a CALOCUS composite score of 20, the recommended level of care is high-intensity outpatient therapy. Therefore, the IOP services provided were medically necessary for this patient.Final Result: The reviewer determined that the requested services 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 psychiatry with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether the RTC services were medically necessary.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In this case, in terms of risk for self- harm, the records support a score of one due to a lack of current suicidal ideation and no self-harming behaviors. With regard to functional status, the records support a score of two due to some problems with comorbidity. In terms of medical, addictive and psychiatric comorbidity, the records support a score of two due to overall medical stability. Regarding level of stress of the recovery environment, the records support a score of one due to a stable living situation. For the level of support for the recovery environment, the records support a score of one due to family support and availability of treatment resources, but some difficulty in relationships with her family members. With respect to treatment and recovery history, the records support a score of three due to recent success at the residential treatment center level of care. Lastly, for engagement and recovery status, the records support a score of one. This is due to cooperation in treatment and insight into the need for treatment and her treatment needs. For a composite score of 10, CALOCUS indicates the appropriate level of care is treatment in a community-based outpatient clinic setting. Therefore, the RTC services at issue in this case were not medically necessary.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 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.