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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of the left side of the colon with a low ileorectal anastomosis with lysis of adhesions. Findings:  The physician reviewer found that the available documentation, the requested completion colectomy and ileorectal anastomosis is not medically necessary for treatment of this patient. The patients complaint of pelvic pain along with clustering of the sitz markers in the rectosigmoid area are concerning for obstructed defecation. This suggests that the patients problem may be due to the ability of the rectum to empty rather than the presence of the sigmoid colon. The patient requires further motility work-up as recommended by her provider, which may include studies such as anorectal manometry and magnetic resonance imaging (MRI) defecography. In the absence of data from these studies, the requested surgery is not supported by the medical literature. Therefore, the requested removal of the left side of the colon with a low ileorectal anastomosis with lysis of adhesions is not medically necessary for 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 surgery with subspecialty certification in colon and rectal surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure (CPT 43284). Findings:  The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the FDA, more data are required before widespread usage can be recommended. Skubleny and colleagues concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, Sheu and Rattner reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remain to be determined. Alicuben and colleagues found that erosion of the LINX device is an important but rare complication to recognize. Avazi and colleagues noted that LINX has significant potential adverse effects and may be associated with poorer outcomes. Therefore, the LINX procedure (CPT 43284) is not likely to be more beneficial for treatment of the patients condition than any available standard.Findings:  Two of the three physician reviewers found the requested LINX procedure (CPT 43284) is 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 requested service is 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 reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 patient has requested authorization and coverage for Euflexxa injection series (weekly for three doses to the right knee). This patient presents with a history of osteoarthritis of the right knee. The patients provider has recommended repeat viscosupplementation with Euflexxa injections, which have previously been successful. The presence of osteoarthritis, primarily in the medial compartment and patellofemoral joint, was confirmed on magnetic resonance imaging (MRI) scans. There is an associated complex tear of the body and posterior horn of the medial meniscus. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is a history of good response to viscosupplementation on multiple occasions in the past. Furthermore, the patients remaining treatment options are limited. The alternative is a total knee arthroplasty. For these reasons, the requested Euflexxa injection series (weekly for three doses to the right knee) is medically necessary for 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomographic angiography (CTA). A study found this patients symptoms of syncope and positional vertigo are consistent with problems involving the posterior cerebral circulation. Treatment of this patients presenting symptoms can be conservative or involve revascularization. Imaging studies are required to determine the exact degree and cause of vertebral artery occlusion, as well as which vertebral artery is dominant. In this patients clinical setting, the CTA was indicated given the patients symptoms and their family history of stroke. For these reasons, the CTA was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 sacroiliac joint fusion procedure (right sided sacroiliac instrumented fusion, allograft, fluoroscopy, robotic assisted) rendered at MemorialCare Long Beach Medical Center in December of 2019.Findings: Three out of three physician reviewers found that sacroiliac joint fusion procedure (right sided sacroiliac instrumented fusion, allograft, fluoroscopy, robotic assisted) rendered at MemorialCare Long Beach Medical Center in December of 2019 was likely to have been more beneficial for the enrollee than any available standard therapy.Current peer-reviewed medical literature states that sacroiliac fusion may be indicated for patients with severe chronic pain localized to sacroiliac joint causing significant functional impairment when other sources of pain have been excluded. There are sufficient quality studies showing sacroiliac fusions superiority over non-surgical management. Minimally invasive sacroiliac joint fusion has also shown to be relatively safe. In this case, the patient had sacroiliac joint pain that caused functional impairment. The patient had persistent symptoms despite conservative treatment. Therefore, sacroiliac joint fusion procedure (right sided sacroiliac instrumented fusion, allograft, fluoroscopy, robotic assisted) rendered at MemorialCare Long Beach Medical Center in December of 2019 was likely to have been more beneficial for the patient than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in orthopedic surgery. All reviewers 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 Afirma gene testing CPT 81210-59 (BRAF gene analysis); CPT 81275-59 (KRAS gene analysis); CPT 81311-59 (NRAS gene analysis); CPT 81401-59 (Level 2 molecular pathology procedure); and CPT 81406-59 (Level 7 molecular pathology procedure). Findings:  The physician reviewer found that While a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, Rao and Bernet indicated that up to approximately 30% of FNA biopsy results are considered to be indeterminate, and the risk of malignancy in these cases are highly variable. When patients with cytologically indeterminate thyroid nodules undergo diagnostic surgery, Kloos states that approximately three-quarters prove to be benign on surgical histopathology. Liu and colleagues concluded, The Afirma gene expression classifier measures 167-gene messenger ribonucleic acid (mRNA) expression panel of thyroid nodules to distinguish benign and malignant nodules. The Afirma gene testing has significantly prevented avoidable thyroid surgeries. Therefore, Afirma gene testing CPT 81210-59 (BRAF gene analysis); CPT 81275-59 (KRAS gene analysis); CPT 81311-59 (NRAS gene analysis); CPT 81401-59 (Level 2 molecular pathology procedure); and CPT 81406-59 (Level 7 molecular pathology procedure) provided was likely to have been moFindings: Three out of three physician reviewers found that Afirma gene testing CPT 81210-59 (BRAF gene analysis); CPT 81275-59 (KRAS gene analysis); CPT 81311-59 (NRAS gene analysis); CPT 81401-59 (Level 2 molecular pathology procedure); and CPT 81406-59 (Level 7 molecular pathology procedure) provided was likely to have been more beneficial for the enrollee than any available standard therapy.re beneficial than standard therapy to evaluate the patients medical condition. Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism. All reviewers 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:  The parent of an enrollee has requested authorization and coverage for speech therapy and occupational therapy services. Findings:  The physician reviewer found that In the most recent Practice Guidelines from the American Academy of Pediatrics on the treatment of children and adolescents with autism spectrum disorder (ASD), Hyman and colleagues state, `Speech-language therapy is the most commonly identified intervention provided for children with ASD. The authors also describe, Almost two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. However, adolescents with autism spectrum disorders have a high rate of irritability and aggressive symptoms. Matson and colleagues indicate, Severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and behavioral interventions can significantly reduce such behaviors. Given the increased physical size of older children and longer history of these problems, treating these behaviors effectively is important. Matson and colleagues conclude, Psychological methods, particularly ABA therapy, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviors associated with autism spectrum disorder in the research literature. In this case, it is documented on multiple occasions in the medical record that the patients aggressive behavior poses significant risk of injury to speech and occupational therapists attempting to provide treatment, even if a behavioral therapist is present. Even with a behavioral technician present, there remains a risk of the patient injuring a therapist. Moreover, the provider notes, Current behavioral therapists are not helping because they are afraid he will become aggressive. The patients current behavior precludes the safe provision of in-person behavior. Therefore, speech therapy and occupational therapy are not medically necessary for treatment of the patient, either in-home or in a clinic setting with a behavioral therapist present. Additionally, the requested services are not within the generally accepted standards of mental health and substance use disorder care. Also, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexilant 60 mg daily. Dexilant, unlike other proton pump inhibitors (PPIs), is released in an extended fashion, resulting in an extended plasma concentration and a higher mean 24-hour intragastric pH than other PPIs. Medical literature note that in a study of 163 patients with gastroesophageal reflux disease (GERD) taking twice-daily PPI to control heartburn, 88% were able to control symptoms with Dexilant once daily. While the American College of Gastroenterology (ACG) guidelines for the treatment of GERD recommend management with PPIs, especially in patients with complications such as Barrett's esophagus, in this case, the records note that the patient has failed a conventional PPI twice daily. In this clinical setting, based on current medical literature, the requested medication is medically indicated. Therefore, Dexilant 60 mg daily is medically necessary for the treatment of this patient. 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

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for 18 additional chiropractic visits, once a week.According to medical literature, There is moderate quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain. Further, researchers concluded that a multimodal approach including spinal manipulation therapy, self-management advice, and exercise is an effective treatment strategy for chronic back pain. In a study by researchers, 12 spinal manipulation visits yielded the most favorable results for patients with chronic low back pain. In this case, the patient experienced ongoing chronic low back pain and has received at least 14 chiropractic sessions between March of 2021 through June of 2021. The patient completed more than 12 sessions over three weeks with only modest improvement. There is no rationale to deviate from cited medical literature. Therefore, 18 additional chiropractic visits, once a week are not medically necessary for treatment of 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 chiropractic 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 patient has requested authorization and coverage for Norco 10/325 mg. The Centers for Disease Control and Prevention (CDC) have issued guidelines for the use of opioid medications in patients with non-cancer related pain for initiation, monitoring and discontinuation. Specifically, the CDC guidelines state that opioids should only be considered when non-opioid and non-pharmacologic interventions have been ineffective. The CDC noted that when utilized,  opioids should be used at the lowest dose that is effective and minimizes opioid-related complications and risks. In addition, opioid management should include consultation and urine toxicology screening and an opioid use contract is recommended between the provider and the patient. Per the CDC, providers should use caution when prescribing opioids at any dosage and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME) per day. The Medical Board of California (MBC) has also provided guidance on the use of opioids which includes balancing the benefit of treatment with opioids against the potential risks. Applying the CDC and MBC guidelines to this patient, any potential benefit with opioid treatment is outweighed by the risks and does not support continued treatment with opioids. This patients records document a history of bilateral shoulder pain that has been managed with Norco. However, there is a lack of documentation that the patient has fulfilled the requirements for continued opioid pain management. The provider noted that multiple urine drug screens have been positive for tetrahydrocannabidiol (THC). Moreover, the patients providers have recommended treatment with physical therapy, cortisone injection, and cognitive behavioral therapy rehabilitation in lieu of continued opioid therapy. Given these findings, the requested Norco 10/325 mg is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 with subspecialty certification in pain management 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 patient has requested reimbursement for bilateral upper lid blepharoplasty. Based on the available documentation, the bilateral upper eyelid blepharoplasty was not medically necessary for this patient. Specifically, there is a lack of documentation of significant visual field obstruction. Current medical literature requires physical examination reports showing that the patient has functional visual complaints related to the eyelids blocking the vision. The physical examination should also support the patients complaints with a margin-reflex distance (MRD) of 2 mm or less, and visual field tests that demonstrate loss of superior visual field and improvement with taping of the eyelids. This patients records do not include photographs or visual field tests to meet the requirements for blepharoplasty. Therefore, the bilateral upper lid blepharoplasty was not medically necessary for 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 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.