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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture treatment twice per week for treatment of the enrollees cervical radiculopathy. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. The researchers systematically reviewed the effectiveness of balance acupuncture for the treatment of neck, shoulder, low back and leg pain. The researchers concluded that balance acupuncture is an effective and safe way for treating these conditions, however it may need further demonstration by more large-scale and well-designed randomized control trials due to the limited quantity and quality of the included studies. There is some peer-reviewed literature supporting the utility of acupuncture for the treatment of the patients medical condition. However, there is lack of peer-reviewed literature demonstrating the amount of acupuncture visits that would be beneficial in this clinical setting. Therefore, the request for acupuncture treatment twice per week has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Urgent Care
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for dental services provided. Findings:  The physician reviewer found that 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 dental services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The progress notes do not describe a complaint of pain. Although the patient states that he presented with severe pain, this is not documented in the records submitted for review. Given that the records provide no notation of pain or infection associated with the patients tooth there is no indication that the patient received emergency dental services. In sum, the services at issue were not necessary for treatment of an emergency dental condition. Thus, the patient did not receive emergency dental services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency dental services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry 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 breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that there is sufficient support for the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: 2/3 of the reviewers determined that the service 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 reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria. Bilateral orchiectomies and vaginoplasty/labiaplasty are part of the surgical transition process for male to female transition. Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female. Furthermore, the medical literature recommends that after a diagnosis of gender identity disorder, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. In this patients case, the recommended criteria have been established. For treatment of her gender dysphoria, her external anatomy should be more consistent with a female anatomy than of a male. Bilateral orchiectomy and vaginoplasty/labiaplasty are consistent with the appropriate female anatomy. The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests. However, the submitted documentation supports that this patient has addressed these issues and her most recent office visits and therapy sessions appear consistent with the Health Plans clinical criteria. As such, the medical documentation supports the requested services in this patients case.Findings:The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for blepharoptosis surgery for treatment of the enrollees eye condition. Findings:  The physician reviewer found that the current treating provider had noted evidence of a right sided eyelid ptosis and per the documentation, the Health Plan authorized correction for this side. Based on the photographs provided, there is asymmetric eyelid ptosis on the right but the eyelid margin on the left appears relatively normal and without evidence of ptosis.  The medical literature indicates that there can be cases when excess eyelid skin may obstruct the visual field and thus may be considered a functional problem.  However, in this patients case, there is a lack of evidence in the photographs and in the clinical records to indicate that she has excess eyelid skin that obstructs her visual field. As documented by the current provider, the patient does not have evidence of a left upper eyelid ptosis. Most recent photographs show evidence of a right eyelid ptosis but a relatively normal appearing left lid margin without ptosis. As such, treatment of dermatochalasis on the left side is consistent with aesthetic goals and not functional ones.  There is asymmetry between the two lid margins. Correction of the left sided dermatochalasis is not medically indicated in this patients case. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
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 19.5 hours per week of applied behavioral analysis (ABA) therapy and 10 hours per month of supervision. for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA therapy is medically necessary for the treatment of children with autism spectrum disorder. One study indicated that intensive behavioral treatment is effective for children with autism. Another study found that children with autism receiving 25 hours per week of direct therapy were likely to have an optimal outcome than those receiving only 18 hours per week. In this case, the patient is already at the minimum level of ABA hours to achieve an optimal outcome. The records show that the patient has made progress with the maladaptive behaviors. However, he continues to have vocal and physical stereotypy at low level of 1.5 times per hour or less.  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 sub-specialty certification in developmental-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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni or Epclusa. Both medications are U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Epclusa as acceptable therapy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral L4-5 decompression with interlaminar device for treatment of the enrollees low back pain. Findings:  Two physician reviewers found that the current peer-reviewed literature and long-term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis and low-grade spondylolisthesis.  This patient presents with persistent low back pain radiating into the left lower extremity with numbness.  Functional difficulty was reported in ambulation.  Her signs and symptoms were consistent with imaging evidence of moderate to severe lumbar stenosis with grade 1 spondylolisthesis at L4-5.  Detailed evidence of comprehensive nonoperative treatment protocol trial and failure has been submitted. Final Result: Two 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: All three physician reviewers are board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator.  Findings:  Three physician reviewers found that the patient has a history of obstructive sleep apnea (OSA). He underwent a polysomnogram (PSG) on 8/16/15 and it revealed an apnea hypopnea index (AHI) of 61. He had a body mass index of 35. By sleep endoscopy, there was complete anterior to posterior collapse of the velum, complete mixed collapse of the hypopharynx and posterior excursion of the tongue base. He was intolerant to continuous positive airway pressure (CPAP). The provider discussed options for implantation with a hypoglossal nerve stimulator. The medical literature does not support the superior efficacy of the requested services in this clinical setting. OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity, and long-term adherence rates approach 50%. After decades of trials with hypoglossal nerve stimulation, the results of these studies were recently published. The STAR trial demonstrated that hypoglossal nerve stimulation led to improvements in objective and subjective measurements of the severity of OSA. However, the STAR trial did not involve patients with AHI less than 20 or greater than 50. Patients with BMI greater than 32 were not included in the study. This patients AHI was 61 and he had a BMI of 35. Final Result: Three 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: All three physician reviewers are board certified in otolaryngology 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 a power wheelchair for treatment of the enrollees lower extremity bilateral paralysis. Findings:  The physician reviewer found that colleagues state that The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Power mobility can benefit specific individuals. Determining who will benefit is a matter of clinical judgement more than adherence to criteria defined by the medical literature. In this case, the patient has utilized a manual wheelchair for many years. He has subjective complaints of arm pain and fatigue but on evaluation he uses a manual wheelchair without difficulty. In addition, evaluation found multiple barriers to implementation of a PWC including lack of transport and lack of ingress/egress to his abode. The patient has a personal mobility deficit that has been effectively treated with a manual wheelchair. A PWC is not medically necessary due to the effectiveness of the manual wheelchair and multiple barriers to usage of a power wheelchair. Accordingly, the request for PWC has not been established as medically necessary for treatment of the patients lower extremity bilateral paralysis. 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 with sub-specialty certification in neuromuscular 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

An enrollee has requested reimbursement for gene panel testing provided. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines recommend molecular gene testing in appropriate cases. In this case, the patient has a complicated presentation as she has long standing ITP and her MDS can be caused by medication (Nplate) or possibly lupus if secondary MDS or could be primary MDS. Treatment would differ if primary versus secondary MDS. Primary MDS could be treated with a stem cell transplant and secondary MDS by withdrawal of medication or possibly treatment of underlying disease. In this clinical setting, molecular gene testing was likely to be more beneficial given that standard testing did not clarify if her MDS is primary or secondary. Accordingly, the gene panel testing provided was likely to be beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing 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 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.