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 Synvisc-One injection. Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. However, there is insufficient evidence for other conditions including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. Clinical examination was consistent with imaging evidence of mild tricompartmental cartilage irregularity and the diagnosis of patellofemoral pain syndrome. X-rays did not evidence right knee osteoarthritis. Functional difficulty was documented with prolonged walking or hiking, prolonged sitting, and mowing the lawn. Conservative treatment had included activity modification, physical therapy, home exercise, and anti-inflammatory medications with slow improvement. Current evidence based medical guidelines and peer-reviewed literature do not support the use of Synvisc-One injections for patellofemoral pain syndrome or in the absence of knee osteoarthritis. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl 100 mcg/hour every 72 hours, Dilaudid 8 mg and Flexeril 10 mg; or in the alternative fentanyl 100 mcg/hour every 72 hours, Norco 10 mg and Flexeril 10 mg for treatment of her back, knee and hip pain. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, the request for fentanyl 100 mcg/hour every 72 hours, Dilaudid 8 mg and Flexeril 10 mg; or in the alternative fentanyl 100 mcg/hour every 72 hours, Norco 10 mg and Flexeril 10 mg are not medically necessary for treatment of the patients medical condition. The documentation submitted for review fails to demonstrate a current reconciliation of the patients medications and an adequate evaluation of her pain condition. In addition, the requested dose of Fentanyl is in excess of that which should be recommended for a non-opioid tolerant patient and places the patient at an increased risk for adverse side effects including life threatening respiratory depression. Final Result: The reviewer determined that the requested medications are 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 physical medicine and rehabilitation 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery on the left foot heel for treatment of his left heel injury. Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent guidelines, the requested follow-up left heel surgery for this patient including exploration for foreign body left heel is not medically necessary. The patient has undergone two exploratory surgeries with removal of foreign body. The patient has also had two follow-up x-rays and two MRIs, both of which do not demonstrate retain foreign body or fluid collection. The patient has undergone an extensive work-up by internal medicine, podiatry, and rheumatology including two MRIs and two x-rays, none of which reveal retained foreign body or fluid collection. 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 podiatry 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 panniculectomy.  Findings:  The physician reviewer found that according a study The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms In this case, the patient presents with significant weight loss following bariatric surgery. She has evidence of a symptomatic abdominal pannus as a result of significant weight loss. Her symptoms have included chronic rashes, abscesses and worsening urinary incontinence.  She has attempted dermatologic treatment with topical measures which has not been able to control her rashes. The photographs submitted for review demonstrate functional impairment related to the pannus, as there is evidence of a significant lower abdominal pannus that hangs below the pubic bone. She also has evidence of abscess formation and skin breakdown. Based on the documentation provided for review, the requested panniculectomy is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery is 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided. 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 the abdominal pain that had been persistent and accompanied by vomiting. The patient underwent diagnostic testing with an EKG and cardiac biomarkers to rule out an acute coronary syndrome, as abdominal pain may represent an angina equivalent. Due to the patients prior abdominal surgery, a CT scan was obtained to rule out bowel obstruction. Given the patients symptoms of ongoing and persistent abdominal pain with vomiting, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date in question. Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Credentials/Qualifications: Physician reviewer number two 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 Androderm patch for treatment for his hormone deficiency. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Low testosterone levels can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, and depressed mood and fatigue.  The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. If testosterone levels of patients diagnosed with hypogonadism fall below 350 ng/dL, many providers often treat these patients.  Although injectable testosterone may be an appropriate therapy for some men, its  efficacy may be limited by variablity of levels and peaks and troughs of the kinetic profile (Raynaud, et al). In this patients case, he was unable to achieve the recommended goal for testoterone levels on the transdermal gel.  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 endocrinology, diabetes and metabolism 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 Integra for treatment of her finger injury. Findings:  Two physician reviewers found that the evidence based literature supports the use of Integra in this patients case. Integra is in the category of a xenograft tissue coverage material with collagen processed from both bovine collagen and a shark collagen. Contraindications include hypersensitivity to bovine collage, chondroitin or silicone. In this clinical setting, there is no documentation of hypersensitivity or allergic reaction to this material. The use of Integra is likely to be beneficial in providing immediate coverage of the amputation site and is likely to limit the formation of a scar. The studies have shown that this process tends to bring nerve ending sensible skin over a larger portion of the fingertip minimizing the area of sensory deficit in the long finger. Maximizing the area of retained sensibility in the fingertip is best assured by the use of Integra, a xenograft material, as an intermediate dressing prior to a decision to either allow healing by secondary intention or autograft from donor site. Additionally, there are studies that indicate that infection and fluid loss from the tissue are likely to be minimized by the use of Integra. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in orthopedic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the intravitreal corticosteroid implant performed. Findings: The physician reviewer found that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presented with unilateral painless loss of vision associated with optic nerve swelling and inferior altitudinal defect. There was no enhancement of the optic nerve on MRI. In addition, the patient appeared to have a contralateral crowded disc with 0.1 cup to disc ratio. Moreover, there is a lack of documentation demonstrating that the optic nerve swelling was related to posterior uveitis instead of ischemia. Given the lack of clinical indication of an inflammatory etiology for the optic nerve swelling, the Ozurdex injection would not be clinically indicated. All told, the intravitreal corticosteroid implant performed on the date of dispute was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers 2/3 determined that the service at issue was 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 & 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment by a provider experienced in holistic and alternative medicine. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The patient was offered traditional care in Plan that has been U.S. Food and Drug Administration (FDA) approved. Alternative modalities for treatment of cancer are often unproven or have been found to be harmful. While some individuals may find some value working with providers trained in alternative treatment options, there is still a lack of peer reviewed evidence to suggest that these alternative therapies outweigh the benefits of standard treatments. Given the paucity of data, the medical necessity for the requested services has not been demonstrated. The available literature appears to also suggest that the use of holistic and alternative therapies may lead to the possibility of harm. Accordingly, it is unlikely that these alternative treatment options will lead to a greater benefit than standard chemotherapy regimens approved by the FDA. Therefore, the requested treatment by a provider experienced in holistic and alternative medicine is not medically necessary. 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 internal medicine with sub-specialty certification in medical 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services provided. Findings:  The patient has a history of left hip pain for several years. Per the consultation the x-rays show bilateral cam femoro-acetabular impingement deformities and Tonnis 3 severe arthritic changes with cysts in the acetabulum and head of the left hip. The diagnosis was severe left hip osteoarthritis. The  orthopedic report indicated that the patient had severe osteoarthritis of the left hip greater than the right hip. The patient underwent minimally invasive left total hip arthroplasty. The patient has requested reimbursement for surgical services provided. 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 surgical services provided on the date in question were not necessary for treatment of an emergency medical condition. The patient presented with an eight-year history of left hip pain. X-rays showed severe osteoarthritis with cysts in the acetabulum and head of the left hip. There was no emergent medical condition noted in the records submitted for review. Based on the clinical documentation submitted for review, the minimally invasive left total hip arthroplasty performed on the date in dispute was not an emergency medical service. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewers 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: Physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Serax 15 mg.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Combining opioids, such as Demerol and Norco, with benzodiazepines, such as Serax, is not recommended. Benzodiazepines in combination with opioids are contraindicated and carry significant risk. Opioid analgesics and benzodiazepines are the prescription drugs most commonly associated with drug overdose deaths. There have been many cohort studies showing the risks of overdose deaths when combining opioids and benzodiazepines. The current medical evidence does not support the requested medication in this clinical setting. 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: Physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested chiropractic care for treatment of her neck pain and migraines. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested services in this clinical setting. The medical literature demonstrates that cervical manipulation and mobilization produced similar changes in individuals.  While there is some low quality data to support cervical manipulation for pain reduction, and increased function in acute pain, further research is recommended. The physician already put in a referral to a physical therapist. In this patients case, physiotherapy was recommended by her provider. There were no results from her sessions with the physical therapist who is able to do mobilizations. The patients submitted records do not demonstrate that this treatment option has been tried and failed. Although some results are promising for chiropractic care, the medical necessity criteria  has not been convincingly shown in this patients case. According to the records, physiotherapy has not been initiated. 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 care 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 vein treatment (radiofrequency ablation, right leg). Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the requested procedure in this clinical setting. The treating provider reported that he performed an ultrasound on the right leg and that the vein is a good target for ablation. The saphenofemoral junction measures at 1.2 cm and the saphenous vein measures at 0.8 and 0.9 cm further down the leg. The patient has failed conservative treatment options and noted that her pain interferes with activities of daily living. Moreover, the medical literature supports the efficacy of this therapy for treatment of the patients medical condition. Final Result: The reviewer determined that the requested procedure 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 vascular 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.