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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to fuse his back bones (lumbar spinal fusion) for treatment of his low back pain.  Findings: The physician reviewer found that evidence-based medical guidelines support lumbar spine fusion as an option for patients with ongoing symptoms, corroborating physical findings and imaging, and after failure of nonoperative treatment, for specific conditions including isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Objectively demonstrable segmental instability includes excessive motion as in isthmic or degenerative spondylolisthesis. Spinal instability criteria include lumbar intersegmental translational movement of more than 4.5 mm. This patient presents with constant severe low back pain, increased with motion and activity. Functional difficulty is noted in activities of daily living. His clinical signs and symptoms are consistent with imaging evidence of spondylosis with bilateral L5 pars defects resulting in unstable spondylolisthesis. There is radiographic evidence of spondylolisthesis with spinal segmental instability on flexion and extension x-rays with translation movement of 5 mm. A diagnostic pars defect injection test provided 100% relief of symptoms. The medical evidence supports the requested services in this clinical setting.  All told, the requested surgery to fuse his back bones (lumbar spinal fusion) and five days hospital stay 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nusinersen (Spinraza) for treatment of her spinal muscular atrophy type 2. Findings: The physician reviewer found that spinal muscular atrophy is a rare autosomal recessive disorder characterized by muscle atrophy and weakness resulting from motor neuron degeneration in the spinal cord and brainstem. It is most commonly caused by insufficient levels of survival motor neuron (SMN) protein, which is critical for motor neuron maintenance, secondary to deletions or mutations in the SMN gene. Spinraza is a modified antisense oligonucleotide that binds to a specific sequence in the intron, downstream of exon 7 on the pre-messenger ribonucleic acid (pre-mRNA) of the SMN2 gene. This modulates the splicing of the SMN2 mRNA transcript to include exon 7, thereby increasing the production of full-length SMN protein. This patient developed spinal muscular atrophy type II with exon 7-8 deletion and her condition is likely to respond to treatment with Spinraza given the current medical literature. Thus, the requested Spinraza is supported as medically necessary for treatment of this patients spinal muscular atrophy.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 neurology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gender confirming surgery for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that based on the medical records provided for this review, the patient has well documented gender dysphoria. She has previously undergone parts of gender transition with facial feminization surgery. Moreover, it has been well documented that she presents with real life experience in the desired role, takes hormones for the desired gender, and has undergone some feminization procedures. As noted in the literature, the surgical approach, bilateral orchiectomies and vaginoplasty, are part of the surgical transition process for male to female transition. This patient is well documented to have gender dysphoria and so, her external anatomy should be more consistent with a female than a male. Bilateral orchiectomy and vaginoplasty are consistent with the appropriate female anatomy. Each patient must be reviewed on a case by case basis to determine medical necessity. Since this patients condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  In this patients case, the medical necessity criteria has been adequately met.  All told, the gender confirming surgery is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients condition constitutes an abnormal body structure. The requested gender confirming surgery is part of the surgical transition from a male to a female. As stated above and supported by the medical literature, the patients male genital anatomy is abnormal for a female. The male genital anatomy in a female is considered a developmental abnormality. Additionally, the surgery would contribute to a lower testosterone level and would be expected to provide a significant improvement in the patients appearance. Therefore, the requested gender confirming surgery is reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing she received. Findings:  Three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), myeloperoxidase, C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing provided was not likely to have been more beneficial than other available modalities for evaluating this enrollee. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. The reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Credentials/Qualifications: 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment at Paradigm Malibu for treatment of enrollee's behavioral health issues.  Findings: The physician reviewer found that the records indicate that this patient could have been transitioned to treatment at a lower level of care. The documentation states that the patient was not at risk of harm to herself or others. Her mood and anxiety symptoms were improving, she has been cooperative with her treatment, and her family was supportive. She has not been receiving any specialized medical or nursing treatment that requires 24-hour monitoring and care. All told, the continued residential treatment at Paradigm Malibu was not and is not medically necessary for treatment of this patients behavioral health issues.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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: An enrollee has requested authorization and coverage for Multaq for treatment of his paroxysmal atrial flutter.  Findings: The physician reviewer found that the request for Multaq has been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient has paroxysmal atrial flutter that has been refractory to ablation, cardioversions and trials of multiple medications. The documentation supports that all classes of antiarrhythmic medications have been tried and failed. In this clinical setting, Multaq is medically reasonable and appropriate. In addition, current guidelines support the use of Multaq in this setting (January, et al). Therefore, the requested medication is medically necessary for treatment of the patients medical condition.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 cardiovascular diseaseand 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 gene testing performed for evaluation of the enrollee, who was diagnosed with indeterminate follicular neoplasm. Findings:  Three physician reviewers found that a fine needle aspiration (FNA) biopsy yielded cytology which was suggestive of a follicular neoplasm (Bethesda Category IV). A specimen was subsequently sent for gene testing rendered. 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, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries.  This test is very sensitive and has a high negative predictive value. A negative Afirma result is suggestive of a benign nodule and can therefore preclude surgical procedures. Final Result: Three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 stem cell treatments for treatment of the enrollees cerebral palsy. Findings:  Three physician reviewers found that there is currently no U.S. Food and Drug Administration approved stem cell therapy for cerebral palsy. While there are some randomized trials that have been completed, most studies have a small sample size that is underpowered to detect statistical differences between groups. The evidence is largely limited by significant heterogeneity across these studies due to variation in the types of cerebral palsy and ages of participants that received intervention, the types of stem cells used, the types of transplant/transfusion methods used, the cell doses, the duration of treatment, the theoretical rationale for why the cells might offer a treatment effect, the type and intensity of concomitant rehabilitation, and the duration of follow up. Based on the available evidence, it is difficult to discern what would be the most effective stem cell therapy protocol and which cerebral palsy patients would best benefit from such therapy. The potential safety risks of stem cell therapy are numerous and not well documented among published studies. There is very limited evidence regarding the short term and long term safety of stem cell therapy for cerebral palsy, especially given the significant heterogeneity across studies in terms of the treatment used and treatment protocol. The paucity of evidence regarding the safety of stem cell therapy for cerebral palsy precludes drawing any conclusions about whether or not this treatment is safe for use among cerebral palsy patients. 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 neurology 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 reimbursement for the positron emission tomography/computed tomography (PET/CT) scan. Findings:  Three physician reviewers found that in this patients case, the guidelines do not support the efficacy of the PET/CT scan at issue. This patient presented with an incidental finding of a 4 mm pulmonary nodule, noted on a CT scan. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules. These evidence based guidelines were revised in 2017 and are widely used throughout radiology.  For incidentally detected nodules that are greater than 8 mm, the Fleischner Society guidelines call for either a follow up CT scan in three months, and/or a PET/CT, and/or a biopsy.  For a nodule detected incidentally that measures less than 6 mm, in low risk patients, the Society does not recommend any further evaluation. In high risk patients, the Society recommends an optional CT scan in 12 months.  For nodules between 6 to 8 mm, follow up CT scans are recommended between 6 to 12 months. The National Comprehensive Cancer Network (NCCN) also has issued guidelines based on the National Lung Screening Trial (NLST) which also suggests that PET/CT scanning is only appropriate for solid nodules greater than 8 mm in diameter. In this patients case, the records do not show whether he is a low or high risk patient. His nodule was measured at 4 mm. Thus, a PET/CT scan would not be routinely performed under both the Fleischner Society and the NCCN guidelines. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. 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 to the emergency department with burning on urination and chills. He also felt as though his bladder was distended. His symptoms had not been relieved by prescription medication. The differential diagnoses in this patient included multiple infectious processes. The CT scan revealed an enlarged prostate, and he was treated for acute prostatitis, which may be associated with acute urinary retention. Such symptoms are consistent with an emergency medical condition. Therefore, the patient received emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest compression vest for treatment of the enrollees bronchiectasis. Findings:  The physician reviewers found that the records provided for review do not document that this patient has undergone evaluation for causes of bronchiectasis to include chronic infection, allergic bronchopulmonary aspergillosis (ABPA), cystic fibrosis, and immunoglobulin deficiency. Furthermore, although there is documentation of minimal bronchiectasis on computed tomography (CT) imaging, the patients history is not consistent with chronic disease and the minimal bronchiectasis present may not be the cause of symptoms. The provider noted the patient has not responded to either postural drainage or use of flutter valves. Additional information on the current evaluation and further testing should be done to better define the cause of the patients symptoms. Given these findings, the requested high frequency chest compression vest is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested device 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 number one, two, and three are board certified in internal medicine with sub-specialty certifications in pulmonary disease and critical care medicine and 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.