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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing care and physical therapy services. Functional impairments due to a cerebral insult, such as a hemorrhagic stroke, can be severe to profound. Although functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes (Alawieh, et al.). Notably, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower to come in the subsequent stages (Kubis). There is a general consensus that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes but there are generally poor data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages (Belagaje, et al.; Gittler and Davis). In this case, the patient sustained an acute hemorrhagic stroke, complicated by early obstructive hydrocephalus. The patients treatment course has been complicated by alcohol withdrawal. More than two months following his initial presentation, the patient has persistent hemiplegia, and he has been unable to ambulate. The records suggest that the patient has plateaued to require significant assistance for his activities of daily living. There is a lack of community treatment options identified, as the patients caregiver(s) are unable and/or unwilling to provide the level of assistance he would require for community reintegration. All told, skilled nursing care and physical therapy services were not and are not medically necessary for treatment of this patient. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eye movement desensitization and reprocessing (EMDR) therapy. The submitted documentation supports the medical necessity of the requested services. Current medical literature supports the use of EMDR psychotherapy as a well-established psychotherapy modality to manage symptoms related to past trauma. Bisson and colleagues report that there is evidence that EMDR is effective immediately post-treatment in the treatment of PTSD. In this case, the patient has a history of significant trauma through childhood with mood and anxiety symptoms and suicidality progressing from that trauma. Although her anxiety and depression are improved with psychiatric medications, the patient continues to struggle significantly with symptoms that are based in that early childhood trauma. The patients psychiatric team has referred the patient for EMDR. While the records do not note a formal diagnosis of PTSD, given that the patient continues to report various issues in relationships and a lack of feeling safe in connections with others that is directly related to the childhood trauma, the requested services are medically indicated. Therefore, EMDR therapy is 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 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: The patient has requested authorization and coverage for cervical spine bone growth stimulator. Khalifeh and colleagues state, Pseudarthrosis is an exceedingly common, costly, and morbid complication in the treatment of long bone fractures and after spinal fusion surgery. Electrical bone growth stimulation (EBGS) presents a unique approach to accelerate healing and promote fusion success rates. Over the past three decades, increased experience and widespread use of EBGS devices has led to significant improvements in stimulation paradigms and clinical outcomes. Various models of electrical stimulation have been proposed and marketed as adjuncts for spinal fusions and long bone fractures. Clinical studies show variable safety and efficacy of EBGS under different conditions and clinical scenarios. While the results of clinical trials do not support indiscriminate EBGS utilization for any bone injury, the evidence does suggest that EBGS is desirable and cost efficient for certain orthopedic indications, especially when used in combination with standard, first-line treatments. In a systematic review of electrical stimulation to enhance spinal fusion, Park and colleagues state, Given the inconsistency in study results, possibly due to heterogeneity in study populations/characteristics and quality, we are unable to conclude that electrical stimulation results in better fusion outcomes compared with no stimulation. The overall strength of evidence for the conclusions is low. In this case, the patient was being treated for disc degeneration, spinal stenosis, and cervical myelopathy. She presented with persistent pain in the cervical spine, with numbness and tingling. X-rays showed good positioning of hardware, without loosening. However, detailed documentation is not evident regarding any significant risk factors for failed fusion. There is no documentation of significant past medical history. There is no tobacco use noted. X-rays did not denote signs of non-union or delayed union that would benefit from the requested electrical stimulation. Therefore, cervical spine bone growth stimulator is not medically necessary for the treatment of this patient.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 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: The patient has requested authorization and coverage for use of a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. In this case, while the records indicate that the patient has various chronic pains, including chronic back pain, and severe congestive heart failure, the records did not document neurological weakness or impairment. Functionally, the patient was observed to have poor endurance and an unstable gait when walking without an assistive device. In the setting of this patients multiple health conditions, including low back pain, a degenerative spine, deconditioning, and obesity, current medical literature supports encouraging increased levels of light, physical activity and exercise, such as walking. Baena-Beato and colleagues report that aquatic therapy programs may decrease levels of back pain and disability. Forhan and Gill note that obesity is a health condition that is associated with mobility disability. Hagen and colleagues conclude that there is empirical evidence that exercise therapy has beneficial clinical effects on most musculoskeletal conditions. Given that the submitted records, overall, do not indicate that the patients mobility difficulties with activities of daily living or community access could not be addressed with a gait implement such as a walker, or by a manual wheelchair, the requested equipment is not medically indicated. The records, in addition, do not indicate that the patients home is accessible to a power mobility device given that it has narrow doorways and is on the second floor without indication of elevator access. Therefore, use of a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community, is not medically necessary for the treatment of this patient.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 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 cardiac computed tomography (CT) with calcium scoring. Based on the records provided for review, this patient presents with significantly increased coronary risk including mixed hyperlipidemia, abnormal serum protein electrophoresis test results, atypical chest pain, and prediabetes. In this circumstance, the clinical guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, cardiac CT scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. Treatment changes or additions 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 (Stone, et al.; Arnett, et al.). Although the results of some of these specialized tests may be considered independent risk markers for coronary disease, there is a paucity of prospective randomized controlled trials demonstrating improved health outcome benefits with treating routinely obtained abnormal results. Therefore, the cardiac CT with calcium scoring was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the cardiac CT with calcium scoring was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-UM genetic testing. There is solid scientific evidence in current medical literature that genetic testing of uveal melanoma tumor can stratify the tumors into high-risk and low-risk for systemic metastasis. Researchers found that gene expression profiling provides a highly accurate and biologically informative gold standard for molecular prognostication. The authors further note that molecular prognostic testing and enrollment of high-risk patients into clinical trials of targeted molecular therapy are rapidly becoming the standard of care in the management of uveal melanoma. It is clear that the service at issue is part of standard management in this clinical setting, and most of the leading centers and ophthalmologists caring for patients with uveal melanoma routinely use and offer this test to their patients. The results from such testing determine how closely to monitor and screen these patients for metastasis, and there is no doubt that having this risk information allows for a reduction in the frequency of screening for those in the low-risk category. The results of such testing provide critical prognostic information that would not be available otherwise, and while the results may not alter the course of the disease in cases where there is no adjuvant therapy currently available, such therapies may be available in the future. In the case of uveal melanoma, there may be limited chances to obtain this genetic information from the tumor, generally at the beginning of therapy, or much later if there is metastasis. When the patient undergoes radiation plaque therapy, the primary tumor will no longer be available to biopsy for this information. Therefore, DecisionDx-UM genetic testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Qbrexza. Medical literatures report that a variety of treatment modalities currently exist to manage hyperhidrosis. The U.S. Food and Drug Administration (FDA) has approved several treatment options for the treatment of treatment of axillary hyperhidrosis, including Drysol, Qbrexza, and Botulinum toxin A. In a study evaluating the safety and efficacy of topical glycopyrronium tosylate in patients with primary axillary hyperhidrosis, researchers report that daily long-term application of glycopyrronium tosylate for up to 48 weeks was generally well tolerated and efficacy was maintained. While Drysol is the most common treatment due to its ease of use, in this case, the records note that the patients axillary hyperhidrosis has not responded to Drysol. Given that current medical literature supports the use of Qbrexza in this clinical setting, the requested medication is medically indicated. Therefore, Qbrexza 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 dermatology 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 Synvisc-One injections in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient had tried and failed other conservative treatments including NSAIDs, a cortisone injection, and physical therapy, with the alternative being bilateral total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One injections in both knees were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patients parent has requested authorization and coverage for Norditropin FlexPro 10 mg/1.5 mL growth hormone. Findings:  The physician reviewer found that This patient presents with a history of short stature in the setting of normal findings on two growth hormone provocative tests and decreased growth velocity. The patients provider has recommended treatment with growth hormone therapy. Based on the available documentation, this patient does not meet the criteria for a U.S. Food and Drug Administration (FDA) approved indication for growth hormone therapy, including idiopathic short stature. In addition, the patient does not meet the requirements for treatment with growth hormone therapy per the Drug and Therapeutics, and Ethics Committees of the Pediatric Endocrine Society. Although the patients recent growth velocity was lower than expected for early-to-mid puberty, this observation alone does not support treatment with growth hormone therapy. The current recommendations for the evaluation of growth failure in young female patients includes karyotype to exclude mosaic Turner syndrome and direct measurements of both biological parents to best estimate the patients midparental target height. Given these findings, the requested Norditropin FlexPro 10 mg/1.5 mL growth hormone is not medically necessary for 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 pediatrics with subspecialty certification in pediatric endocrinology 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 inpatient hospitalization services. The California Department of Public Health (CDPH) requires three consecutive negative cultures, two weeks of therapy, and clinical improvement before allowing patients with tuberculosis out of isolation. In this case, while the patient was not acutely ill, he was found to have active tuberculosis and was being assessed for pulmonary lesions.  Although he was started on appropriate therapy, the patient continued to have positive sputa for tuberculosis. The patient underwent antituberculosis therapy and his first set of three negative cultures were obtained. The records stated that the county health department was required to clear this patient for discharge. This is relatively common practice as it is necessary to assure that the household has no children at high risk for acquiring tuberculosis, instruct the patient in how to take the drug therapy, and arrange follow up. Health department clearance was still pending until the end of the hospitalization. Given that this patient had active tuberculosis, required isolation, and required health department clearance prior to discharge, the services at issue were medically indicated. Therefore, inpatient hospitalization services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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 referral to a cardiologist.  Findings:  The physician reviewer found that records document that this patient presents with a history of transient ischemic attack (TIA). The patient has requested a referral to a cardiologist. However, there is a lack of documentation of symptoms, signs, or physical findings concerning for a cardiac abnormality requiring cardiologic consultation. A chest x-ray was interpreted to show no evidence of acute cardiopulmonary disease. In addition, the available reports do not include any laboratory studies revealing results that require further evaluation by a cardiologist. Moreover, the patient is under the care of a provider who did not recommend a cardiology consultation. For these reasons, the requested referral to a cardiologist is not medically necessary for 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 internal medicine with subspecialty certification in cardiovascular disease 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.