Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing. Findings:  The physician reviewers found that the medical evidence supports the services at issue in this patients case.  The cytopathology of the 2 cm thyroid nodule was consistent with follicular lesion of undetermined significance.  The risk of malignancy is 5% to 15% in these nodules.  The newest 2015 American Thyroid Association guidelines state that for nodules with follicular lesion of undetermined significance cytology, molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery.  The American Thyroid Association also recommends taking the patients history, ultrasound appearance and other clinical factors in consideration in order to make medical and surgical decisions.  In this patients case, Afirma Gene Expression Classifier testing performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 3 of 3 reviewers determined that the services at issue were 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services. Findings:  The physician reviewer found that Based on the available documentation, the RTC services provided were not medically necessary for treatment of this patients medical condition. The patient showed minimal post-acute withdrawal symptoms, there was no evidence of suicidality, homicidality, or violence or aggression towards others, and there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. The patient was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care in a less restrictive treatment setting. He was motivated and appeared to be working the program. He had a sponsor. He was three days post discharge from detoxification and had relapsed on one triazolam. Moreover, he had coping skills with the capability of implementation. He could have continued treatment and recovery on an ambulatory basis such as PHP. As of the date of service in question, the patient no longer met the American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for emergency room 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. In this case, the patient presented with pain in the  gums for two days. The patient rated pain at 5/10. The patient denied difficulty swallowing and no trismus was noted. There was no documentation of difficulty breathing. 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 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 reimbursement for gene test related to prostate cancer, called Confirm MDx. Findings:  The physician reviewers found that there is a lack of medical literature that indicates the benefit of the services at issue in this clinical setting. The gold standard in the management of prostate cancer remains the identification of prostate cancer on a prostate biopsy to be followed by the appropriate treatment. ConfirmMDx has not been validated with prospective randomized clinical trials. There is a lack of evidence to show a difference in long term or short term outcomes, alteration of treatment approach, improvement in quality of life or an improvement in overall or progression free survival.  The risk of detecting cancer is not well defined in this test. Moreover, knowing the risk of detecting prostate cancer on repeat biopsy, as suggested by the ConfirmMDx test, would not preclude the provider from requesting a biopsy because this test has no impact on survival or management. In addition, the identification of risk (high versus low) grade disease, would not be beneficial since a tissue diagnosis is needed to confirm the diagnosis as well as render the histological behavior of the disease. For these reasons, ConfirmMDx performed was not likely to have been more effective than the available methods for the evaluation of this patients medical condition. Final Result: 2 of 3 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services rendered at Hoag Neurobehavioral Health, LLC. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The records did not show that the patient was in withdrawals. There was no evidence of suicidality, homicidality, violence or aggression towards others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would have supported the level of care at issue.  By the first date of service in question, he was medically stable to the point where he did not require 24/7 monitoring.  He was also psychiatrically stable.  There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptoms that would interfere with his care. His home environment was supportive and conducive to his recovery. He had no prior treatment at a lower level of care, and there was no indication that treatment at a lower level of care would lead to decompensation or deterioration. He could have continued treatment and recovery on an ambulatory basis such as partial hospitalization program or intensive outpatient program. For the reasons stated above, substance abuse residential treatment center services rendered at Hoag Neurobehavioral Health, LLC during the dates of service in question were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lipiflow treatment (0207T, 0330T). Findings:  The physician reviewers found that the documentation provided does not support the superior efficacy of the requested services in this clinical setting. There is insufficient information to determine if this patients symptoms of decreased near vision and night vision are caused by MGD and dry eye syndrome. Refractive error should be ruled out as the cause for these symptoms and this has not been documented. While there is some support for Lipiflow treatment, it is unclear from the documentation provided if this patient has failed standard therapies, such a warm compresses, lid scrubs, artificial tears, and omega-3 supplementation. Although dry eye syndrome can cause visual symptoms, there is insufficient evidence to justify the use of Lipiflow for a condition that is commonly and effectively treated with conservative measures. Therefore, Lipiflow treatment (0207T, 0330T) is not likely to be more effective than other treatment options in this patients case. Final Result: 3 of 3 reviewers determined that the requested services are 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 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 physical therapy. Findings:  The physician reviewer found that the request for physical therapy is not medically necessary for treatment of the patients medical condition. Physical therapy is a widely used treatment for low back pain. However, the duration and frequency of physical therapy treatments are not adequately addressed in the medical literature. Studies indicate that there is a benefit to therapeutic exercise tailored to the patients condition. In this case, the patients most recent physical therapy note does not have a clear treatment diagnosis or rationale supporting skilled intervention. Based on the clinical documentation submitted for review, additional skilled physical therapy is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon sinus ostial dilation. Findings:  The physician reviewers found that nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but the etiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no generally accepted management protocol. While sinus ostial dilation, with or without balloon sinuplasty, can be a therapeutic option for patients with chronic sinusitis, the criteria have not been met in this patient. The records do not include chronology of disease or treatment, and there is no documentation that the patient was treated with maximal medical therapy prior to the CT scan. Moreover, nasal polyposis was documented on endoscopy and imaging, which is not an indication for balloon sinuplasty. For these reasons, the requested balloon sinus ostial dilation is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested procedure 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: 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services provided. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient received emergency medical services during the date of service at issue. The U.S. Department of Veteran Affairs practice guidelines for the assessment and management of patients at risk for suicide indicate that anxiety is a significant and modifiable risk factor for suicide, and benzodiazepines with a short half-life, such as alprazolam, should be avoided. In this case, the patient presented acutely anxious. She was experiencing chest pain, was suicidal, and she was out of her medication. She had multiple external anxiogenic stressors. In addition, the patient was experiencing concerning somatic symptoms and more than likely a discontinuation syndrome from the selective serotonin reuptake inhibitor and the short-acting benzodiazepine. The patient required emergent evaluation to properly evaluate her psychiatric condition, stabilize her acute distress, rule out medical etiologies and determine the most appropriate level of care. Further, the emergency services were reasonably expected to improve the patients condition and prevent a more severe episode of illness. Therefore, the services at issue were necessary for treatment of a psychiatric emergency medical condition. Thus, the patient received psychiatric emergency medical services on the date of service at issue.Final Result: The reviewers determined that the patient received psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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 parent of an enrollee has requested authorization and coverage for behavioral therapy, occupational therapy and speech therapy. Findings:  The physician reviewer found that, according to Centers for Disease Control and Prevention (CDC) on the diagnosis of autism, There are many tools to assess ASD in young children, but no single tool should be used as the basis for diagnosis. Diagnostic tools usually rely on two main sources of information-parents or caregivers descriptions of their childs development and a professionals observation of the childs behavior. Although no single tool should be utilized, there are several autism specific evaluation tools available such as the Autism Diagnostic Observation Schedule (ADOS) and the Childhood Autism Rating Scale. In this case, it does not appear that a valid autism screening test was utilized. While the GADS was clinically useful in the past, the diagnosis of Aspergers disorder no longer exists with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. This fact, coupled with age appropriate skills in cognition/general ability, academic skills, language, motor skills and social-emotional function make the diagnosis of autism unlikely. In addition, the in-Plan records from the multidisciplinary evaluation were not consistent with an ASD. The patients speech and occupational therapy assessments demonstrated an alert and interactive child who does not qualify for speech or occupational services. Based on the documentation submitted for review, the request for behavioral therapy, occupational therapy and speech therapy have not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis. Findings:  Three physician reviewers found that the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature supports the utility of the proposed procedure in this clinical setting. Studies evaluated the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain. The authors review showed Level II evidence for long-term effectiveness of radiofrequency neurotomy in the lumbar and cervical spines, for facet joint nerve blocks in the cervical, thoracic, and lumbar spine. In this case, the patient has lumbar facet pain corroborated by history, physical exam and MRI. There is no evidence of nerve root compression on MRI. Therefore, the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested procedure is 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 anesthesiology with sub-specialty certification in pain medicine 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 homocysteine testing. Findings:  Three physician reviewers found that the guidelines of the American College of Cardiology (ACC) do not recommend testing for homocysteine levels. Rather the ACC guidelines recommend use of standard risk factor assessment and standard lipid panels. The C-reactive protein (CRP) was mentioned as a possibly benefit in the asymptomatic individual with other normal risk factors but homocysteine was not mentioned. Studies noted that homocysteine level measurement or treatment with folic acid has not been proven to be of clinical benefit. In addition the patient has established cardiovascular disease and is already under treatment. This patient was not being evaluated for screening purposes. Therefore, homocysteine testing performed was not likely to have been superior over the standard options of evaluating this patient. Final Result: 3 of 3 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 internal medicine with sub-certification in cardiovascular disease 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.