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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a left high condylar shave as a component of the approved corrective jaw surgery. Disturbances in the growth pattern of the mandibular condyle during the normal growth period may result in condylar hyperplasia and is diagnosed by bone scan. Abu Arqub and colleagues report that condylar hyperplasia is one of the causes of asymmetric facial growth resulting from overgrowth or hyperactivity in the mandibular condyles and that treatment of malocclusion secondary to condylar hyperplasia may involve orthognathic surgery and condylar surgery if the condyle shows hyperactivity. In this case, given that the patients malocclusion is a skeletal deformity that is the result of left condylar hyperplasia, creating a left-side cross bite, mandibular asymmetry, and transverse maxillary deficiency, and as a bone scan showed the hyperactivity of the left condyle, the requested service is medically indicated. Thus, a left high condylar shave as a component of the approved corrective jaw surgery is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, there is an abnormal structure of the body, as the patients condylar hyperplasia resulted in mandibular asymmetry, class III malocclusion, and canted maxilla. Condylar hyperplasia is a developmental abnormality secondary to disturbances in the growth pattern of mandibular condyle during the growth period. The requested orthognathic surgery will correct the patients occlusion and mandibular asymmetry, and the TMJ surgery will cease the patients condylar growth and prevent future relapse. The proposed surgery will definitely change both the patient's facial appearance and craniofacial function. Thus, the requested procedure is being performed to improve function and to create a more than minimal improvement in the patients appearance. For these reasons, a left high condylar shave (as a component of the approved corrective jaw surgery is reconstructive in nature for this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The parent of an enrollee has requested authorization and coverage for a cranial (head) remolding orthosis custom helmet.Dolichocephaly is an elongation of an infants head that is frequently seen in premature infants due to post-natal positioning. This head molding/shaping is not unusual with breech presentations. Plagiocephaly is a flattening of the back of the head that is typically associated with supine positioning and sleeping. The first line of defense with these abnormal head shapes involves repositioning, and in the presence of torticollis, physical therapy. Significant abnormalities, with either one dominant abnormal head shape (e.g., positional plagiocephaly with diagonal difference > 10mm, brachycephaly > 91%, dolichocephaly < 82%) or a combination of abnormal head shapes (e.g., plagiocephaly with brachycephaly, plagiocephaly with dolichocephaly) merit use of a cranial orthoses to prevent unnecessary stress to the developing nervous system with subsequent neurologic issues. Tamber and colleagues conducted a study that concluded there is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy. In this case, the patient has moderate plagiocephaly and severe dolichocephaly based on anthropometric measurements. Under these circumstances, use of a cranial orthosis is medically necessary and appropriate to improve head shape and prevent unnecessary morbidity. Accordingly, the requested cranial (head) remolding orthosis custom helmet is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for continuation of tolerance induction program. The patients provider has recommended treatment with oral immunotherapy for food allergies. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend oral immunotherapy as a standard of care treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment (Nowak-Wegrzyn, et al.). Although several studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials are inconsistent and do not demonstrate that oral immunotherapy is superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal symptoms (Scurlock). Therefore, the requested continuation of tolerance induction program is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics 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 proton beam radiation therapy. Findings:  The physician reviewer found that A significant concern for treatment mediastinal lymphomas is the risk of secondary malignancy, especially in younger patients. Hoppe and colleagues report that compared with three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT), proton therapy reduces the radiation doses to all major cardiac subunits. Timlin and colleagues estimate that proton therapy decreases the average risk of a secondary cancer due to radiation therapy by 40% when compared to IMRT. The International Lymphoma Radiation Oncology Group (ILROG) supports the use of proton therapy for young, female patients in this clinical setting. In this case, given that proton therapy was likely to have been more effective in decreasing long term toxicity, especially secondary malignancy, in this young, female patient, the service at issue was likely to have been more beneficial than any other standard treatments for her condition. Therefore, proton beam radiation therapy was likely to have been more beneficial for treatment of the patient's condition than any available standard therapyFindings:  Two of the three physician reviewers found the proton beam radiation therapy at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services 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 radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Current medical literature does not support the use of the DecisionDx-Melanoma test for the staging or treatment of melanoma, and there is a lack of evidence regarding its clinical utility, reliability, or improved outcomes for melanoma patients. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of cutaneous melanoma do not recommend the use of the service at issue. The American Academy of Dermatology guidelines of care for the management of thin melanomas, as in this case, do not report any practical benefit from the use of the DecisionDx-Melanoma testing. In this case, the results from the testing would not change the outcome or treatment for this patient, who would be required to have a wide local excision and then periodic follow-up skin examinations. Therefore, DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not 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 upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Freestyle Libre 2 sensors. CGMS devices are one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night (Olczuk and Priefer). In the medical literature, CGMS devices been demonstrated to be clinically valuable due to their accuracy, convenience, and improvement of software. CGMS can promote glycemic and weight control, to help reduce the risk of hypoglycemia and hyperglycemia, and improve lifestyle behaviors. Zheng and colleagues noted that CGMS devices have become a useful tool for patients with diabetes in terms of real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. CGMS has been demonstrated to be a safe method, with high accuracy in glycemic values and to have a low complication rate, for patients with type 2 diabetes. Moreover, this patient has successfully used a Freestyle Libre 2 CGMS for at least a few years with good management of diabetes. The Freestyle Libre 2 CGMS requires use of sensors, which are medically necessary for this patient to continue to manage diabetes. For these reasons, the requested Freestyle Libre 2 sensors are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for SPRINT peripheral nerve stimulator. Helm and colleagues assessed nine studies evaluating the effectiveness of peripheral nerve stimulation (PNS) for the treatment of patients with chronic pain conditions. The authors found that PNS requires further documentation of its effectiveness and expansion of its indications in order to become more widely accepted. Another review by Kaye and colleagues reported that, Further studies are needed as the long-term risks and benefits of peripheral nerve stimulation have not been well studied as most information available on the effectiveness of peripheral nerve stimulation is based on shorter-term improvements in chronic pain. In this case, the patient has chronic chest wall pain due to a variety of factors including thoracic outlet syndrome, thoracic neuroforaminal  narrowing with radicular pain, and pectus excavatum status post video assisted thoracoscopic surgery (VATS) procedure. The patient has tried and failed several treatment modalities including pulsed radiofrequency neuromodulation, physical therapy, nerve blocks, acupuncture, steroid injections, and a spinal cord stimulator. The provider has recommended a single stage 60 day peripheral nerve stimulator treatment. However, there is a lack of clinical studies demonstrating that peripheral nerve stimulator use is safe and effective for patients with intercostal neuralgia. In addition, there is a lack of data showing that peripheral nerve stimulator use is superior to standard available therapies. Based on these findings, the requested SPRINT peripheral nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injections in the left knee and authorization and coverage for a requested Orthovisc injection series in both knees.Current medical literature pertaining to viscosupplemention reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with chondromalacia and osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, there is documentation of chondromalacia of patella of both knees. Conservative treatment including physical therapy, platelet rich plasma injections, and cortisone injections have been tried without success. Under these circumstances, the Orthovisc injections in the left knee were medically necessary to treat the patients medical condition. In addition, the requested Orthovisc injection series in both knees is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients medical condition. Therefore, the Health Plans denials 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: The patient has requested reimbursement for residential treatment center (RTC) services and intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for the RTC services and the IOP services. These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services. The patients score of 4 in level of functioning also supports treatment at this level of care. In terms of length of stay, the patient met the criteria for level 5B moderate intensity intermediate stay residential treatment programs with length of stay up to 60 days due to significant disturbance in interpersonal skills as well as serious impairment in expected role functioning in work, school, and home. In addition, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services were medically necessary for treatment of this patient. These findings give the patient a composite score of 19, which is consistent with high intensity community based services. In addition, the IOP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the IOP services were medically necessary for treatment of this patient. All told, the RTC services and IOP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral nerve block injections (greater occipital nerve) and other peripheral nerve or branch. The International Headache Society (IHS) describes occipital neuralgia as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distributions of the greater, lesser and/or third occipital nerves, noting that the pain may be unilateral or bilateral with radiation into the temple or even behind the eye commonly triggered by head movements. The IHS notes that part of the diagnostic criteria is that tenderness to palpation  and pain are eased temporarily by local anesthetic block of the affected nerves. In a prospective study on the effectiveness of treatment of occipital neuralgia using nerve block techniques, Jukys and ustickas reported that occipital nerve block with a local anesthetic and corticosteroids provided a safe, technically simple, and effective treatment method that carries a minimal risk of side effects for patients with medically refractory occipital neuralgia. In this case, the patients symptoms are suggestive of occipital neuralgia. Given that occipital nerve blocks can aid in both diagnosis and treatment of occipital neuralgia and are supported in current medical literature as a safe and effective method for pain management, bilateral nerve block injections (greater occipital nerve) are likely to be more beneficial for treatment of the patients condition than any available standard therapy. Given that other peripheral nerve or branch does not appear to pertain, other peripheral nerve or branch are not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral nerve block injections (greater occipital nerve) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 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.