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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for orthotic shoe inserts for treatment of the enrollee, who has been diagnosed with chronic knee pain and severely flat feet. Findings:  The physician reviewer found that after careful review of the enclosed information, it was well-established that this patient has experienced significant knee pain which had not responded to surgical repair.  Physical examination assessed severe biomechanical abnormalities of both feet including severe hindfoot valgus, forefoot abduction and loss of medial arch bilaterally. There is correlation between the patients foot biomechanical abnormalities and knee pain.  Furthermore, the medical studies have demonstrated that patients with severe hindfoot valgus, forefoot abduction and loss of medial arch bilaterally are at a much greater risk of certain foot osteoarthritis and tendinopathies. In this particular case, the patients feet are significantly malformed from a biomechanical perspective with excessive hindfoot valgus.  This hindfoot valgus is causing genu valgum and knee pain. For these reasons, the custom functional orthotics is medically indicated for this patient to correct the foot biomechanics, staving off both foot pain and knee pain.  Therefore, orthotic shoe inserts are medically necessary for the treatment of this patients medical condition. Final Result: The reviewers determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the bilateral digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 reimbursement and prospective authorization and coverage for the Botox injections for the enrollees myofascial pain and temporomandibular joint (TMJ) arthralgia. Findings:  The physician reviewers found that Botox injections significantly reduce pain in patients with myofascial pain syndrome compared with placebo. Based on the medical literature review, Botox has been shown to be the best modality for pain control after attempts of standard treatments have failed. In this case, the patient has undergone standard treatments for her myofascial pain without relief. After two treatments of Botox injections she has experienced relief of her facial spasm and relief of her bilateral jaw fatigue. Given the clinical documentation submitted for review, the Botox injections were and are 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 services at issue were and are 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:  Physician reviewers number one, two, and three are board certified in oral and maxillofacial surgery 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan for evaluation of the enrollee, who is being treated for hemangiopericytoma. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. One advantage of PET scan, as opposed to other cross-sectional imaging such as MRI and CT is that PET scan enables an evaluation of the entire body as opposed to the focal nature of MRI and CT.  Unsuspected additional occult lesions are more easily detected by PET. Hemangiopericytomas of the breast are very rare.  The uncertainty is clear in the referring providers note.  Hemangiopericytomas can occur anywhere in the body.  They originate in the walls of capillaries, and are more commonly seen in the head and neck.  In addition, as noted in the European Sarcoma Networks practice guidelines, A biopsy may underestimate the tumour malignancy grade. Therefore, when pre-operative treatment is an option, radiological imaging (including positron emission tomography, PET) may be useful, in addition to pathology, in providing the clinician with information that helps to estimate the malignancy grade (i.e., necrosis).  In one study, it was noted that, The accurate diagnosis of HPC [hemangiopericytoma] depends on the appropriate histological and immunohistochemical examination.  Surgical resection is the treatment of choice and due to scarcity of cases and unpredictable biological behavior of these tumors long term follow-up may be warranted. All told, a careful, thorough pre-operative evaluation is reasonable, especially in view of the need for long term follow-up.  A baseline PET scan could potentially be invaluable, as it would be for any other soft tissue sarcoma. For all these reasons, PET scan is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an eight week intensive outpatient program services (IOP) for treatment of the enrollees behavioral health conditionFindings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. In the documents provided for review, there was a lack of evidence of interdisciplinary treatment planning. There was no mention of the patients level of craving, skills developed, steps worked on, identification of triggers, or relapse prevention.  There was no interdisciplinary treatment plan with goals, description of how further treatment would help the patient improve beyond what she had already achieved in IOP, or if she had even developed skills to manage her symptoms or make changes. Her issues of depression and anxiety, reported on admission, were not addressed.  It is unknown if she had developed, or was in the process of developing, sources of outside support. The patient had no suicidal or homicidal ideation.  She attended and participated in groups. There is a lack of evidence that she requires intensive evaluation and treatment at IOP level of care. The patient may be treated at a lower level of care on an outpatient with concurrent community support, such as a 12 step program. Final Result: The reviewer determined that 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical spine magnetic resonance imaging (MRI) for evaluation of the enrollees cervicalgia. Findings:  The physician reviewer found that there are no red flags to indicate immediate MRI scan of the cervical spine without a trial of conservative management. In particular, a cervical spine x-ray series showed degenerative changes and no fracture or malalignment. There is no history of trauma, infection or cancer. Neurological exam is essentially unremarkable. Absent a trial of conservative management for six weeks, the requested MRI of the cervical spine is not medically necessary for evaluation of this patients neck pain. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 laboratory testing for evaluation the enrollees irritable bowel syndrome. Findings:  Two physician reviewers found that there is a lack of peer-reviewed literature supporting the use of IgG food allergy testing for the evaluation of gastrointestinal symptoms. According to one study Although skin testing and in vitro serum immunoglobulin assays may help in the evaluation of suspected food allergies, they should not be performed unless the clinical history suggests a specific food allergen to which testing can be targeted. Furthermore, these tests do not confirm food allergy. Confirmation requires a positive food challenge or a clear history of an allergic reaction to a food and resolution of symptoms after eliminating that food from the diet. These and other recommendations are derived from the Guidelines for the Diagnosis and Management of Food Allergy in the United States, published by the National Institute of Allergy and Infectious Diseases. The laboratory testing performed is not standard of care. As such, the testing at issue was 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 testing at issue was 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: Reviewers one and two are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. Reviewer three is board certified in allergy and immunology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni once daily for 12 weeks.Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines do not restrict provision of hepatitis C therapy to specialists except in certain complex cases, in which referral to a specialist center is recommended and this case does not meet guideline criteria for specialist referral. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for emergency services provided on 4/25/16. 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 emergency department services provided on 4/25/16 were necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient presented with ear pain, crying and in distress. There are several entities which may present with persistent and worsening ear pain, including otitis externa, otitis media, perforation of the tympanic membrane, malignant otitis, and mastoiditis, as well as referred pain from the jaw or teeth. Otitis externa is the most benign of these conditions, and the presence or absence of a fever cannot reliably rule any of the complications in or out. The differentiation requires a thorough ear, nose, and throat exam. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, 17 hours per month of supervision and one hour per week of parent training. Findings:  The physician reviewer found that a study indicated that intensive behavioral treatment is effective for children with autism. The study by Orinstein and colleagues found that children with autism receiving 25 hours per week of direct therapy were likely to have an optimal outcome than those receiving only 18 hours per week. In this case, the patient continues to have issue with non-compliance which have slightly increased. She has made progress with her current level of ABA services, however she still has not met her non-compliance goals. 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 pediatrics with sub-specialty certification in developmental-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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a transcutaneous electrical nerve stimulation (TENS) device and electrodes for treatment of the enrollees low back pain with radiation to right anterior thigh. Findings:  The physician reviewer found that while TENS may reflect the longstanding accepted standard of care within many medical communities, the results of clinical trials are inconclusive regarding improved health outcomes. Overall, the published studies do not provide information on the stimulation parameters which are most likely to provide optimum pain relief, nor do they answer questions about long-term effectiveness. Several published evidence based assessments of TENS have found that evidence is lacking concerning effectiveness. Many studies only evaluated single-dose treatment, while other problems included statistical methodology, small sample size, influence of placebo effect, and difficulty comparing the different outcomes that were measured. One study reported that the treatment of neuropathic pain is largely empirical, often relying heavily on data from small, generally poorly-designed clinical trials or anecdotal. They reported an indication of TENS for phantom limb pain. In addition, another study found that TENS may be a supplement to medical treatment in the management of spasticity in spinal cord injury. Further, more research supported use of TENS in treating multiple sclerosis in patients with pain and muscle spasm. However, TENS is not recommended for use in treating chronic low back pain. Upon review of the submitted documentation, the requested TENS device and electrodes are not medically necessary for treatment of this patients medical condition. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser hair removal of excess growth of perianal hair.Findings:  The physician reviewer found that Hirsutism is a condition that refers to hair growth where hair does not normally grow. This condition is usually due to a malfunction of the pituitary gland in men or from certain medications. This patients record does not support the diagnosis of hirsutism. Perianal hair growth is normal and would not be worsened from previous shaving. The patient does not have an abnormal body part or an abnormally functioning body part. The medical studies indicate that shaving does not contribute to increase hair growth. As the patient does not have an abnormally functioning body part, any service to correct the problem would not be considered medically necessary. There is a lack of evidence in the body of literature to associate perianal hair growth to repeated hemorrhoid treatment. 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 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.