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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for the gene test (DecisionDx-Melanoma test) for malignant melanoma on her right medial breast, 0.65 mm Breslows depth and Clarks Level II. Per testing report, the DecisionDx-Melanoma class was 1 and sub-class was 1A. A Class 1A signature is associated with the lowest risk of recurrence within five years. According to the medical literature, the use of the DecisionDx-Melanoma assay panel is not currently recommended. There needs to be prospective analyses of patients who are representative of the general primary melanoma patient population focused on definitive assessment of the sensitivity and specificity of this test. Guidance on interpretation of the results of the DecisionDx-Melanoma assay is critical since a lack of understanding of test results by clinicians may prompt additional or more frequent diagnostics than needed without definitive patient benefit. There is the necessity for a much larger trial to properly utilize this testing procedure as the basis for diagnostic recommendations. The DecisionDx-Melanoma assay is not considered to offer additional benefits in patient management of melanoma. This test is not approved for melanoma testing by any other regulatory bodies for this diagnosis.  The clinical value of this test remains unclear and although there is interest in newer diagnostics, such as gene profiling, to help determine risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. There is insufficient evidence to propose routine clinical management, including decision making regarding sentinel lymph node biopsy, should be altered by the results of gene expression profiling. The use of this test has not been shown to improve health outcomes in melanoma.                                                   Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology and are actively practicing.  All three 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 patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was in withdrawal and his disease had worsened as evidenced by increased frequency of relapses. The patient met dimension 2 as his continued substance use placed himself and others at serious risk of injury due to his driving while intoxicated. For dimension 3, the patient reported feelings of hopelessness and suicidal ideation. The patient met dimension 4 since he was admitted voluntarily, but this was the first time he attended treatment willingly, so his readiness to change was new and vulnerable. For dimension 5, the patient met this criterion given his pattern of multiple relapses within recent weeks while trying to maintain sobriety on his own. Without any major changes, he was likely to relapse again. The patient met dimension 6 as he was homeless. The patient required safe and stable living environment in order to develop his recovery skills. Thus, the patient met the ASAM criteria for Level III treatment, which was similar to what patient received at the facility. Given these findings, the RTC services were medically necessary for 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 psychiatry with expertise 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for uvulopalatopharyngoplasty (UPPP) procedure. Although continuous positive airway pressure (CPAP) is considered first-line therapy for OSA, it is also associated with a 25-50% non-adherence rate. This patient is considered non-adherent as he has been unable to tolerate CPAP. One meta-analysis found that objective and subjective sleep-related outcomes improved significantly after UPPP for at least 34 months postoperatively (He, et al.). A systematic review found that CPAP non-adherence rates could be as high as 33% in many CPAP clinical trials, with a likely reduction in clinically meaningful benefit (Rotenberg, et al.). The study found a greater mortality among CPAP users compared to those who underwent UPPP for OSA, even after adjusting for age, gender, race, year of treatment, and comorbidities. Surgical risks are weighed against the risks of untreated OSA, including cardiovascular disease, hypertension, cognitive dysfunction and depression . This patient presents with severe OSA. His treatment has included an appropriate trial of CPAP, yet he has been unable to obtain substantial benefit from the device due to intolerance. Based on available clinical documentation, the requested UPPP procedure is 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 UPPP is 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 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.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services.  Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder. Overall, the patient demonstrated significant symptoms that warranted emergency treatment according to Health and Safety Code section 1317.1. Applying the LOCUS criteria, this patient presented with serious risk of harm (score 4), due to compromised ability to care for herself. The patient demonstrated moderate functional impairment (score 3) as evidenced by her inability to work, identify support, and function in her marital role. The patient had significant comorbidity (score 3) as evidenced by spiral fracture of her right arm, recent alcohol use, and contentious home situation. The patients recovery environment was extremely stressful (score 5) considering that her husband kicked her out of the house. Her recovery environment provided limited support (score 3). The provider noted that no one accompanied the patient to the emergency department. The patients brother provided transport to her stepdown to transitional living center. The patient has shown limited response to treatment (score 3) as the records noted that she was discharged just four days prior and she decompensated in that short timeframe. The patients caretaker has been obstructive (score 3). The caretaker was unable to work constructively with the patients providers. The patient participated in treatment and was compliant with medications in the hospital. She was ultimately agreeable to be discharged to a transitional living center. This gives the patient a composite score of 24, which is consistent with medically managed residence based services, such as inpatient psychiatric hospitalization. Therefore, the emergency medical services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were emergency services as defined by California law and 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 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 valganciclovir HCL 450 mg tablets. Current data shows that valganciclovir is likely to result in higher serum levels than other antivirals because of greater absorption of this drug. However, this patients records do not support an indication for treatment with valganciclovir. The risk of CMV progression is very low in the setting described and based on recent testing. Moreover, Stelara has not been associated with a higher incidence of infectious complications than patients treated with placebo. All told, the requested valganciclovir HCL 450 mg tablets are 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 internal medicine with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for intensive tube weaning program services. The enrollee has diagnoses of hypertrophic cardiomyopathy and Noonans syndrome. He was an oral eater until approximately three months of age. He breast-fed for the first four weeks of his life and transitioned to bottle feeding. His family observed loud breathing, frequent vomiting, and poor weight gain during this time. He was hospitalized at one and a half months for 10 days due to recurrent vomiting and failure to thrive. He underwent a supraglottoplasty for his laryngomalacia and tracheomalacia. He was hospitalized one month later for recurrent vomiting, chronic upper respiratory infections, and failure to thrive. A nasogastric (NG) tube was placed due to decreased weight gain, feeding refusal, and failure to thrive. The enrollees vomiting continued while at home on NG tube and a gastrostomy (G) tube was placed. Following the G-tube (GT) placement, the vomiting decreased, and the enrollee started to gain weight appropriately. Although the vomiting appeared to resolve with the G-tube, he continued to refuse feedings. The family worked on decreasing the pressure to eat at mealtimes, but he continued to refuse and his gagging or vomiting with solids increased. Because of the lack of progress in oral feeding, the enrollees parents pursued a remote, home-based, child-directed weaning program, using hunger induction as part of the treatment. The enrollee participated in the program. He responded well to the decrease in calories via tube and started to show more interest in solid foods at the table. The enrollees skills quickly improved and he was able to eat small bites of food. His weight at the beginning of the hunger induction was 20 pounds, 4.91 ounces. On day five of treatment he weighed 19 pounds, 10 ounces; indicating a two percent loss. On the last day of treatment he weighed 19 pounds, 8 ounces; indicating a total of four percent weight loss throughout the intensive portion. His weight at day ten of follow-up was 19 lbs., 8.4 ounces; indicating maintenance of his weight without supplementation. The family reports dissatisfaction with the lack of a weaning plan by the gastroenterology (GI) and occupational therapy (OT) team, and believed that waiting years to proactively encourage oral intake would be detrimental to the enrollees development.. Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for hypoglossal nerve stimulation device. There is evidence to establish that implantation of a hypoglossal nerve stimulation device results in improved health outcomes for patients with OSA. Currently, patients with a positive OSA diagnosis, CPAP failure or intolerance, a BMI less than 32 kg/m2, and favorable palatal collapse are considered for hypoglossal nerve stimulation. Medical literature shows that patients achieve a benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of OSA. This patient meets the clinical criteria for surgical management of his OSA symptoms with the requested procedure. He has undergone a drug induced sleep evaluation documenting the location of obstruction with anteroposterior collapse at the tongue base. The patient has narrowing of the hypopharyngeal and anteroposterior palatal airway on sleep endoscopy. Given these findings, the requested hypoglossal nerve stimulation device is 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 hypoglossal nerve stimulation device is 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 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 1 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in internal medicine 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for a power mobility scooter. The enrollee has lower back pain due to degenerative disc disease (DDD), inability to walk, and morbid obesity. She was evaluated due to complaints of pain in her left toes and complaints of redness, swelling, burning, and occasional purple discoloration of her toes. Physical therapy assessment for the requested mobility scooter indicates the powered equipment (mobility scooter) is not medically necessary but instead a four-wheeled walker with a seat was recommended to help the patient keep ambulating and take rest breaks as needed; and considered the heavy duty four wheeled walker with a seat is medically necessary to increase her safety and decrease her fall risk due to altered balance. According to the medical literature, studies go against recommending motor scooters prematurely because of the risk of further physical de-conditioning, leading to permanent disability and increased cardiovascular risk.  Interventions, such as scooters, that improve self-perceived quality of life, can have detrimental long-term effects by increasing cardiovascular risk, particularly insulin resistance. Risks should be carefully weighed before approving their use, as well as ensure healthy levels of activity afterward. There is insufficient evidence in the record supporting the patient has mobility deficits which impair her participation in mobility-related activities of daily living. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for safety sleep bed. Researchers noted that assessing children with autism for sleep disorders is critical as inadequate sleep can have detrimental effects on memory, attention, cognition, daytime behavior, and even language acquisition. Medical literature found that increased night time awakening and decreased willingness to fall asleep were shown to be associated with poor appetite and growth. Increased aggression, hyperactivity, and social difficulties could be indicators for poor mental health outcomes that were observed due to sleep disturbance secondary to autism. Applied behavior analysis (ABA) may be effective over time, but ABA is not an immediate solution to the patients current safety concerns. The patient has demonstrated persistent behaviors that put herself and her family at risk of injury at bedtime and throughout the night. These behaviors include kicking, hitting, biting, head banging, and trying to leave the house. The patient does not have the awareness or insight to realize the risks involved for herself or others. According to the patients parent, past attempts to contain the patient in secure bed tents were initially successful, until she grew strong enough to break through these bed tents. It is reasonable to conclude, based on the prior behavior patterns that the patient would settle down and fall asleep if contained in a secure bed for the night. This would allow the patient and her family to sleep through the night, which is essential for the patients optimal functioning and development. Given the current medical literature, the requested safety sleep bed is 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for physical and occupational therapy in a skilled nursing facility (SNF). The records provided for review do not demonstrate that this patient requires skilled nursing level of care services. The documentation does not reveal complex wound care, new enteral feeding or other skilled nursing needs that requires a SNF admission with services performed only by a skilled nurse within a SNF. The patient does not require continued skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide reasonable treatment at a SNF level. The patient has been receiving therapy for her condition. The documentation does not support that she needs a skilled therapist to supervise or perform this therapy at a SNF level. The patient may benefit from additional physical, occupational and speech therapy but the documentation does not support that she needs inpatient care in a SNF with a skilled professional therapist on a daily basis. All told, the requested physical and occupational therapy in a SNF is not medically necessary for treatment of 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for shunt placement. Researchers evaluated the safety and effectiveness of endoscopic third ventriculostomy and ventriculoperitoneal shunt for patients with non-communicating hydrocephalus. The authors found that endoscopic third ventriculostomy provided greater benefits in terms of hospital stay, infection, reoperation and overall major complications. The records document that this patient has persistent hydrocephalus and symptomatic headaches. Treatment has included endoscopic third ventriculostomy without substantial symptomatic improvement. Since this patient failed treatment with endoscopic third ventriculostomy, placement of a ventriculoperitoneal shunt is appropriate for symptomatic relief. All told, the requested shunt is medically necessary for 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 neurological 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.