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

An enrollee has requested reimbursement for monitored anesthesia care (MAC) provided for a colonoscopy. The submitted documentation supports that the services at issue were medically necessary. Studies have indicated that monitored anesthesia care is indicated if the patient has a prior history of intolerance to colonoscopy under conscious sedation. In this case, the patient has a pertinent past medical history that is significant for both GERD and rectal cancer. In addition, the patient has previously undergone four colonoscopies. The records indicate that the patient did not tolerate colonoscopy under moderate sedation. Further, the diagnosis of GERD places the patient at increased risk of aspiration and/or a pulmonary complication during the colonoscopy. Therefore, the patient meets the medical criteria for the use of monitored anesthesia care during the colonoscopy. Accordingly, the monitored anesthesia care (MAC) provided was medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An individual is requesting authorization and coverage for individual outpatient psychotherapy at a frequency of once per week. Findings:  The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. At this time, for patients experiencing temporary regressions noted by worsening depression, there is no medical evidence to support weekly psychotherapy as opposed to other treatment modalities . In this case, when the patient reported worsening depression, he was appropriately offered a social anxiety group and a Cognitive Behavioral Therapy (CBT) group in which skills training is taught. There is no evidence to statistically support the use of weekly psychotherapy as a superior treatment for a patient under these circumstances. In fact, the submitted documentation reflects that the patient achieved good stability with the psychotherapy he had previously received, and the program that was offered to him was more than adequate to re-attain stability, given his behavioral health. Accordingly, individual outpatient therapy sessions at a frequency of once per week are not medically necessary to treat 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 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 a consultation for a Kyphoplasty. The submitted documentation does not support that the requested service is medically necessary. The California Technology Assessment Forum (CTAF) concluded that balloon kyphoplasty meets CTAF criteria for safety, effectiveness, and improvement in health outcomes for the treatment of recent (less than three months old) osteoporotic vertebral compression fractures confirmed by MRI. Balloon kyphoplasty does not meet CTAF criteria for the treatment of chronic (greater than three months old) osteoporotic, traumatic, or pathologic vertebral compression fractures.In this case, the patient presents with a history of vertebral compression fracture at T12 due to a fall. There is no evidence of osteoporosis or vertebral body neoplasms. She reports ongoing back pain, with functional limitations in walking tolerance due to back pain and spasms. Conservative treatment has included rest, medications, and a trial of bracing. There is imaging evidence of a subacute (approximately 70%) compression fracture with marrow edema involving the body of the T12 vertebra with mild retropulsion of the posterior superior margin of the fractured vertebra partially effacing the anterior subarachnoid space without cord compression or significant central canal stenosis. Current evidence-based medical guideline criteria for balloon kyphoplasty have not been met. There is no evidence of osteoporosis, and kyphoplasty is not supported for traumatic vertebral compression fractures. Under these circumstances, the requested consultation for kyphoplasty is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The submitted documentation supports that the requested medication is medically necessary. The 2018 American College of Rheumatology recommendations for patients with psoriasis complicated by psoriatic arthritis indicate that oral small molecules (OSMs) are the first line therapy for cases where both psoriasis and arthritis are not severe. OSMs include methotrexate, sulfasalazine, cyclosporine and apremilast (Otezla).In this case, the patient has a history of psoriasis and psoriatic arthritis. The patient has tried and failed treatment with topical steroids. The American College of Rheumatology recommends apremilast (Otezla) among first line therapies for patients under these circumstances. Accordingly, Otezla tablets are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The overarching goal of home health care is to optimize each childs health and function while minimizing recurrent or prolonged hospitalizations through the provision of comprehensive, family-centered health care rendered in a nurturing home environment. In the current era, alternative models of service delivery such as homebased nursing services have become more important, and also as it has become more feasible to provide hightechnology interventions at home. Accepted indications for private duty nursing often include the administration of medications, monitoring oxygen saturations, and enteral feeding, all of which are required in this case. According to this patients home nursing health plan, skilled nursing services were indicated to conduct the following: monitor vital signs; perform nursing assessment; provide G-tube care; implement seizure precautions; monitor lungs sounds; perform oral suctioning; assist with range of motion; and monitor for skin breakdown. While her parents are nurses and may be able to meet the ongoing needs of their child in the short-term, this is not sustainable for long-term care. According to researchers, 54% of families caring for a child with special needs reported that a family member stopped working because of the childs health, with more than 20% of families reporting financial problems attributed to their childs condition. Given these findings, the private duty nursing services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral transforaminal epidural injections. Lumbar epidural steroid injections under fluoroscopic guidance can be advantageous in diagnosing a patients pain source as well as for treatment of low back and lower extremity radicular pain. These procedures have been shown to be effective for pain relief in the short-term with few adverse events. In this case, the patient presents with a history of low back and left lower extremity pain associated with positive straight leg raise on the left. In determining the source of her pain, there are two factors to consider: the sacral insufficiency fracture resulting from radiation therapy; and the spinal pathology with L4-5 spondylolisthesis associated with lateral stenosis and L5 radiculopathy. The provider has recommended transforaminal epidural steroid injections for determination of the pain source to be followed by a limited laminotomy, if needed. Based upon the review of the literature, this is a reasonable indication for transforaminal epidural steroid injections and will help direct this patients care. As such, the requested transforaminal lumbar/sacral epidural steroid injections are supported as medically necessary for evaluation and treatment of this patients medical condition. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. Findings:  The physician reviewer found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial demonstrated that the hypoglossal nerve stimulator was safe and effective in a small subset of patients with obstructive sleep apnea who failed continuous positive airway pressure (CPAP), had nonconcentric airway collapse, had an apnea-index index (AHI) between 20 and 50, and had a body mass index (BMI) less than 32. With a BMI of 30.66, AHI of 34.3 and nonconcentric airway collapse, this patient meets the criteria for the requested services. She has failed CPAP, which is the gold standard treatment for obstructive sleep apnea. Therefore, the requested implantation of hypoglossal nerve stimulator is likely to be superior over other treatment options. Final Result: Three physician reviewers found 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, 2 and 3 are board certified in physical medicine and rehabilitation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oncotype DX Prostate Cancer Assay.Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The National Comprehensive Cancer Network (NCCN) recommends Oncotype DX Prostate Cancer Assay for men with low-risk or favorable intermediate-risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. This prognostic information includes likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Patients with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate Cancer Assay was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 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 authorization and coverage for three trigger point injections. Findings:  The physician reviewer found that the efficacy of trigger points is well documented in the literature if the points are clearly identified and injected or dry needled. The interrater reliability for identifying myofascial trigger points is an important consideration. Documentation of the clinical aspects of myofascial trigger points also includes the taut band, local twitch response, and referred pain patterns. In this case, the patient has fibromyalgia and has had hip surgery and shoulder surgery which have left her with constant pain. The patient has had physical therapy in the past and describes it as less than effective. She had medication trials with tramadol and ibuprofen and also uses cannabis for pain. While the progress notes describe the location of the trigger points, they do not detail the taut muscular band and pattern of radiation. The description of the trigger points and the pattern of radiation are not documented. Under these circumstances, the present request for three trigger point injections is not medically necessary to treat the patients medical condition at this time.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 anesthesiology, with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommend that residential treatment, or similar care that is higher than an outpatient level, is indicated for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this case, the patient required a safe and stable living environment in order to develop his recovery skills, thus qualifying him for American Society of Addiction Medicine (ASAM) Level III treatment. This is consistent with the level of services that the patient received at the RTC. The severity of the patients illness was evidenced by blackouts, continued relapses, and drinking at work. Residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Under these circumstances, the residential treatment center (RTC) services at issue were medically necessary to treat the patients medical condition.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 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: The patient has requested authorization and coverage for the convergent procedure (CPT 33266). Findings:  The physician reviewer found that the peer-reviewed medical literature, the convergent procedure is described to include epicardial and endocardial ablations, which are different but combined to provide a superior outcome. In one comparative study, Jan and colleagues evaluated patient outcomes with the convergent procedure and catheter ablation alone. The authors concluded that treatment of paroxysmal atrial fibrillation with the convergent procedure showed less arrhythmia recurrence compared to catheter ablation. In addition, Kress and colleagues demonstrated improved results with the hybrid convergent procedure in managing atrial fibrillation compared to catheter ablation. The procedure avoids the need for sternotomy, and to obtain similar efficacy to the convergent procedure would likely require open sternotomy procedure. In this patients case, the provider noted that the patients stress test was cancelled as the patient was in atrial fibrillation. A computed tomography (CT) of the chest on 7/11/18 revealed showed extensive coronary atherosclerosis, which the provider noted was concerning for ischemia or coronary stenosis. Given these findings, the requested convergent procedure (CPT 33266) is likely to provide this patient with a greater health benefit than treatment with catheter ablation alone. One reviewer found that the convergent procedure (CPT 33266) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in surgery with subspecialty certification in surgical critical care and is actively practicing. One Reviewer is board certified in surgery with subspecialty certification in thoracic surgery and is actively practicing.  One Reviewer is board certified in surgery with subspecialty certification in thoracic surgery and is 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.