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

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Applying the child and adolescent level of care utilization system (CALOCUS), the PHP services provided were not and are not medically necessary for treatment of this patients medical condition. The patient demonstrated moderate risk of harm (score 3) with a recent suicide attempt by overdosing on Prozac and intermittent passive suicidal thoughts. The patients functional status was moderately impaired (score 3) as he was unable to attend school due to his symptoms. The patients affect became brighter. He went to lunch with a church group leader and went hiking with his family. He was forward thinking and talking of volunteering. The patients co-morbid conditions are significant (score 3) and include major depressive disorder, generalized anxiety disorder, and social anxiety disorder. However, the patient did not have serious medical problems which would require intensive monitoring. The patients recovery environment is mildly stressful (score 2), his environment is described as supportive (score 2) and his parent is willing to participate in treatment. The patient demonstrated significant response to treatment (score 2) as he was participating in treatment and his thoughts of suicide had decreased. The patient was constructive in treatment (score 2) and has been engaged with his providers. These give the patient a composite score of 17, which is consistent with intensive outpatient program (IOP). The patient continued to need treatment for his of major depressive disorder, generalized anxiety disorder, and social anxiety disorder, but this could have been done in a less restrictive environment. Therefore, the PHP services provided were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and 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 with expertise 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management System (LINX). Findings:  Two of the three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. For these reasons, the LINX Reflux Management System is not likely to be of greater benefit than other available treatment options.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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: A patient has requested authorization and coverage for viscosupplement/hyaluronic acid injections. The submitted documentation does not support the medical necessity of the requested medication. The evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with severe osteoarthritis of the knee who have failed conservative treatment, including corticosteroid injections. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with advanced osteoarthritis of the right knee. However, the patient recently completed physical therapy with improvement noted, and underwent a recent corticosteroid injection, with no documentation of inadequate response. Therefore, in this clinical setting, the requested viscosupplement/hyaluronic acid injections are not medically necessary for the treatment of the 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 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: A patient has requested authorization and coverage for Norco, four pills per day. The submitted documentation supports the medical necessity of the requested medication regimen. Per the Centers for Disease Control guidelines, patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages. In this case, the patient is being stepped down greater than 30% in a one-step process. There is no titration down with other hydrocodone dose combinations that are available. A gradual taper is often necessary and if not successful, alternate detoxification may be indicated. Alternative therapies should be implemented to replace the analgesia provided by the hydrocodone. In the interval, the requested Norco, four pills per day, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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/IPL treatment skin greater than 500 square centimeters. According to the current medical literature, laser treatment or intense pulsed light (IPL) would be expected to improvement the telangiectasias of rosacea, but not the inflammatory component. As the requested services will not address the patients problematic symptoms, the requested services are not supported as medically necessary. With regard to the whether the service should be provided as a reconstructive procedure, the patient presents with an abnormal condition related to disease. However, there is a lack of documentation of a functional limitation associated with this abnormal condition. The requested treatment is expected to improve the telangiectatic component of rosacea, which is mainly considered a cosmetic concern. Moreover, the treatment is not likely to provide a more than minimal improvement in the patients appearance. Thus, the requested laser/IPL treatment skin greater than 500 square centimeters is not supported as reconstructive in nature. 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Exondys 51. Findings:  Three physician reviewers found there is sufficient support for the requested medication in this clinical setting. The U.S. Food and Drug Administration has approved eteplirsen for the treatment of patients with exon 49-50 deletion. A study showed that the deterioration in respiratory muscle function with eteplirsen treatment as measured by the forced vital capacity was half that seen in the natural history of patients with Duchenne muscular dystrophy. This patient has been followed by a neuromuscular specialist, and has documented stable upper extremity and lower extremity function. Maintenance of these functions are significant for independence and quality of life. In this patients case, Exondys 51 is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology with special qualification in child 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.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for out-of-network mental health services on the basis the services were emergent. Review of the submitted documentation demonstrates a psychiatric evaluation was not performed upon admission. There was no risk assessment performed by a licensed professional; thus, an emergency medical screening or examination as required above was not performed. Further, patients who are experiencing a psychiatric emergency medical condition are considered an imminent danger to themselves or others. This can be due to a variety of factors including, mania, psychosis, suicidal ideation, homicidal ideation, delusions and delirium. Per the submitted documentation, the patient was not experiencing any of these symptoms. The patients vital signs were stable. He was compliant with treatment. The physician note did not mention that the patient was an imminent danger to himself or others and required emergent hospitalization. All told, based upon the submitted documentation, the patient was not experiencing a psychiatric emergency medical condition.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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: Urgent Care
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for mental health treatment services received for treatment of experiencing a psychiatric emergency. Findings:  The physician reviewer found that patients who are experiencing a psychiatric emergency medical condition are considered an imminent danger to themselves or others. This can be due to a variety of factors including, mania, psychosis, suicidal ideation, homicidal ideation, delusions and delirium. Per the submitted documentation, the patient had none of these symptoms. Upon admission, the patient did not have any suicidal or homicidal ideation. She was anxious and depressed. The patient on multiple occasions stated that she preferred to be treated in a less restrictive environment as an outpatient. The patient stated that she felt stable and wished to be discharged home. Although the patient required treatment for her anorexia nervosa, anxiety and depression, the services rendered are not considered emergent services as defined above.  All told, based upon the submitted documentation, the patient was not experiencing a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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 reimbursement for the acupuncture services. For patients with low back pain, providers should consider the use of medications with proven benefits in conjunction with back care information and self-care. Providers should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For most patients, first-line medication options include acetaminophen or nonsteroidal anti-inflammatory drugs. For patients who do not improve with self-care options, providers should consider the addition of non-pharmacologic therapy with proven benefits. In this patients records, there is insufficient documentation of a patient work-up and tried and failed treatments to justify the need of acupuncture. The provider has not documented any physical/orthopedic examination of the low back, pain scales, functional deficits or failed conventional treatments. Therefore, the acupuncture services and future acupuncture services were not and are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 oriental 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 reimbursement for the services. Findings:  The physician reviewer found that applying the child and adolescent level of care utilization system (CALOCUS) to determine the necessary level of care for children, this patients records do not support the medical necessity of the services provided. The patient presented a composite score of 18 which correlates with intensive outpatient services. Overall, the progress notes do not document a serious mental health symptoms on the part of the patient. There was no documentation of serious depression, anxiety or psychosis. During her stay, the patient was noted to be cooperative in treatment and was noted to be benefiting from her therapies as judged by her improved insight and judgment. For these reasons, the services at issue were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of both legs for treatment of the enrollees leg swelling and not reconstructive in nature.  Findings:  The physician reviewer found that consistent with lipedema of the lower extremities without evidence of lymphedema. The patient has undergone extensive conservative management, including compression wrapping, physical therapy, successful weight loss and extremity massage. Her lipedema has been noted to have adversely affected her function with chronic pain and difficulty with ambulation. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema. As noted by Rudkin and colleagues, lipedema is distinct from lymphedema. Schmeller and colleagues concluded that tumescent liposuction is a highly effective treatment for lipoedema with good morphological and functional long-term results. As this patient has a well-recognized condition of lipedema significantly affecting her function, and has failed treatment with reasonable conservative measures, the requested liposuction of both legs is medically necessary. In addition, the records indicate that the patient has an abnormal condition. This abnormal condition is causing the patient functional impairment. The abnormal condition is secondary to weight loss, which is a treatment for obesity, which is considered a disease. The patients functional impairment is likely to improve with the requested procedure. All told, the requested bilateral lower extremity liposuction is supported as medically necessary and reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dental services provided on the basis that the services were emergent. Emergency dental and oral surgery services are those necessary to stabilize an acute injury to sound and natural teeth. The provided history and radiographs show the teeth involved, have had a long history of dental procedures including prior failed root canal treatments and crown placements. The patient first presented for the recurrence of pain in this area approximately months prior to the dates of service at issue. Given the approximate history of symptoms in the teeth involved, the extractions performed during the period at issue were shown to be for treatment of a chronic dental condition. The progress notes provided confirm the subsequent bone grafting procedures were in preparation for future tooth replacement with dental implants, again a dental procedure for tooth replacement resulting from a chronic rather than an acute condition. Based upon the information set forth above, the patient history and medical records provided demonstrate that the services provided were services for treatment of a chronic dental condition and not emergency medical services as defined by California law.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dentistry 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.