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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for hyperbaric oxygen therapy. The enrollee has a history of ulcerative colitis since age 16. He was evaluated at the wound care center due to complaints of an ileal pouch sinus. He had a total colectomy with ileal pouch anastomosis performed approximately 30 years ago; after failing outpatient treatment with prednisone, Entocort and 5-aminosalicylic acid (5-ASA). He recently started Entyvio for continued pouchitis. A pouchoscopy showed a sinus tract in the ileal pouch. The gastroenterologist recommended a hyperbaric oxygen evaluation to determine if the pouchitis could be placed in remission. A magnetic resonance imaging (MRI) scan showed a small fluid-filled sinus tract extending from the anterior anus. Given his concomitant diabetes, this tract is at high risk for infection and may be an atypical diabetic ulcer. The gastroenterologist believed the enrollee may benefit from hyperbaric oxygen. A systematic literature review demonstrated the need for well-controlled, blinded, randomized trials in order to understand the benefit of hyperbaric oxygen for this condition. A study designed to trial hyperbaric oxygen therapy for ulcerative colitis was terminated early due to small enrollment. The use of hyperbaric oxygen is not considered a scientifically proven treatment for this enrollees condition. Medical literature notes hyperbaric oxygen therapy (HBOT) has been shown to be efficacious in treating various conditions; including perianal Crohn's disease. While it is hoped that hyperbaric oxygen therapy would place the enrollee in remission and decrease the chance of infection, larger clinical studies are needed to determine the safety and efficacy of hyperbaric oxygen therapy for patients with ulcerative colitis and pouchitis. There are multiple articles detailing how hyperbaric oxygen therapy is well-tolerated and effective for ulcerative colitis; however, the majority of articles relate to hospitalized patients treated for moderate to severe flares.  Therefore, while the literature does indicate this may be a promising treatment in the future, additional studies are needed to define long-term safety and efficacy.  Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for intraoperative radiotherapy, procedure 77469. The enrollee had a screening mammogram which showed clustered microcalcifications in the superior region of the left breast. She had a diagnostic mammogram, confirming microcalcifications in the left breast measuring about three millimeters. A core biopsy showed ductal carcinoma in situ, high grade, estrogen receptor (ER) positive, and progesterone receptor (PR) positive. A magnetic resonance imaging (MRI) scan showed an oval mass measuring three millimeters in the left breast upper hemisphere at 12 oclock. A diagnostic mammogram and ultrasound showed a nodule measuring five millimeters in the left breast at 12 oclock correlating to the MRI nodule on outside imaging. There was also a second nodule at 11:30 oclock that did not correlate. The biopsy of the second nodule in the left breast showed fibroadenoma. By her imaging studies, she appeared to have a less than one-centimeter tumor; non-palpable. Her radiation oncologist noted the enrollee would be a candidate for treatment with intraoperative radiation therapy (IORT) under the clinical protocol. The enrollee chose to proceed with IORT. Peer-reviewed literature supports the use of IORT for this enrollee. Those with low-risk ductal carcinoma in situ were categorized as suitable. Two randomized intraoperative radiation therapy trials for early-stage breast cancer were recently published. With 29 months of median follow-up the results of IORT with 50-kV devices are promising as data from accelerated partial breast RT. Professional guidelines suggest that more breast cancer individuals can benefit from accelerated partial breast irradiation (APBI), including younger enrollees and those with low-risk ductal carcinoma in situ (DCIS). Those age 50 or older should be considered suitable for APBI; those age 40-49 who meet other pathologic suitability criteria should be considered cautionary; and those younger than 40 or those who do not meet the pathologic criteria should be considered unsuitable. The definition of low-risk DCIS includes screen-detected disease, low to intermediate nuclear grade, tumor size 2.5 cm and surgical resection with margins negative at 3 mm. This enrollee meets the guidelines for partial breast irradiation and IORT.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology 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 facial feminization services (CPT codes 14020, 21137, 21209, 30520 (RT and LT), 30140 (RT and LT), 30465, and 15824). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help remedy an incongruent physical appearance and gender identity. In addition, WPATH noted that non-genital surgical procedures, especially facial feminization procedures, are of greater practical significance in a patients daily life than reconstruction of the genitals. The guidelines further report that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Similarly, Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved patients mental health-related quality of life. The records provided for review include documentation from several providers who support the patients facial feminization surgeries as medically necessary to help alleviate her significant discomfort due to the masculine features of her face. Given these findings, the facial feminization services (CPT codes 14020, 21137, 21209, 30520 (RT and LT), 30140 (RT and LT), 30465, and 15824) 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 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

An enrollee has requested authorization and coverage for a custom right knee orthosis.The submitted documentation does not support that the requested orthosis is medically necessary. The documentation does not reveal physical exam evidence of a deformity of the knee or leg that interferes with fitting, disproportionate size of thigh and calf, or minimal muscle mass upon which to suspend an orthosis. The submitted physician examination notes do not reveal objective evidence of right knee instability such as varus/valgus or drawer signs. The documentation includes conflicting notations, as one progress note records that the patient has no known allergies while also noting that the patient reports that he has an allergy to material in knee braces. The physical exam reveals no evidence of significant leg edema, and the documentation does not identify any material to which the patient reports an allergy. In addition, the patient's stature does not establish medical necessity for a custom brace, as a prefabricated brace with extensions for tall patients and extra-large straps for obese patients on a prefabricated brace are alternative options. The documentation also does not reveal objective evidence of an inability to ambulate with an appropriately fitted prefabricated knee orthosis. Under these circumstances, the requested custom right knee orthosis is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested orthosis 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 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 patients parent has requested reimbursement and prospective authorization and coverage for services provided at a specific facility. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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 CALOCUS criteria, this patient has significant potential for risk of harm (score 4) given his history of violence toward his parents, therapist and coach as well as possession of a gun. He has demonstrated moderate functional impairment (score 3) and continues to refuse to take medications to improve his symptoms. The patient has significant comorbidities (score 3) that interfere with his ability to make demonstrable progress in treatment including abuse of cannabis. The patient is likely bipolar due to his poor impulse control, irritable mood, insomnia, agitation, and violent behavior. The patients recovery environment is moderately stressful (score 3) given the patients history of violence toward his family members and possession of a gun without his parents knowledge. The patient has a role expectation that exceeds the patients capacity given his age and developmental level. The patients recovery environment is supportive (score 2) as his father is a physician who is invested in the patients welfare. The patient has demonstrated poor response to prior treatment and recovery management (score 4) without remission or control of symptoms. The physician reviewer found that provider reports the patient is making slow progress and requires long-term placement to continue to make progress. The patient has been adversarial in treatment (score 4). The records document that the patient has been actively hostile with his providers. His parents have been willing to accept and participate in the patients treatment plan (score 2) and have engaged in therapy via videoconferencing. This gives the patient a composite score of 25, which is consistent with medically monitored residence based services, such as residential treatment center (RTC). Based on the patients risk of harm, he qualifies for medically monitored residence based services, both on CALOCUS mandatory and composite scoring criteria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the pelvis.Endometriosis is an inflammatory disease in which endometrial-like tissue forms lesions outside the uterus. Its primary manifestations include dyspareunia, dysmenorrhea, chronic pelvic pain, and infertility. In general, hormonal therapies do not eliminate endometriosis. The diagnosis is made clinically in most patients. Often, pelvic examination findings correlate with laparoscopic diagnosis, however many patients diagnosed with endometriosis have normal pelvic exam findings. Ultrasonography is indicated in all patients, but MRI is said to be indicated for those patients in whom ectopic endometrial tissue was not clearly detected (Collinet, P., et al). Mendez Fernandez and colleague have stated that MRI, with careful examination technique and interpretation, enables more accurate and complete diagnosis and staging than ultrasonography, especially in cases of deep pelvic endometriosis. Moore and colleagues have noted that chronic pelvic pain is a multispecialty complaint that is difficult to treat. The physician reviewer found that  conducted a retrospective study of pelvic MRI and concluded with a recommendation of pelvic MRI in the evaluation of patients with refractory pelvic pain.In this case, the patient has chronic pelvic pain that persists following two surgical procedures and a recent celiac plexus block. The patient has had multiple negative imaging studies that include ultrasound and CT imaging. Under these circumstances, MRI of the pelvis is a reasonable next step that is supported by medical literature. Therefore, MRI of the pelvis is medically necessary to treat the 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
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for occupational therapy services with providers certified in sensory integration therapy. To determine the medical necessity of ABA, research by Papatola and Lustig provides guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are: (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on this definition, the requested services are not medically necessary in order to treat the patients autism and associated conditions. Specifically, the patient does not meet section (c), as sensory integration therapy is not supported in the medical literature as an effective modality for the treatment of autism. In addition, it is unclear whether young patients who present with sensory-based problems have an actual distinct disorder of the sensory pathways of the brain or whether these deficits are simply characteristics associated with other developmental and behavioral disorders (Zimmer, et al.). A systematic review of studies employing sensory integration therapy for children with autism found limited evidence to support its effectiveness. Out of 25 reviewed studies, only three yielded positive results (Lang, et al.). Research indicates that when compared to behavioral methods, sensory integration therapies for children with developmental disorders do not exceed those gains made using behavioral methods alone. The physician reviewer found that these findings are consistent with the National Standards Project (NSP), which is currently the largest examination of research supporting interventions that target the core characteristics of autism in young patients on the autism spectrum. The NSP considers sensory integration therapy to be an unestablished intervention for the treatment of autism, meaning there is a lack of evidence in the scientific literature that allows firm conclusions about its effectiveness in patients with autism. Overall, the research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Given these findings, the requested occupational therapy services with providers certified in sensory integration therapy are 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Nicotinamide adenine dinucleotide (NAD) intravenous (IV) therapy. Researchers noted that fluoroquinolones are generally safe and well tolerated; however, rare but serious adverse events have been reported. The authors discussed the problem of persistent multisystem adverse effects as a possible complication. However, the authors did not provide any recommendations for treatment of quinolone toxicity. NAD IV therapy is not an effective treatment for quinolone toxicity. In this case, the records do not support the proposed diagnosis of quinolone toxicity as the underlying etiology of the patients multi-organ symptoms. The patients symptoms include a blotchy rash, intermittent left arm numbness and poor circulation in the left upper extremity. The records do not include a thorough work-up including physical examination and laboratory testing to assess for other potential causes for the patients symptoms. The current data does not support a role for NAD IV therapy in this clinical setting. Therefore, the requested NAD IV therapy is 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 medication is 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 family practice 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: The patient has requested reimbursement for facial feminization services. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help remedy an incongruent physical appearance and gender identity. In addition, WPATH noted that non-genital surgical procedures, especially facial feminization procedures, are of greater practical significance in a patients daily life than reconstruction of the genitals. The guidelines further report that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Studies demonstrated that facial feminization surgery, like genital surgery, improved patients mental health-related quality of life. The records provided for review include documentation from several providers who support the patients facial feminization surgeries as medically necessary to help alleviate her significant discomfort due to the masculine features of her face. Given these findings, the facial feminization 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 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.