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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric intensive outpatient program (IOP) services (24 sessions). The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The composite score is then used to determine the level of care needed. Applying the LOCUS guidelines, this patient met the criteria for IOP level of care services. The patient was at moderate risk of harm (score 3) due to chronic suicidal ideation and a recent suicide attempt two days prior to IOP admission. The patient demonstrated moderate functional impairment (score 3) given his inability to perform activities of daily living, difficulty sleeping, and inability to maintain intake. The patient has no significant comorbidities (score 1) per the records. The patients recovery environment was moderately stressful (score 3) as he was recently divorced and lives in the same home as his ex-wife. The patient identified that the holidays are major trigger for him. The patients recovery environment provided limited support (score 2) due to his social isolation and strained relationship with his ex-wife. The patient has exhibited poor response to prior treatment (score 4) as he failed prior IOP one month prior to readmission, as well as outpatient treatment, which recently consisted of daily services. The patient was constructive in treatment (score 2). The provider noted that the patient was adherent with his care and compliant with his medications. This gives the patient a composite score of 18, which is consistent with high intensity community based services, such as IOP. Given this support, the psychiatric IOP level of care services (24 sessions) 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for implantable ambulatory event monitors (HCPCS C1764) and mobile cardiac telemetry (CPT 93285). Based on the records provided for review, this patient presented with symptomatic atrial fibrillation, a patent foramen ovale, and an embolic renal artery thrombosis. In this circumstance, the guidelines recommend treatment with chronic anticoagulation, even without evidence of recurrent atrial fibrillation. This patient underwent cardiac monitoring, which might have yielded additional information about the patients condition. However, current medical guidelines do not support use of continuous real-time monitoring by telemetry services or implanting loop recorders when extended off-line external monitoring is sufficient. The documentation does not demonstrate that this patient has tried these devices and that these devices have failed or were not tolerated. Implanted loop recorders or recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services have not been shown to improve health outcome compared to standard monitoring techniques in this clinical setting. For these reasons, the implantable ambulatory event monitors (HCPCS C1764) and mobile cardiac telemetry (CPT 93285) were not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty certification in cardiovascular 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: An enrollee has requested reimbursement for rhinoplasty and lip lift services.In this case, documents indicate that the patient has a diagnosis of gender dysphoria. Preoperative progress notes reflect that rhinoplasty and lip lift services were performed as gender affirming facial surgery to improve the patients feminine appearance. Rhinoplasty and lip lift services addressed the masculine impression of the patients facial features in relation to one another, and permitted the harmonization of these features with regard to other modified structures. Under these circumstances, the rhinoplasty and lip lift 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 to treat 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: An enrollee has requested reimbursement for kidney ablation with radiofrequency (CPT 50592 and 76940). The goal of care for patients with metastatic triple negative breast cancer is palliation of disease-related complications, improvement in disease control interval, maintenance of quality of life, and improved overall survival. Although systemic therapy for metastatic triple negative breast cancer is one treatment option, it is associated with significant toxicity risk and poor disease control, decreased quality of life, and uncertain benefit in terms of overall survival. Current guidelines for treatment of oligometastatic breast cancer support the option of surgery, radiotherapy, or regional chemotherapy. This patient previously benefited from prior oligometastatic resection, with resection of a right lower lung mass. Recently, she underwent radiofrequency ablation of a kidney lesion, which is consistent with the current recommendations in the peer-reviewed medical literature. Tumor ablative therapy for this patient was likely to result in a high likelihood of complete tumor response, low toxicity, maintenance of quality of life, and possible of improved disease control interval and long-term survival, compared to the alternative standard of care of systemic therapy. All told, the kidney ablation with radiofrequency (CPT 50592 and 76940) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the kidney ablation with radiofrequency (CPT 50592 and 76940) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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 patient has requested authorization and coverage for Plaquenil 200 mg two tablets once daily. Based on the records provided for review, this patient does not meet the current American College of Rheumatology (ACR) criteria for systemic lupus erythematosus (SLE). There is limited documentation to include positive anti-nuclear antibodies (ANA), photosensitivity, and arthralgias. However, there is a lack of evidence of neurological symptoms and hematologic issues, or malar or discoid rash. Plaquenil has been associated with potential side effects with long-term use such as retinopathy and peripheral neuropathy. Moreover, the records do not include documentation that the patient underwent testing for glucose-6-phosphate dehydrogenase (G6PD), which is required for all patients prior to receiving Plaquenil. All told, the requested Plaquenil 200 mg two tablets once daily is 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 rheumatology 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 reimbursement and authorization and coverage for continued Skilled Nursing Facility (SNF) services.In this case, the patient sustained bilateral hip/femur fractures at the subtrochanteric level, for which she underwent surgical repair. The patient had been improving with therapies, and she was mobilizing household distances with a walker at the contact guard assist level. Records reflect that the patient had otherwise plateaued with respect to her self-care skills, at the moderate assist level for lower body self-care. She did not have any ongoing skilled nursing or medical needs requiring ongoing Skilled Nursing Facility (SNF) level of care. Accordingly, Skilled Nursing Facility (SNF) services provided during the period under review were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement and authorization and coverage for continued Skilled Nursing Facility (SNF) services with rehabilitation services, physical therapy, occupational therapy, and speech therapy. The patient had a baseline functional status that was compromised by multiple illnesses. The patient was using a walker for mobility, and she then had a very protracted hospitalization that followed an acute respiratory failure event that required intubation and prolonged mechanical ventilation. The patient developed generalized debility and contractures in her distal lower extremities, and she underwent rehabilitation on an inpatient basis for a prolonged period of time, but made minimal functional progress. Throughout rehabilitation, the patient remained nonambulatory, and she had significant impairments in cognition, safety awareness, and carryover that limited her progress. There were otherwise no skilled nursing or medical needs requiring ongoing inpatient care, and the patients care could be provided in a less intensive rehabilitative setting. Accordingly, continued Skilled Nursing Facility services with rehabilitation services, physical therapy, occupational therapy and speech therapy were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for hydrocodone-acetaminophen (Norco) 10-325 mg oral tablets (until surgery). The Federation of State Medical Boards guidelines state that the use of opioid therapy depends on a providers evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has chronic low back pain with lumbar radiculopathy status post two previous spine surgeries. He was scheduled for a lumbar fusion procedure, which was postponed due to COVID-19 restrictions. Treatment has included a multimodal strategy of medication management. He underwent an epidural steroid injection, which reportedly provided four hours of pain relief. His provider has recommended physical therapy and treatment with pain management. The patient is noted to have a prior diagnosis of opioid use disorder and cannabis dependence, with a recent positive toxicology report for THC. The current national guidelines do not support treatment with Norco in this patients case, as the benefits of opioid therapy do not outweigh the risks of self-prescribing behavior given his previous history of chemical dependence. All told, the requested hydrocodone-acetaminophen (Norco) 10-325 mg oral 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 anesthesiology with subspecialty certification in pain management 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

An enrollee has requested authorization and coverage for Crysvita injections and laboratory monitoring of serum phosphorus and Vitamin D levels every three (3) months. In this case, the patient has a diagnosis of familial X-linked hypophosphatemic Vitamin D refractory rickets and a medical history of impingement syndrome of the left shoulder and left carpal tunnel syndrome due to this condition. The patient has also been treated with Crysvita and reported decreased leg pain while taking this medication. Given the risk presented of elevated phosphate levels and Vitamin D levels for patients treated with Crysvita, careful monitoring of Vitamin D and phosphorus level is therefore medically necessary for patients taking Crysvita. Accordingly, the requested laboratory monitoring of serum phosphorus and Vitamin D levels every three (3) months is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication and requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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 hydroxychloroquine 200 mg twice daily. The records provided for review document that this patients rheumatoid arthritis is stable with no current evidence of synovitis. Due to the potential side effects with long-term use such as retinopathy and peripheral neuropathy, it is reasonable to taper the patients hydroxychloroquine dose while her condition is stable. The records do not include documentation that the patient underwent testing for glucose-6-phosphate dehydrogenase (G6PD), which is required for all patients prior to receiving hydroxychloroquine. In patients with low G6PD levels, hydroxychloroquine has been associated with hemolysis. In addition, hydroxychloroquine is a long-acting agent and there is a low chance of a disease flare with a mild taper. The lower dose is safer over time, especially in this patient who is also taking Enbrel and methotrexate. Given these findings, the requested hydroxychloroquine 200 mg twice daily is 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 rheumatology 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 residential treatment center (RTC) services. 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) developmental, medical, substance use 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. This gives the patient a composite score which is consistent with medically monitored community based services. However, due to the patients scores on risk of harm, the recommended level of care is Level 5 medically monitored residence based services. Thus, the RTC services provided were medically necessary for this patient. Given these findings, the RTC services provided, and 90 days of psychiatric RTC services, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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

An enrollee has requested authorization and coverage for Botox injections at a dosage of 600 units every 12 weeks. Cervical dystonia (CD) is a movement disorder that is clinically characterized by involuntary contractions of cervical muscles which cause abnormal head movements and postures. The Highlights of Prescribing Information for Botox recommend a total dose not to exceed 360 units administered every 1216 weeks, or at longer intervals, with dosing tailored to the individual patient based on head and neck position, localization of pain, muscle hypertrophy, patient response, and adverse effects history. This recommendation is based primarily on the protocol of a pivotal, randomized, double-blind, placebo-controlled phase 3 clinical trial. In this case, the patient has cervical dystonia with torticollis and laterocollis. She has been treated with Botox injections, and her provider has requested further treatment with an increase of dose up to 600 units. However, the medical literature does not support a dosage of greater than 360 units. Accordingly, the requested Botox injections at 600 units every 12 weeks are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested dosage of medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology 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.