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

The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level criteria for Clinically Managed High-Intensity Residential Services. The patient was at risk for acute withdrawal, given his continuous long-term alcohol abuse. However, the patient did not require inpatient level of care, given the reported absence of a history of complicated withdrawal. The provider reported that the patient was at serious risk from continued substance use. The provider noted that the patient was at risk of harm to himself or others, given his known agitation and impulsivity. The records documented significant mood instability, which required frequent staff intervention and support. The patients mental status was sufficient to permit participation. The records demonstrated a consistent inability to control his impulses, which placed him at imminent risk of relapse and thus potential for harm to self and others. The patient demonstrated poor insight and limited motivation for change. A structured 24-hour program with therapy and milieu were integral to a long-term positive outcome. The patient was unable to control his substance use disorder without the structure provided by a 3.5 level facility. The patient showed an inability to recognize relapse triggers and lack of insight into his illness. Dimension 6 is met by the records, which state that the patients family and social system included others who participate in substance use. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for the medication Nutropin AQ Nuspin. The submitted documentation does not support that the requested medication is medically necessary at this time. Medical literature shows that FDA approved indications for growth hormone for pediatric patients include growth hormone deficiency, growth failure associated with chronic kidney disease, idiopathic short stature, and short stature associated with Turner syndrome. Researchers state that accurate measurement of height and weight using standardized techniques is a fundamental component of pediatric medical visits. They state that calculation of height velocity over time enables comparison with standardized growth charts to identify potential deviations from normal. In this case, however, there is insufficient evidence of poor growth in the medical records provided. The submitted documentation records only two heights for the patient, taken three months apart, and no records of a prior growth chart. This limited information does not permit a determination of whether the patient has poor growth velocity. Calculating growth velocity based on only two measurements that are taken three months apart is insufficient evidence for poor growth. Therefore, while the patient may be demonstrated to meet the criteria in the future, the submitted documentation is not sufficient at this time. Under these circumstances, Nutropin AQ Nuspin is not medically necessary to treat the patients medical condition at this time.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 pediatrics, with subspecialty certification in pediatric endocrinology, 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 patients parent has requested reimbursement for mental health services. Treatment in a group home or RTC facility would have been appropriate in this clinical setting. However, the patient participated in a wilderness therapy program that is accredited as an educational program, but not as an RTC. CALOCUS specifies the essential elements a program needs to provide adequate care at the RTC level. An RTC involves treatment in which the essential element is the maintenance of a milieu in which the therapeutic needs of the child or adolescent and family can be addressed intensively. Researchers reported that patients should be treated in the safest and least restrictive environment and needed services should be wrapped around to provide more intensive home or community-based services. When less restrictive resources are inadequate or inappropriate for the patients needs, an RTC may be indicated. The researchers noted that the mental health services should include a psychiatrist with training and experience consistent with the age and problems of the children and should be family-driven. The records do not demonstrate that the appropriate level of care was provided. Specifically, there is no mention of a psychiatrist or primary care provider being involved in the patients treatment. Further, the services provided were not family-driven. All told, the mental health services were not medically necessary for treatment of this patient. 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 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Soolantra cream. Rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. U.S. Food and Drug Administration (FDA) approved treatments include topical metronidazole and azelaic acid. Combination of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. The standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and anti-infection treatments. Since this patient has failed standard treatments, the next step to therapy should include the anti-Demodex cream Soolantra. Given these findings, the requested Soolantra cream is medically necessary for treatment of this patient. 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

The patients parent has requested authorization and coverage for tofacitinib (Xeljanz). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tofacitinib (Xeljanz) is medically necessary for treatment of the patients medical condition. Researchers reported that autoimmune-triggered non-scarring hair loss is a feature of alopecia areata (AA). Initially patchy and often self-limited, severe hair loss forms include the complete loss of scalp hair or alopecia totalis (AT) and complete loss of all hair or alopecia universalis (AU). Medical literature reported that Xeljanz (is an oral Janus kinase (JAK) 1/3 inhibitor that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe rheumatoid arthritis. Researchers also noted that after two months of treatment with tofacitinib, there was some improvement in psoriasis, with partial hair regrowth on the scalp and face. After three more months of treatment with tofacitinib, there was complete regrowth of the scalp hair, along with significant regrowth of the eyebrows, eyelashes, and facial hair. Researchers reported that systemically administered JAK inhibitors prevented the development of AA, while topical administration promoted hair regrowth and reversed established disease. In this case, the patient has been diagnosed with alopecia of the scalp, eyebrows, and eyelashes and has failed treatment with other medications. The medical evidence supports the requested medication in this clinical setting. Therefore, tofacitinib (Xeljanz) is medically necessary for the treatment of this patient. 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

The patients parent has requested authorization and coverage for 12 speech therapy sessions. The requested 12 sessions of speech therapy are medically necessary for treatment of this patients medical condition. The records document that the patient has both Rett syndrome and congenital cytomegalovirus infection. Congenital cytomegalovirus infection can cause hearing impairment and cognitive deficits. Researchers noted that patients with Rett syndrome oftentimes have severely impaired speech and language abilities. A survey of speech therapists providing care to children with Rett syndrome reported that communication skills were substantially improved with intervention. Augmentative and assistive communication devices may be required to enable children with Rett syndrome to communicate. These services require sessions with an experienced speech and language therapist. Given these findings, the requested 12 sessions of speech therapy are medically necessary for treatment of 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. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for a consultation with a plastic surgeon. Based on the available documentation, the request for a consultation by a plastic surgeon for an evaluation of this patients complaints is appropriate. The results of the evaluation and subsequent work-up by the provider would determine whether surgical intervention is warranted. The records document new complaints of breast pain and itchiness since her prior evaluation. The evaluation by a plastic surgeon is appropriate, as primary care physicians are not adequately trained in the evaluation of breast implants. All told, the requested consultation with a plastic surgeon is medically necessary for 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 82.3 hours per month of direct 1:1 applied behavioral analysis (ABA) services (Code 97153) and 1.17 hours per month of report writing (Code 90889). 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. While this patient meets the medical necessity criteria for the Health Plans authorized 47.7 hours of 1:1 ABA per month, she does not meet medical necessity criteria for the additional 82.3 hours per month based on subsection (d). As the increase in ABA is only for a short duration, this suggests that the level of medically provided ABA is not medically necessary. The Behavior Analyst Certification Board (BACB) reports that when determining treatment intensity, the time the client spends in activities such as school and other therapies should not be counted in or deducted from the recommended number of hours of ABA treatment. As the intensity is adjusted to account for school or other activities, it is not medically required at all times. Therefore, the requested 82.3 hours per month of direct 1:1 ABA services (Code 97153) and 1.17 hours per month of report writing (Code 90889) 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. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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 magnetic resonance imaging (MRI) of the lumbar spine and pelvis (procedure codes 72148 and 72195). The Health Plan denied the request and reported the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were medically necessary for the evaluation of the patients medical condition. The American College of Radiology appropriateness criteria indicates that MRI of the lumbar spine is usually not appropriate for acute, subacute, or chronic uncomplicated low back or radiculopathy without red flags or prior management. In this case, there was no documentation of any red flags, such as neurological compromise. There was no indication of how many physical therapy sessions the patient had or the results of those sessions. There was also no documentation of a repeat ultrasound of the left ovary indicating a need for an immediate pelvic MRI. The clinical presentation of left sciatica does not support the medical necessity of a pelvic MRI. Therefore, MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services 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 radiology 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 enrollee is requesting authorization and coverage for cyst removal. The enrollee has had a conjunctival cyst of the left eye for over a year. The enrollee complained of excessive watering, morning crust formation, burning and pain. She has tried hot compresses and artificial tears. The enrollee indicated the cyst has grown larger and requested an appointment with ophthalmology to have it removed. The medical literature indicates an epidermal inclusion cyst (EIC) is a dermal implantation cyst of epidermis. It can be congenital or acquired. The acquired form is usually in a site of prior trauma, which causes occlusion of the orifice of the hair follicle. Treatment options include excision and marsupialization, which involves a surgical technique of cutting a slit into an abscess or cyst and suturing the edges. The requested cyst removal is medically necessary to treat the enrollees medical condition as it is for symptomatic relief.  The cyst is causing visible irritation, discomfort and pain. The alleged abnormality is an abnormal structure of the body due to the disease, dry eye syndrome. It will not provide more than a minimal improvement in the enrollees appearance. However, the cyst removal will improve function, as it will decrease pain and inflammation. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition and is reconstructive in nature.Credentials/Qualifications: The physician reviewer is board certified in ophthalmology 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 patient has requested reimbursement and prospective authorization and coverage 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. The patients meets the criterion for dimension 1, as the records document mild to moderate withdrawal symptoms including pulse rate ranging from 81-120, paroxysmal sweating, bone and joint aches, and tremor. For dimension 2, the patient has ongoing tremor and remains at risk for overdose when not supervised. Dimension 3 is also met given the patients PTSD, depression and anxiety with suicidal ideation. The presence of these comorbid conditions place the patient at higher risk for continued substance abuse. For dimension 4, the patient has demonstrated mood swings, irritability, and recent heavy use. He requires a higher level of accountability and although he is somewhat willing, he is not yet fully able or ready. Dimension 5 is satisfied considering the patients reports of cravings to use, prior relapses, and compulsive behaviors. The provider noted that due to the patients ongoing psychiatric symptoms and ambivalence about utilizing the skills provided, he remains at high risk for relapse. For dimension 6, the patients social network is comprised of friends who use. Prior premature release to this recovery environment has led to recurrent relapse. The patient requires a safe and stable living environment in order to develop his recovery skills. Based on the records, the patient qualifies for ASAM Level III treatment, at least similar to what patient has been receiving at the current RTC facility. Given the severity of the patients illness, the 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 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 reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. The specialized skill, knowledge and judgment of a skilled professional nurse has not been required to safely and effectively provide this patient with medically necessary and reasonable treatment. The patient did not have complex wound care, a tracheostomy tube or other daily SNF level skilled nursing. Based on the patients functional status, the patient did not require services on an inpatient basis, in a SNF setting. All told, the SNF services provided were not and are not medically necessary for treatment of this patient. 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 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.