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

Nature of Statutory Criteria/Case Summary: The patients representative has requested reimbursement and prospective authorization and coverage for inpatient psychiatric treatment. 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. These scores give the patient a composite score of 24, which is consistent with medically managed residence based services, such as inpatient psychiatric treatment. One study showed that in psychotic disorders, violence was associated with paranoid ideation. Medical literature states this patient has the following risk factors: previous and current violence, previous and current threats, previous and current mental illness, lack of insight into illness and behavior, expresses suspicion and a lack of empathy. Given the patients ongoing symptoms and high risk of violence due to his mental illness, inpatient psychiatric treatment was and is 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly individual therapy visits and monthly psychiatric visits. The medical records indicate that the patient has been receiving therapy on outpatient basis at an interval of every two weeks for the past six to seven months. Clinical recommendations from the patients provider include continuation of therapy every two weeks. The intervals of psychotherapy are defined by patient symptom presentation and progress in treatment. The progress notes reflect that the patient is progressing in treatment. In addition, the patient has not been demonstrating severe symptoms such as suicidal or homicidal ideation, psychosis, or aggressive behavior. Therefore, weekly individual therapy visits are not supported by the clinical information provided for review. Further, the patient appears stable on her current medication regimen. The most recent progress notes indicate the patient could follow-up with her psychiatrist every four to six weeks. Thus, the requested monthly psychiatric visits are not medically necessary for treatment of this patient. All told, the requested weekly individual therapy visits and monthly psychiatric visits 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 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 enrollees parent is requesting reimbursement and authorization and coverage for psychiatric intensive outpatient program (IOP) services. The enrollees admission diagnoses were disruptive mood dysregulation disorder, unspecified anxiety disorder, cannabis use disorder, severe; and to rule out attention deficit, hyperactivity disorder; predominately inattentive presentation.  Previous treatment includes individual therapy, residential therapy, and medication management. His treatment plan on admission focused on stabilizing his mood by decreasing depressive symptoms from several times daily to a few times weekly. Other objectives included abstinence from drinking alcohol and using other substances, as well as cutting or other self-harm behaviors; decreasing severe anxiety symptoms from several times daily to a few times weekly. The enrollees treating physician believes he should show a 60-70% reduction in the frequency of unstable mood, explosive episodes, and highly irritable mood.  He currently exhibits difficulty with these symptoms about 80-90% of the time. The enrollee exhibits significant difficulty modulating unstable mood, anxiety, and impulsivity problems.  He struggles with destructive and impulsive behaviors. The enrollee continues to struggle using constructive ways of communicating his frustration with others, low frustration tolerance, drug-seeking behaviors and overall poor judgment. CALOCUS scores were utilized in this case to assess appropriate level of care. For risk of harm, the enrollees score is 3, due to substance use. For functional status, the enrollees score is 4, as he had been asked to leave school, and had been truant. For comorbidity, the enrollees score is 3, due to disruptive mood disorder, anxiety, cannabis use, and rule-out attention deficit hyperactivity disorder (ADHD). For recovery environment level of stress, the enrollees score is 4, due to substance use and conflicts with his father. The physician reviewer found that  recovery environment level of support, the enrollees score is 3, due his parents being inconsistent with consequences. For treatment and recovery history, the enrollees score is 4, due to due to multiple previous failed attempts of treatment. For engagement and recovery status, the enrollees score is 4, due to the childs difficulty committing to treatment; such as vaping while he was in the program. The enrollees composite CALOCUS score is 25, which correlates with Intensive Outpatient Program. The enrollee was being considered for residential treatment, so stepping down to a lower level of care would not be appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor (CGM). CGM is a tool to visualize the important role that diet, exercise, stress management, and the appropriate selection of diabetes medications can have in managing type 2 diabetes. Several diabetes organizations have reviewed the literature on the appropriate use of CGM in diabetes management and concluded that CGM may be a useful educational and management tool. Most summaries of CGM studies found that having a standardized glucose pattern report, such as the ambulatory glucose profile report, helps facilitate effective shared decision-making. According to the most recent American Diabetes Association (ADA) guidelines, the chronic care model includes the following elements to optimize the care of patients with chronic disease: delivery system design (moving from a reactive to a proactive care delivery system); self-management support; and decision support. In this case, the CGM system will be a beneficial tool for the patient to optimize his lifestyle and therapy. Moreover, the device meets the elements of the ADA chronic care model for optimization of therapy. Even though this patient has diabetes type 2, his diabetes control has been suboptimal despite treatment with three non-insulin medications. He is motivated to control his diabetes with feedback from the CGM. Given these findings, a CGM is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 internal medicine with subspecialty certification in diabetes, endocrinology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eNeuras single pulse transcranial magnetic stimulation (TMS) mini device. TMS is U.S. Food and Drug Administration (FDA) approved, and supported in the medical literature as a safe and effective, for the treatment for migraines. In addition, the eNeura single pulse magnetic stimulation has obtained FDA clearance for the treatment of migraine, both abortive and preventive. Medical literature found a mean reduction in headache days from baseline and decreased acute medication use with use of the eNeura sTMS device. This patient has failed numerous prior therapeutic agents. Treatment with the eNeura sTMS device has provided her with decreased headache frequency and improved quality of life. She has a history of POTS and fibromyalgia, and her provider noted that the patient is sensitive to medications. One study found that most neuromodulation techniques are better tolerated as compared to the majority of pharmacological approaches. This patient has responded well to the eNeura sTMS device after failing multiple medications. Given these findings, the eNeuras single pulse TMS mini device is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DDAVP desmopressin acetate injections. There is sufficient support for the requested medication in this clinical setting. Central diabetes insipidus is a common sequela of cranial surgery and radiation therapy. DDAVP is a cornerstone of therapy. Per the submitted documentation, this patient has not benefitted from the oral form of this medication. He has been well-maintained on the injectable form of this medication. In this patients case, the records support the use of the injectable form of this medication, as it has been demonstrated to be effective. Therefore, DDAVP desmopressin acetate injections are 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 internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient skilled nursing facility (SNF) services, to include physical therapy, occupational therapy, and speech therapy. Based on the available documentation, this patient does not require inpatient SNF services to improve function. She does not require any skilled nursing or rehabilitation services on a daily basis. She does not require skilled therapy to prevent deterioration with mobility or activities of daily living or to establish a safe and effective maintenance program. Although further therapy is indicated, the patient has been medically stable, and can receive further services at a lower level of care. For these reasons, inpatient SNF services, to include physical therapy, occupational therapy, and speech therapy is 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 board certified in internal medicine with expertise in skilled nursing facilities 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 wound debridement, wound VAC, and flap technique to close the wound. The enrollee has also requested authorization and coverage for inpatient hospitalization services until the enrollees wound is stabilized medically.The submitted documentation does not support that the requested services are medically necessary. Researchers state that a fundamental way in which nurses and care staff may contribute to maximizing the healing potential of existing pressure ulcers is by repositioning those patients who are unable to reposition themselves. They state that international best practice advocates the use of repositioning as an integral component of a pressure ulcer prevention and management strategy. Research states that one should consider autolytic debridement with appropriate dressings for dead tissue and consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful.In this case, the patient has multiple medical conditions as well as a stable sacral wound. Elective surgery to surgically debride, excise, and close a stable sacral decubitus is not indicated. Wound debridement, wound VAC, and flap technique to close the patients wound is not medically necessary to treat the enrollees condition and would be contraindicated. The sacral decubitus is not a significant medical problem in view of the patients medical condition. It is stable and not infected.  It does not require inpatient hospitalization for treatment, and inpatient hospitalization services until the patients wound is stabilized medically is not necessary to treat the patients condition. Therefore, wound debridement, wound VAC, and flap technique to close the wound are not medically necessary to treat the patients medical condition, and inpatient hospitalization services until the patients wound and infection are stabilized 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee replacement and right knee replacement. In their multicenter longitudinal cohort study, Riddle and colleagues concluded that the risk-to-benefit ratio for total knee arthroplasty (TKA) is best for patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility, and a BMI less than 40. The authors found that surgical outcomes are less favorable for patients who have mild or moderate symptoms. Medical literature shows a national cohort sample study of 2,040 hip and 2,964 knee replacements evaluating pain and function according to BMI status. Within this sample, 14% of hip and 25% of knee patients were severely or morbidly obese. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity is not a deterrent to undergoing total joint replacement to relieve symptoms. Another group reported similar findings. This patient presents with progressive worsening bilateral knee pain. The records document that the patients pain is severe and interfering with his ability to perform activities of daily living. Clinical examination findings are consistent with radiographic evidence of severe bilateral knee osteoarthritis. The records include detailed evidence of long-term non-operative treatment without sustained improvement. His BMI is elevated at 41.87. There is documented weight loss since 2017. He meet the other evidence based medical criteria for TKA. Current medical literature supports proceeding with TKA in the setting of the patients current BMI. Therefore, the requested right knee replacement and left knee replacement are medically necessary for 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for targeted therapy and radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines support the use of radiation therapy to relieve biliary obstruction from a hepatocellular mass. A course of palliative radiation therapy may be beneficial for this patient if she is able to tolerate the treatment. The goal of palliative radiation therapy would be to shrink the mass and relieve the patients biliary obstruction. This is a common indication for radiation therapy. All told, the requested targeted therapy and radiation therapy are medically necessary for treatment of 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 radiation oncology 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 10 treatments of systemic hyperbaric oxygen therapy.The American Academy of Otolaryngology-Head and Neck Surgery has recently updated its guideline on sudden sensorineural hearing loss. Part of the guideline states that hyperbaric oxygen therapy (HBOT) is not commonly used as therapy for sudden sensorineural hearing loss (SSNHL) in the United States and is not currently FDA approved for this indication. The Guideline cannot recommend HBOT but reserves it as an option when combined with steroid therapy in SSNHL as primary therapy within two weeks of onset of symptoms and as salvage therapy when used within four weeks of onset. In this case, the patient experienced a recent change in her hearing, and an initial audiogram documented some mild to moderate hearing impairment in the left ear. The hearing loss was between 15 to 30 dB with retained discrimination at 88%. Treatment initiated with 60 mg of prednisone tapering was subsequently followed by two therapeutic intratympanic injections. The patients hearing loss did not improve over six weeks. For that reason, the patient requested 10 treatments of systemic hyperbaric oxygen therapy to try to improve the hearing. As noted above, the medical literature reflects uncertainty regarding the real benefit of hyperbaric oxygen therapy for sudden sensorineural hearing loss. Furthermore, the patient has received standard therapy and has passed the recommended timeline of any benefit possible with adjunctive hyperbaric oxygen therapy. Under these circumstances, 10 treatments of systemic hyperbaric oxygen therapy 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 otolaryngology 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.