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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction assisted protein lipectomy (SAPL) (CPT 28999 and 76499). The SAPL approach discussed by researchers is optimal to address the fluid portion of lymphedema swelling, which predominates during the early stages of the disease process. SAPL removes the otherwise permanent solid component of the swelling, usually found in chronic cases. In this case, the patients left leg does not reduce in size to match the right leg, even with maximum lymphedema therapy. Thus, her condition is likely due to solid, rather than fluid swelling. In this clinical setting, SAPL is indicated to provide significant volume reduction. Moreover, the patient has tried and failed a properly planned and administered lymphedema therapy regimen with manual lymphatic drainage, fitted compression garment use, and bandaging. She has significant disability from chronic lymphedema of her left leg. Physical examination reports chronic, non-compressible, solid predominant, stage 2 congenital lymphedema of her left leg. All told, the requested SAPL (CPT 28999 and 76499) is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The patients lymphedema is a congenital and developmental abnormality. The purpose of SAPL is both to improve function and to create a normal appearance, to the extent possible. Given these findings, the requested SAPL (CPT 28999 and 76499) is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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 patient has requested authorization and coverage for surgical consultation and/or bilateral breast implant removal with en bloc capsulectomy. Authors noted that, autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. Researchers also reported that, the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Overall, ASIA is not a confirmed disease entity. Moreover, ASIA is not associated with saline breast implants. This patient presents with bilateral breast pain. She has with subpectoral saline implants. A mammogram showed a small nodular density in the inferior left breast, and the provider recommended further examination. There is no report of any abnormal physical findings related to the breast implants. Further, there are no constitutional symptoms consistent with breast implant illness documented in the records provided for review. All told, the requested surgical consultation and bilateral breast implant removal with en bloc capsulectomy 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 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 patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) rehabilitation services including physical therapy. Based on the documentation provided for review and medical literature, this patient does not require SNF services with the specialized skill, knowledge and judgment of a skilled nurse to administer medical treatment. The records do not indicate that the patient has a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The patients current functional level does not require ongoing SNF level skilled therapy services. Although the patient is likely to benefit from physical therapy services, the patient does not require these services on a daily basis. All told, the SNF rehabilitation services including physical therapy 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: 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. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying the ASAM guideline, the patient is at risk for subacute withdrawal. The patients CIWA has been positive for moderate agitation, anxiety, paroxysmal sweating and tremors. The records document that the patient is in need of medically assisted treatment. Continued substance use poses a serious risk to the patients health. Substance use disinhibits the patients existing premorbid functioning and conditions such as anger, self-harming behaviors, and aggression. Moreover, the chart indicates a history of recurrent suicidal ideation and feelings of hopelessness. The patients mental status is sufficient to permit participation. However, he has been unable to control his substance use without 24-hour support especially given his premorbid impulsivity, social isolation and withdrawal. His significant functional deficits require 24-hour staff availability for intervention. The patient has exhibited limited insight into his substance use disorder and is currently developing coping skills. He continues to require 24-hour support given his limited social support and absent coping skills. The patient does not recognize his relapse triggers and lacks insight into the benefits of care. The patients fear is a trigger and results in anger. He also tends to act out in self-destructive ways, which requires 24-hour supports to redirect him from using. The patients recovery environment is too chaotic to support his sobriety. His significant other uses substances and his adopted parents appear to be largely unaccepting of his gender choice thereby perpetuating his tendency to self-isolate and use substances as a maladaptive coping strategy. Given these findings, the dual diagnosis RTC level of care 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 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 patients parent has requested authorization and coverage for one hour of family therapy once per week in-home, one hour of individual therapy once per week in-home, one hour of gender therapy twice per month in-home, and skills trainer services five days per week in-home. The patients current providers did not document symptom severity to support these additional wraparound services. Rather, the providers recommended case management, behavior support, group therapy, and a skills trainer three days per week. Given the information available regarding the patients symptoms, the requested services are not required to meet the essential health needs of the patient. Moreover, the requested in-home services would be for the convenience of the patient. In this case, telehealth services were recommended to enable the patient to participate in services from home. There is significant literature demonstrating the efficacy of telehealth service delivery for patients with depression. All told, one hour of family therapy once per week in-home, one hour of individual therapy once per week in-home, one hour of gender therapy twice per month in-home, and skills trainer services five days per week in-home 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 patient has requested authorization and coverage for excimer laser therapy (30 sessions). The patient has been diagnosed with vitiligo. The patient was noted to respond well to prior excimer laser therapy. Researchers noted that a 308nm excimer laser (EL) has been widely used to treat patients with localized vitiligo. EL treatment would not increase the risks of premalignant skin lesions and skin cancers in patients with vitiligo. Based on our results, EL is likely to be a safe treatment option for patients with localized vitiligo. In this case, the patient was noted to respond well to prior excimer laser therapy. The medical evidence supports the requested services in this clinical setting. Therefore, excimer laser therapy (30 sessions) is medically necessary for the 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 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: Upheld Decision of Health Plan

The patient has requested reimbursement for Stelara injections administered by a nurse at a doctors office. The records provided for review document that the initial Stelara injections administered by a nurse at a doctors office was indicated because the patient had active disease and was not able to self-inject due to dexterity issues. The provider noted that the patient had enough clinical improvement to support continuation of Stelara, which suggests that the patient should have been able to self-inject at home. A history of noncompliance with therapy does not support treatment in the providers office in lieu of self-injecting. Medically necessary treatment should be consistent with the patients diagnosis and symptoms at the time of therapy, not due to convenience of the patient or the provider. Moreover, the Health Plans formulary includes other U.S. Food and Drug Administration (FDA) approved medications for the treatment of psoriatic arthritis including Enbrel, Humira, Remicade and Cosentyx. If the patient did not receive adequate improvement in hand synovitis to self-administer Stelara, these alternative therapies would have been appropriate. All told, the Stelara injections administered by a nurse at a doctors office 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollees parent has requested authorization and coverage for spinal surgery for placement of the vertebral body tethering (VBT). There are multiple studies showing the safety and benefit of VBT, with the potential to avoid fusion. The records provided for review document that this patients imaging demonstrated an apex right thoracic curve of 40 degrees and an apex of the left lumbar curve of 20 degrees after doffing the brace. Based on the current medical literature, the requested spinal surgery for placement of the VBT system is 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 services are 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 neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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 acupuncture services at least sixteen (16) times per year. The patient has been diagnosed with hyperlipidemia, polyosteoarthritis, essential hypertension, and unilateral inguinal hernia. The patient reported upper and lower extremity joint pain. Physical examination findings included tenderness to palpation of the knee joints, hand joints, and wrist joints. In this case, there was no documentation of pre- and post-acupuncture baselines for comparison purposes. After an unknown number of prior acupuncture sessions, there was no documentation of the total number of sessions completed and any specific, measurable, objective functional improvement to support the reasonableness and necessity of any additional acupuncture sessions. The medical evidence does not support the requested services in this clinical setting. Therefore, acupuncture services at least sixteen (16) times per year are not medically necessary for the 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 O.M.D., L.Ac. 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

An enrollee has requested reimbursement for the OncotypeDX-Prostate Cancer Assay. The OncotypeDX-Prostate Cancer Assay is a real time polymerase chain reaction assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score suggests a more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy in newly diagnosed low or low-intermediate prostate cancer. While OncotypeDX may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to support routine use. All told, the OncotypeDX-Prostate Cancer Assay was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were at issue were not likely to be more beneficial for evaluation 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 urology 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

An enrollee has requested authorization and coverage for tobramycin 20 mg/budesonide 0.6 mg.The submitted documentation does not support that the requested medication is medically necessary. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline on adult sinusitis lists intranasal saline and corticosteroids, but not intranasal antibiotics such as tobramycin, for symptomatic relief of chronic rhinosinusitis. A 2016 Cochrane systematic review did not identify any eligible randomized controlled trials comparing intranasal (topical) antibiotics with other therapies for the medical management of chronic rhinosinusitis. In this case, the patient has been diagnosed with chronic rhinosinusitis and has no documented evidence of nasal polyposis before or after endoscopic sinus surgery. There are no reported patient comorbidities, such as asthma or cystic fibrosis, that might warrant deviation from the AAO-HNSF clinical practice guideline, which does not include intranasal antibiotics such as tobramycin for symptomatic relief of chronic rhinosinusitis. Under these circumstances, tobramycin 20 mg/budesonide 0.6 mg is not medically necessary for treatment of the patients condition.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 otolaryngology-head and neck 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

An enrollee has requested reimbursement for right knee surgery.The patient had clinical exam findings that were consistent with imaging evidence of a complex medial meniscus tear and mild medial tibiofemoral compartment chondromalacia. The patient reported right knee pain with mechanical symptoms of locking and catching, and he was experiencing significant functional limitations in activities of daily living. X-rays in the pre-operative period documented well-maintained joint spaces in all three compartments. He reportedly failed conservative treatment, including activity modification, home exercise, and physical therapy. He underwent right knee surgery that included right knee arthroscopic partial medial and lateral meniscectomy, synovectomy of all 3 compartments, loose body removal and chondroplasty of all 3 compartments. Operative findings at the time of surgery documented a small lateral meniscus tear, grade chondromalacia changes in the undersurface of the patella, trochlear groove, lateral femoral condyle, medial tibial plateau, and lateral tibial plateau, grade changes in the medial femoral condyle, and loose bodies within the joint. Current evidence based medical literature supports surgical intervention for treatment of the patients right knee medical condition. The patients signs, symptoms and clinical exam findings were strongly correlated with imaging evidence of a complex medial meniscus tear. There was also no evidence of significant osteoarthritis in the right knee that would have precluded proceeding with repair of the meniscal tear. Records also indicate that there was a failure of reasonable conservative treatment. Under these circumstances, the right knee surgery at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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.