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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with articular gout. Laboratory results revealed a uric acid level of 9.5 mg/dl. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted the patient has tried and failed treatment with allopurinol, indomethacin, and colchicine. The patient has requested authorization and coverage for brand name Uloric. 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 brand name Uloric is medically necessary for the treatment of the patients medical condition. Researchers reported, Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine are appropriate first line options for treatment of acute gout, and certain combinations can be employed for severe or refractory attacks. Per the authors, Low dose NSAID therapy is an appropriate choice for first-line gout attack prophylaxis, unless there is lack of tolerance or medical contraindication. Authors reported, Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option. Steroids are among the most effective anti-inflammatory medications available and have been shown to be as effective as NSAIDs for managing gout, with fewer adverse effects. In this case, there was no documentation of the presence of acute or even chronic gouty arthritis on examination or radiographs despite the patients history of increased uric acid. There was also no documentation that the patient has failed to respond to a full dose of allopurinol. Finally, the patient has not tried and failed generic Uloric, and there is no history of intolerance or contraindication to generic Uloric. The patient does not appear to have renal insufficiency. The medical evidence does not support the requested medication in this clinical setting. Therefore, brand name Uloric is not medically necessary for the 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 internal medicine with sub-specialty certification 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for intense pulse light (IPL) treatment. This is a patient with dry eye syndrome (DES), bilateral blepharitis (eyelid inflammation), keratoconjunctivitis sicca (dryness of the membrane that lines the eyelids and covers the white of the eye, and the clear layer in front of the iris and pupil) and meibornian gland dysfunction (MGD or lack of adequate oil secretion in tears). The provider reported that the patients visual acuity is 20/30 in the right eye and 20/20 in the left eye. The patient experiences a little DES improvement with topical cyclosporine (Restasis) eye drops, preservative-free artificial tears (PFATs), fluorometholone (FML) steroid eye drops, and nightly eye ointment. The current treatment plan is to continue the PTATs, eye ointment, to increase Restasis drops to three times a day, and to continue FML drops four times a day for two weeks. The provider requested intense pulse light (IPL) treatment. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to support IPL therapy as likely to be more beneficial than any other standard treatment (PFATs, eye drops, and ointments) for this patients eye conditions. According to the Preferred Practice Patterns of the American Academy of Ophthalmology 2018, there are several in-office procedural treatments available that may unclog the meibomian gland such as IPL therapy or mechanical means such as gland probing or microblepharoexfoliation (a micro-sponge to physically scrub the edge of the eyelids and eyelashes). Although there have been industry-sponsored studies, independent, randomized, masked clinical trials have yet to be performed to assess efficacy of these treatments. IPL therapy/treatment has not received final approval from the appropriate regulatory bodies for the patient's diagnoses of dry eye syndrome, blepharitis, keratoconjunctivitis, or MGD. Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in ophthalmology        and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services. Per the American Society for Reproductive Medicine (ASRM), patients preparing to undergo gonadotoxic medical therapy, radiation therapy, or gonadectomy should be provided with prompt counseling regarding available options for fertility preservation for iatrogenic infertility. Currently, embryo, oocyte, and ejaculated or testicular sperm cryopreservation remain the principal established modalities for fertility preservation. The ASRM specifically mentions that in the setting of emergent fertility preservation, initiation of the stimulation should start as soon as possible regardless of phase of menstrual cycle (so-called immediate or random-start COS). This patients records document that this was the approach followed by the treating provider. There was a high probability that the planned cancer treatment would adversely affect the patients fertility potential. Thus, it was the best option for maximizing the patients chances of achieving an ongoing pregnancy. All told, the fertility preservation services provided 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 obstetrics and gynecology with subspecialty certification in reproductive 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: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for acupuncture services. The records provided for review indicates that this patient is status post shoulder surgery with subsequent frozen shoulder. The patient reports severe pain and a limited range of motion, which has delayed his ability to progress in physical therapy. The patient underwent treatment with acupuncture before and after surgery with gains described as significant pain relief and improved range of motion. Current medical literature supports a role for acupuncture in this clinical setting. Medical literature notes that acupuncture is an effective long-term treatment for patients with shoulder pain (from soft tissues lesions). Based on the peer-reviewed medical literature and this patients prior response to care, the acupuncture treatment and five additional acupuncture treatment sessions were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in oriental 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 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 does not meet 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. Given the findings, the RTC level of care services 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Humatrope Cartridge 12 mg.This patient has an estimated predicted adult height of 53, based on the most recent bone age. This is more than two standard deviations below his mid-parental target height of 58. Without treatment, this patient is unlikely to reach his genetic potential. He failed growth hormone stimulation testing with a peak of less than 10 ng/mL with two provocative tests. This is supportive of growth hormone deficiency, in combination with the poor prediction from the bone age. This patient has open epiphyses and there is still time for him to benefit from growth hormone treatment. The records document obesity and the patient is in early puberty, which explains why his bone age is slightly advanced. The advanced bone age suggests that he will probably not have enough time for catch-up growth in the next few years. There is sufficient support for the requested medication in this clinical setting. Therefore, Humatrope Cartridge 12 mg is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for breast surgery. Authors state that the characteristics of tuberous breast deformity include a contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with a constricted breast base, and nipple areola complex herniation with a normal breast base. Researchers noted that the surgical options include one- or two-stage procedures, which lead to a high degree of patient satisfaction and low complication rates. Tuberous breast deformity and breast asymmetry do not cause problems with lactation or represent functional disabilities. Thus, correction of tuberous breast deformity and correction of breast asymmetry are not medically necessary. 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. Tuberous breast deformity and breast asymmetry are not present at birth and consequently do not represent congenital breast deformities (Cruz). Although tuberous breast deformity is not considered a congenital breast deformity, it represents a developmental abnormality. In this patients case, there is no reported functional deficit. The breast asymmetry is within the wide range of normal and does not represent an abnormal appearance. However, the patients bilateral tuberous breast deformity is consistent with a significantly abnormal appearance in the photographs provided for review. The requested procedure will help to create a normal appearance to the extent possible and provide more than a minimal improvement in the appearance of the patient. Given this support, the requested breast surgery 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 excess skin removal (15832 RT and LT; excision of excessive skin and subcutaneous tissue of the thigh). Based on review of the records and photographs provided for review, the requested services do not meet the criteria for medical necessity. The patient is still obese by BMI criteria. The patient complains of functional issues, but there is a lack of documentation of functional limitations from the provider. Moreover, the records do not report that the patient has failed adequate treatment of her rashes with creams, including antibacterial or antifungal therapies. The American Society of Plastic Surgeons (ASPS) states that medial thigh lift is a procedure that treats the excessive skin and fat of the medial thigh and may include liposuction. The ASPS noted that severe excessive skin in the medial thigh region is required to be considered a functional abnormality. Thus, the requested excess skin removal (15832 RT and LT; excision of excessive skin and subcutaneous tissue of the thigh) is not 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. This patients condition does not constitute an abnormal structure of the body. There is a lack of documentation to support the presence of functional disability. In addition, the records do not describe failure of conservative therapy to address a functional disability. Moreover, the requested surgery would not provide more than a minimal improvement in the appearance of the patient. All told, the requested excess skin removal (15832 RT and LT; excision of excessive skin and subcutaneous tissue of the thigh) is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for heavy metal blood testing (including mercury and aluminum). In a recent publication representing a consensus of the Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics, American Academy of Pediatrics, Hyman and colleagues noted that, shared decision making calls for collaboration with families in evaluation and choice of interventions. However, the authors found there is a lack of evidence for routine testing of hair, blood, or urine for environmental toxins or heavy metals outside of laboratory screening for lead exposure. This patient has been diagnosed with autism spectrum disorder. Consistent with the recommendations in the medical literature, lead testing is indicated, while there is a lack of support for including testing for other heavy metals. All told, the requested heavy metal blood testing (including mercury and aluminum) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested heavy metal blood testing (including mercury and aluminum) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. 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. Applying the LOCUS guidelines, the patient met the criteria for RTC services. The patient was at serious risk of harm (score 4) due to a recent pattern of excessive substance use resulting in loss of self-control and harmful behaviors. The patient has been unable to abstain from substance use as demonstrated by his behaviors, and his friends decision to express their concerns to his parents. The patient exhibited serious functional impairment (score 4) given his inability to engage in school, work or other obligations. The patient has significant comorbidity (score 3) considering the interaction between his depression and anxiety with substance use disorders. The patients recovery environment was moderately stressful (score 3) due to family discord and easy access to substances. The patients recovery environment was supportive (score 2) given her parents active participation in the patients treatment. The patient has demonstrated poor response to treatment (score 4). The records document that the patient failed to progress and reported continued symptoms despite intensive and repeated exposure to treatment. The patient was incompletely engaged in treatment (score 3) due to his resistance to participate in treatment and his pessimism about recovery. This gives the patient a composite score of 23, which is consistent with medically monitored residential services. Furthermore, the patient qualified for level 5C moderate intensity long-term RTC, due to minimal past response to treatment and uncontrolled substance use, which had a destabilizing effect on the patients anxiety and depression. Per LOCUS, for level 5C programs, the length of stay will vary from two months to a year. In this case, the recommended length of stay in the RTC was 90 days, which was the length of patients participation in the program. Given these findings, the psychiatric 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 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.