Persius/hicric huggingface dataset:
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 six months of two sessions per week of in-person, outpatient occupational therapy services to provide caregiver/parent education, home management, and training (inclusive of feeding and toilet-training) or six months of one session per week of the above services. Researchers note, Children with autism spectrum disorder (ASD) have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. The authors further state that with its focus on sensory integration and sensory-based interventions, relationship-based and interactive interventions, and developmental skill-based programs, occupational therapy (OT) may provide a leading role in affecting positive change in children with ASD. In this case, the records noted that the patient made good progress in previous therapy programs, and was most recently noted to have achieved all established goals. However, given that she continues to have deficits in multiple areas including fine and gross motor skills, self-regulation, performance of self-care skills, and tolerating a varied diet, ongoing OT is medically indicated. Therefore, six months of two sessions per week of in-person, outpatient occupational therapy services to provide caregiver/parent education, home management, and training (inclusive of feeding and toilet-training) are 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 pediatrics with sub-specialty certification in pediatric critical care 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: An enrollee has requested authorization and coverage for Xyosted.Findings: Male hypogonadism is a clinical syndrome that results from failure to produce physiological concentrations of testosterone, normal amounts of sperm, or both. Hypogonadism may arise from testicular disease (primary hypogonadism) or dysfunction of the hypothalamic-pituitary unit (secondary hypogonadism). Xyosted is FDA approved for the treatment of hypogonadism. Guidelines support the use of testosterone enanthate for the treatment of hypogonadotropic hypogonadism. In this case, the patient has hypogonadotropic hypogonadism and they have tried injection testosterone cypionate without much improvement in symptoms. The patient also has declined topical therapy out of concern for the risk of exposure to their spouse and children. The patient has tried samples of Xyosted and he reported that the Xyosted had improved results compared to injection testosterone cypionate. Under these circumstances, the requested medication, Xyosted, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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 for suction assisted lipectomy (CPT code 15877). The World Professional Association for Transgender Health (WPATH) lists chest surgery, creation of a male chest, as a medically necessary treatment for gender dysphoria. Olson-Kennedy and colleagues reported that chest surgery is a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. In this case, the patient had a diagnosis of gender dysphoria, and received liposuction as part of male chest reconstruction surgery to prevent dog-ears, a common complication of mastectomies. Given that the service at issue was part of a medically necessary gender affirming surgery, it was medically indicated. Therefore, suction assisted lipectomy (CPT Code 15877) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 transgender health 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 an orthopedic consultation at a tertiary level facility. Findings:  The physician reviewer found that Patellar dislocations are complex and include many causes such as trochlear dysplasia, patella alta, a high tibial tuberosity trochlear groove distance, weaknesses of the vastus medialis obliquus or a lesion of the medial retinaculum. Recent studies have focused on the medial patellofemoral ligament (MPFL) and have shown that the MPFL is the most significant passive stabilizer of the patella. Following patellar dislocation, an MRI should be standard practice to detect an MPFL rupture, osteochondral lesions, or other risk factors for redislocation. An acute first-time patellar dislocation without osteochondral lesions and without severe risk factors for a redislocation should follow a conservative treatment plan. If surgical treatment is required, the best postoperative results occur when the MPFL is reconstructed.In this case, the patients history of continuing pain one year after an acute patellar dislocation is of concern. Although the patients MRI does not show a definite MPFL rupture, continued follow-up by the tertiary care provider will be necessary to make a definitive diagnosis and perform repairs as needed to achieve a good result. Accordingly, the requested orthopedic consultation at a tertiary level facility is medically necessary for treatment of the patients medical condition (dislocated patella).Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient's 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominoplasty.The submitted documentation does not support that the requested services are medically necessary. The World Professional Association for Transgender Health (WPATH) has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The WPATH also includes non-genital, non-breast surgical interventions among the listed surgical procedures for the treatment of patients with gender dysphoria. In this case, however, while the patient states that the requested abdominoplasty is sought as a medically necessary part of his female-to-male transition, abdominoplasty may be performed for cosmetic purposes as well, and there is not sufficient documentation that the requested abdominoplasty would be performed as a treatment for gender dysphoria. Therefore, the requested abdominoplasty is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patient's medical condition. Therefore, the Health Plans denial should be upheld.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xifaxan 550 mg tablets. Small intestinal bacterial overgrowth (SIBO) is a known cause of gastrointestinal distress and is likely a primary contributing factor to IBS. SIBO is typically treated with antibiotics. However, there is a lack of treatment options specifically approved for this indication by the U.S. Food and Drug Administration (FDA). Xifaxan (rifaximin) has been FDA approved for treatment of diarrhea predominant inflammatory bowel syndrome (IBS) and has been found to be effective in the treatment of SIBO in adults. (Gatta and Scarpignato). Prospective data from Scarpellini and colleagues demonstrated that, antibiotics are an effective means of treating SIBO in children and, although non-rifaximin antibiotics appear to produce greater resolution, the data is weaker for such medications and rifaximin has demonstrated safety in a greater number of participants and studies. Given this support, the requested Xifaxan 550 mg tablets are 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 pediatrics with subspecialty certification in pediatric gastroenterology 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 pimecrolimus 1% cream (Elidel). Researchers describe Hailey-Hailey disease as an inherited disease that presents with lesions typically distributed symmetrically within intertriginous regions such as the retroauricular folds, lateral aspects of the neck, axillae, umbilicus, inguinal, and perianal regions. The authors report that treatments include topical and systemic agents. Medical literature note that topical immunomodulators, such as pimecrolimus, may lead to an improvement of the clinical picture of patients with Hailey-Hailey disease. In this case, the patients disease involves areas in the armpit and breasts. She has responded well to triamcinolone and Elidel for maintenance therapy. As such, in this clinical setting, the requested medication is medically indicated. Therefore, pimecrolimus 1% cream (Elidel) 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance transportation services. Findings:  The physician reviewer found that Parastomal hernias are a known complication following urinary diversion. Most patients are asymptomatic or have minimal symptoms. In a few patients, acute surgical intervention is required involving both the urinary and gastrointestinal systems. Oftentimes specialists from surgery and urology are required to safely perform the surgical procedure. This patient met the criteria for urgent transfer per the evaluating provider. He was accepted by the tertiary care center where the initial procedure was performed. The urgent transfer via air ambulance was consistent with the recommendations in the current medical literature. All told, the air ambulance transportation 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 urology 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 budesonide 3 mg, three capsules every morning for six months. Corticosteroids have been demonstrated to be safe and effective for the treatment of Crohns disease (Lichtenstein, et al.). Budesonide is unique in that it directly treats the gastrointestinal tract, avoiding the systemic side effects associated with corticosteroids (Ha and Khalil; Sandborn, et al.). In addition, the American Gastroenterological Association (AGA) guidelines support the use of budesonide in low-risk Crohns disease patients for maintenance therapy. This patient has a diagnosis of Crohns disease. He has maintained remission on budesonide after failure of Pentasa. Given the support in the current guidelines and medical literature, the requested budesonide 3 mg, three capsules every morning for six months 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 internal medicine with subspecialty certification in gastroenterology 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 Lap Sleeve Gastrectomy (CPT 43775).The submitted documentation supports that the requested services are medically necessary. By standard, a patients original weight at the time of their initial presentation is the weight that is recorded and utilized for weight loss surgery evaluation. Standard published guidelines support the use of a patient's initial weight in the bariatric program when determining eligibility. It is understood that a patient with a BMI of 35 kg/m2 who is forced to proceed with insurance mandated weight loss may then lose weight. This is in preparation for bariatric surgery, however, and it is understood that without a definitive tool, the patient would likely regain all of their weight and more. In this case, the patient has no evidence of barriers to surgery, and it is her original weight and BMI, together with her completed dietary and behavioral evaluations, that establish that she meets guidelines for treatment of morbid obesity. Accordingly, the requested Lap Sleeve Gastrectomy (CPT 43775) is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 reimbursement for air ambulance transportation services. The records provided for review document that this patient presented with a history of severe anorexia and bulimia. She required specialized treatment for her eating disorder to include weight restoration and medical stabilization. Per Mattison and colleagues, patients with unstable medical conditions, including those with an evolving, unpredictable, or rapidly changing medical condition should not fly on commercial aircraft. At the time of transfer, the patient did not meet criteria for commercial air travel as she required monitoring of her cardiac status due to malnutrition and risk of arrhythmias and hypotension as well as hourly monitoring of her glucose. The patient also required assistance with transfers due to weakness from malnutrition. Ground ambulance transportation was not recommended for this patient due to the cross-country distance, which took 29 hours in travel duration. Air transport is appropriate in cases of rough terrain or a long distance, as in this patients clinical scenario (Sirbaugh, et al.). Based on the information provided for review, the air ambulance transportation 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 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 antibiotic protocol therapy services. The European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis are made according to the level of organ involvement and specific clinical manifestations. As per the EULAR statement, Raynauds phenomenon is treated with calcium channel blockers such as nifedipine and phosphodiesterase-5 inhibitors including sildenafil. For severe Raynauds that has persisted despite oral therapy, intravenous iloprost should be considered. Digital ulcers have been demonstrated to respond to iloprost, phosphodiesterase inhibitors, and bosentan. The recommendations also indicate that methotrexate has been shown to be effective for the treatment of skin changes in early diffuse systemic sclerosis while proton pump inhibitors can be effective for acid reflux. Current studies do not support antibiotic protocol therapy to treat the skin thickening and acid reflux this patient is experiencing as clinical manifestations of her systemic sclerosis, or to address her Raynauds with digital ulcers. The patients records do not include evidence of small intestine bacterial overgrowth, which would warrant treatment with antibiotics. For these reasons, antibiotic protocol therapy services and future antibiotic protocol therapy 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 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.