Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. Based on the submitted medical documentation, this patient did not receive emergency medical services. The patient was diagnosed with low volume intermediate risk prostate cancer. This type of prostate cancer is a slow growing cancer and can also be managed with active surveillence in some patients. The current medical literature does not support that the treatment outcomes are better if the disease is managed on an emergent basis. The patient was offered an appointment with an in-network provider. The patient did not follow-up on the recommendations of the Health Plan and decided to undergo surgery with an out-of network provider. The records do not document acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions and/or serious dysfunction of any bodily organ. Therefore, the services at issue were not necessary for the treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. The records indicate that the patient was admitted to the RTC due to some oppositional behaviors, anxiety symptoms, and difficulties with social interaction. The progress notes did not describe any significant mood symptoms. The records suggest the majority of the patients functional impairment was due to his autism spectrum disorder and difficulties with social interaction. The progress notes do not reflect any occurrence of any intensive family therapy prior to admission. While at the treatment center, the patient was engaging in cognitive behavioral therapy. The progress notes did not indicate that there were any issues with substance use, history of suicidal ideation or thoughts or suicide attempts, and he was not noted to have aggressive behaviors or self harm behaviors during his stay. The patient denied any serious depression or anhedonia during his stay. According to the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient was considered a low risk of harm as evidenced by the the medical records documenting a lack of active suicidal ideation and no history of suicidal ideation or attempts. During his stay, he did not exhibit any aggressive behaviors. Due to his lack of severe symptoms and dangerous behaviors, treatment in a less restrictive care setting was appropriate, especially as related to family therapy and cognitive behavioral therapy for his anxiety symptoms. Due to the patients mild symptoms and lack of evidence to support failure of less restrictive treatment, the RTC services were not medically necessary for treatment of this patients behavioral health issues. 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 sub-specialty 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement for premium intraocular lenses. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees macular degeneration and cataracts. A review of the record indicates that the enrollee had right eye cataract surgery performed on 04/10/2018, and left eye cataract surgery performed on 05/08/2018. On these dates of service, the enrollee also had premium intraocular lenses implanted. The enrollee has stated that premium intraocular lenses were necessary to treat her macular degeneration.The submitted documentation does not support that the services at issue were medically necessary. Records of the patients history and physical reflect that the patient had macular degeneration and was found to have decreased visual acuity and cataracts on examination. The physician recommended cataract surgery with presbyopia correcting IOL implants. The patient has argued that premium intraocular lens implants were necessary in order to provide functional vision postoperatively. However, medical literature confirms that cataract surgery using a standard (monofocal) IOL is just as likely to correct a patients vision and provide functional improvement. The purpose of implanting presbyopia correcting intraocular lenses is to attempt to provide less dependence on glasses after cataract surgery. The additional benefits of the accommodating IOLs are for the patients convenience only. There is no evidence in the medical literature that presbyopia correcting IOLs would provide an additional benefit above standard IOLs and postoperative glasses or contacts. Therefore, although the cataract surgery itself was medically necessary, the use of premium intraocular lenses rather than standard monofocal intraocular lenses was not necessary. Accordingly, premium intraocular lenses were 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 patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees opioid dependence, Bipolar II Disorder, and attention deficit hyperactivity disorder.At issue in this case is whether the requested residential treatment center services provided are medically necessary for treatment of the enrollees medical condition.The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance uselack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.The patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for American Society of Addition Medicine Level III treatment at least i.e. residential or inpatient treatment similar to what the patient received at the facility. Patients conditions wax and wane. A relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce the risk of relapse.Given the severity of the enrollees illness (multiple detoxifications, short periods of sobriety and multiple relapses), residential treatment was in accordance with generally accepted standards of medical practice, and clinically appropriate for the patient's illness, and is therefore medically necessary.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 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: An enrollee has requested authorization and coverage for bilateral Euflexxa injections, one a week for 3 weeks. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. A review of the records indicates that the enrollee is diagnosed with primary osteoarthritis of both knees, and is status post bilateral arthroscopic partial lateral Meniscectomy. Progress notes indicated the enrollee had presented with bilateral knee pain, and is unable to perform activities of daily living comfortably now due to her condition. The enrollee reported that past lubricant injections had provided pain relief lasting 6 months. The provider recommended bilateral knee Euflexxa injections, weekly, for 3 weeks. The submitted documentation supports the medical necessity of the requested treatment. Given the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intraarticular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. This shows that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Euflexxa injections one a week for three weeks into both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested treatment 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 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: An enrollee has requested reimbursement for residential treatment center (RTC) services. The American Psychiatric Association (APA) treatment guidelines recommend that RTC or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The records indicate that this patient required a safe and stable living environment in order to develop recovery skills. Further, the records demonstrate that the patient meets the American Society of Addiction Medicine (ASAM) criteria, thus qualifying for ASAM Level III treatment, which is consistent with residential or inpatient treatment. Given that she met the these criteria, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Accordingly, the RTC services provided were medically necessary for treatment of the patients medical condition. 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: Overturned Decision of Health Plan

A female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA) procedures. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees lymphedema. A review of the records indicates that the enrollee has been diagnosed with lymphedema. The enrollee underwent excision of a left thigh liposarcoma with subsequent radiation therapy. Left thigh swelling was first reported, and a diagnosis of lymphedema was given. The records indicated a protein lipectomy was performed, and was noted as the first step in a comprehensive lymphedema treatment program. The provider noted the next step would be VLNT and LVA surgeries to repair and improve the lymphatic system. The submitted documentation supports the medical necessity of the procedures at issue. This patient has significant swelling of her left lower extremity related to post-surgery and post radiation for her left thigh liposarcoma. The initial SAPL (suction-assisted protein lipectomy) was performed as a prerequisite to the proposed VNLT (vascularized lymph node transfer) and LVA (lymphaticovenous anastomosis) procedures. This patient has failed conservative therapy, resulting in approval of the SAPL procedure, the proposed VNLT and LVA procedures should be considered medically necessary in the treatment of this patient's severe left lower extremity lymphedema. The current medical evidence supports the medical necessity of the proposed procedures in this clinical setting. Therefore, the requested vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA) procedures are medically necessary for the treatment of this patient.
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 epidural injection. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees degenerative disc disease. The submitted documentation supports the medical necessity of the requested procedure. Researchers indicated that epidural steroid injection has shown short-term improvement for radicular pain but not for other types of low back pain. A study indicated that there was moderate evidence of short-term benefit of radiculopathy with epidural steroid injection. The medical records provided for review document physical exam findings consistent with radiculopathy; in association with plan for epidural steroid injection; and quantify the duration or degree of relief from previous epidural steroid injection in support of repeat epidural steroid injection. Therefore, the requested epidural steroid injection is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested procedure 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 with sub-specialty certification in pain management 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 magnetic resonance imaging (MRI) of the pelvis. The submitted documentation supports the medical necessity of the requested service. Hip pain is a common and disabling condition that affects patients of all ages. The causes of hip pain depend on the location, such as the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain may be due to osteoarthritis, hip labral tears, or may be radicular from the upper lumbar spine. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, or may be localized to a tumor mass. Lateral hip pain occurs with greater trochanteric bursitis or femoroacetabular impingement. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses. X-rays do not always show the pain source. MRI may show occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. MRI of the pelvis is useful for the diagnosis of rectal pain. It has an accuracy of 95% in the detection and localization of deep endometriosis. The current medical evidence supports the requested service in this clinical setting. Therefore, the requested MRI of the pelvis is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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: An enrollee has requested authorization and coverage for bilateral Synvisc injections. The submitted documentation supports the medical necessity of the requested services. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. In this case, the patient has been diagnosed with moderate osteoarthritis of both knees. She has constant bilateral knee pain with difficulty with activities of daily living. Insufficient relief with corticosteroid injections is documented. Therefore, the requested bilateral Synvisc injections 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 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

An enrollee has requested authorization and coverage for Harvoni 90-400mg tablet for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.  The provider documented that there were significant findings in the laboratory results and reviewed them with the enrollee. The enrollee is reported to have a history of chronic hepatitis C. The plan of care included an order to start Harvoni 90-400mg once daily for twelve weeks.According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. Findings: recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic Hepatitis C genotype 1 regardless of fibrosis stage. Finding report that AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this enrollees Hepatitis C infection.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 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.