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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met the criteria for high intensity community based 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 criteria, this patient was at serious risk of continued use and relapse. The patient endorsed continued use during IOP treatment. Kratom use may result in agitation, seizures, and respiratory depression at higher doses (DArrigo). The patients mental status was sufficient to permit participation in treatment. The patient was unable to control his substance use without intensive support. He also has comorbid depression and anxiety. The patient demonstrated limited insight and awareness regarding his need for continued care. His substance use substances continued despite the structure of the IOP and was likely to escalate in a less structured environment, especially given his struggles with family dynamics. The patient was actively oppositional in addressing his substance use disorder and he took measures to avoid detection of continued use while in IOP. His perspective impaired his ability to make decisions about his care and he attributed his issues to his mothers controlling nature. The patient did not recognize relapse triggers and lacked insight into the benefits of continued care. The records documented that the patient wanted to leave the program and continued to use substances despite attempts to engage him in recovery. The patients recovery environment was too chaotic to support his treatment goals. The documentation states that the patient was at risk for acute withdrawal as evidenced by his history of delirium tremens and his use of Kratom. All told, the IOP 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 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

The patient has requested reimbursement for the fertility preservation services. The records provided for review document a diagnosis of stage 3 left breast cancer. The patient is planned to undergo treatment with chemotherapy. Treatment with chemotherapy has been found to significantly impair future fertility. With current technology, embryo and oocyte cryopreservation is the standard of care in this clinical setting. The American Society of Clinical Oncology (ASCO) and the American Society for Reproductive Medicine (ASRM) support fertility-sparing treatment. All told, the fertility preservation 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 obstetrics and gynecology 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 enrollee is requesting authorization and coverage for tab-style adult diapers and bed pads. The enrollee has a history of diabetes mellitus, and incontinence. A progress note showed the enrollee had a history of mixed incontinence, with five or more events per day. She has tried Oxybutynin without improvement and has tried one session of pelvic floor physical therapy. The physicians assessment was stress incontinence versus overflow incontinence, and urinary retention. This enrollee was evaluated by a urogynecologist. He advised pelvic floor exercises, physical therapy, timed voiding, and urge suppression. There was no advice given regarding the use of absorbent bladder protection pads. Medical records do not demonstrate a chronic pathological condition causing either her suspected stress or overflow incontinence. Studies have shown that extended use of adult diapers can exacerbate incontinence instead of improve it, and that refraining from the use of these products may alleviate or resolve incontinence.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in family practice 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for air ambulance transfer. The enrollee experienced a hemorrhagic stroke while on vacation. He was taken to the hospital and underwent a decompressive craniectomy with placement of a drain. He was taken off the ventilator the next day and a computed tomography of the head showed no further bleeding or swelling. He was transferred by air ambulance to a neurological institute for further management. A letter from the treating physician indicates the enrollee had dense left-sided hemiparesis and significant deficits, with an extensive need for continuing, specialized medical care. The records show the enrollee had a large right parietal brain bleed. He also experienced left-sided paralysis after the bleed. Though his computed tomography angiogram was normal, a subarachnoid hemorrhage due to an aneurysm remains likely. An angiogram and management by a neuro-intensivist in an intensive care unit setting was essential; this is supported by literature, which shows individuals who experience a brain bleed require specialized care by neurologists.  There was no report of any neurologists on staff at the treating hospital and thus the treating hospital was not equipped to provide the necessary care for this enrollee.  Transfer to a neurological intensive care unit was medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.  Credentials/Qualifications: The physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for DecisionDX-Melanoma genetic testing assay. The enrollee was diagnosed with cutaneous melanoma. She underwent the DecisionDX-Melanoma genetic testing assay. The enrollees physician reports current cutaneous melanoma management guidelines indicate post-surgical management should be tailored to an individuals probability or risk of recurrence. The risk classification provided by the DecisionDX-Melanoma test is used to better estimate an individuals risk of recurrence. This result helps determine appropriate surveillance, clinical follow-up and specialty referral. The DecisionDx-Melanoma gene panel is not currently recommended by any standard treatment guidelines. Providers may suggest that those who are shown to be at high risk for metastasis as a result of this test undergo more frequent clinical evaluations and imaging. However, if additional therapies are either contraindicated or not available, this categorization may increase anxiety without real benefit to the individual. This enrollee is not a good candidate for the DecisionDX-Melanoma genetic testing assay. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee.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 dermatology 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for prostatic urethral lift. The enrollee has benign prostatic hypertrophy. His medical history includes diabetes mellitus and high body mass index. He reports symptoms of difficulty urinating, urine leakage, straining, frequent urination during the night, and weak urine flow. Progress notes from urology reported diagnoses of acute prostatitis and urinary retention. The plan included discussion of the medication finasteride and potential surgical interventions, including the Urolift procedure. Governmental organization guidelines indicate the requested procedure is approved for those with prostates whose weight is less than 80 grams. Records show the enrollee has been recently treated for prostatitis and urinary tract infections, but these diagnoses have not been corroborated by a urologist. The medical records for this enrollee report a history of recent prostatitis and urinary infection, but records do not provide evidence of a urinalysis or of a prostate examination. Professional society guidelines for evaluation and preoperative testing report criteria such as medical history and urinalysis as data to be included in the assessment. Also mentioned is assessment of prostate size and shape with the use of diagnostic procedures. Records provide insufficient evidence of the measurement of these parameters.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for vest airway clearance system. The enrollee has a history of pulmonary fibrosis, bronchiectasis, and chronic obstructive pulmonary disease. He requires chest physical therapy to clear secretions and currently does not have a caregiver to perform it. The enrollees advocate reports consistent, aggressive airway clearance is necessary for the enrollee to maintain his pulmonary function. Retention of secretions can lead to chronic inflammation and progressive lung damage, with the possibility of developing resistance to standard treatment. Medical records did not demonstrate this enrollee had a continuous, productive cough for more than six months. Records do not demonstrate that this enrollee experienced frequent exacerbations, more than two, in the last year which required treatment with anti-infective medications. This enrollee was not described as having copious, difficult-to-expectorate sputum. Records indicate the enrollee demonstrated mostly clear secretions, which were triggered by allergies. The records do not support more than two exacerbations, as defined by literature, over a period of one year, which would support more aggressive management. An expert consensus in the management of bronchiectasis due to various etiologies reports that, for children and adults with a productive cough due to bronchiectasis from any cause, the recommendation is for teaching airway clearance techniques by professionals with advanced training in airway clearance techniques.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pulmonary disease 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee has osteoarthritis of the left knee. She has complaints of dull, constant pain that is exacerbated by walking and exercise. The enrollee stated her symptoms began approximately five years prior.  She has tried anti-inflammatory medications, a steroid injection and viscosupplementation (Synvisc One).  The physician indicated the enrollee had joint space narrowing in the medial compartment; according to imaging. The physician indicated viscosupplementation (Synvisc One) has provided relief in the past; therefore, the physician recommended an additional injection. A professional society reports the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who are not good candidates or who do not respond to other treatment options. The use of viscosupplementation (Synvisc One) injections are indicated for those who have ongoing history of knee pain with joint space narrowing. Therefore, the enrollee is an appropriate candidate to undergo the requested injection as it has previously provided good relief.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 one hour of one-on-one therapy sessions with a therapist trained in borderline personality disorder, every other week. The records provided for review support a diagnosis of borderline personality disorder, which is characterized by marked distress, functional impairment, and self-destructive behavior. Controlled trials have demonstrated that dialectical behavioral therapy (DBT) is effective for patients with borderline personality disorder. DBT consists of a combination of individual psychotherapy, group skills training, telephone coaching, and a therapist consultation team. Successful treatment is comprised of weekly meetings with an individual therapist and one or more weekly group sessions. The American Psychiatric Association (APA) guidelines note that treatment plans for borderline personality disorder need to be flexible and individually tailored. In this case, the patient has a long history of borderline personality disorder as well as depression. She has participated in multiple prior treatment courses at various levels of intensity. Her Health Plan has offered DBT group, but not the weekly individual psychotherapy that is an integral part of empirically supported DBT treatment. Given these findings, the requested one hour of one-on-one therapy sessions with a therapist trained in borderline personality disorder, every other week is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for post-acute skilled nursing services. The documentation does not support that this patient requires post-acute skilled nursing services. The patient does not require complex wound care. He does not have a tracheostomy tube or other skilled nursing need that requires continued services performed by a skilled nurse in a skilled nursing facility (SNF). This patients functional status does not require continued skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist in a SNF. The patients providers have recommended that the patient be discharged with a caregiver and lower level of therapy. All told, the requested post-acute skilled nursing services 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for gastric peroral endoscopic myotomy (G-POEM). The enrollee has a history of gastroesophageal reflux disease, gastroparesis and repaired paraesophageal hiatal hernia. He underwent Linx band placement and his gastroesophageal reflux disease improved, but he subsequently developed belching and bloating. Testing revealed delayed gastric emptying. He underwent balloon dilation of the pylorus with Botox to the pylorus, but his symptoms did not improve. He was treated for Helicobacter pylori and the Linx band was removed without improvement. The gastroenterologists impression was gastroparesis. This procedure is not approved by governmental bodies and it is not included in any society guidelines.  Despite literature showing improved outcomes in nausea and vomiting, the studies are short-term and involve small numbers of enrollees. More investigation is needed to identify optimal candidates, a standardized approach to pre-operative and post-operative testing, and a standard endoscopic approach. This enrollee may have pyloric dysfunction as a mechanism for delayed gastric emptying, but he failed pyloric dilation.  It is not clear if this enrollee would benefit from another pyloric interventional procedure. There are no validated criteria defining a distinct subset of individuals with decreased pyloric distensibility. Large, prospective, randomized trials are needed. There are several limitations that exist because a gold standard does not exist to which the effectiveness of G-POEM can be compared.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for laparoscopic ablation of uterine fibroids. The enrollee has uterine fibroids. Testing showed four fibroids. The enrollees physician reports the enrollee has chronic menorrhagia, which has resulted in chronic iron-deficiency anemia. She has chronic fatigue as a result of the anemia. The enrollees physician is requesting the Acessa procedure to improve the enrollees quality of life. Candidates for myolysis are limited to women with fewer than four fibroids, with the largest being less than 10 centimeters in diameter. A professional society practice bulletin contains no recommendations regarding myolysis as an alternative to hysterectomy in the management of fibroids. The gold standard technique for fibroid treatment remains hysterectomy, although myomectomy may be considered the gold standard for a uterine-sparing procedure. Literature shows ablation is appropriate when there is evidence the enrollee has multiple indications for the procedure, including the enrollee wanting uterine-conserving treatment, as well as being premenopausal. Based on the gap noted in dates of her recent menses, this enrollee is likely perimenopausal.Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gynecology 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 a similar medical condition.