Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for the cystatin C blood test. The enrollee has a history of cerebrovascular accidents. The enrollees medical history includes hypertension, diabetes, hypothyroidism, moderate non-proliferative diabetic retinopathy and nuclear cataracts in both eyes. The enrollees physician referred the enrollee to a nephrologist, due to severe hypertension with multiple strokes. Lab results showed the enrollees cystatin C level was elevated. Serum creatinine level is consistent with the diagnosis of kidney disease. Scientific evidence in peer-reviewed literature does not show a result of improvement in health outcome in using the serum cystatin C level as likely to be more beneficial than the standard testing of serum creatinine level. When comparing cystatin C-based glomerular filtration rate estimates to creatinine-based GFR glomerular filtration rate, studies showed precision may be worse with cystatin C-based estimates. Some guidelines recommend using serum creatinine as the initial test. Therefore, at the current time serum cystatin C measurement does not have any value over the standard measurement of serum creatinine in the diagnosis of kidney disease. The cystatin C blood test is used as a confirmatory test when the diagnosis is uncertain. In addition, it is reasonable to use cystatin C blood testing in patients with clear reductions in muscle mass that are otherwise reasonably healthy. This enrollees diagnosis of kidney disease is certain and he does not have a significant reduction in muscle mass. The cystatin C blood test has not been proven to change any clinical outcomes in any patient compared to standard testing of kidney function. Final Result: Three of the three reviewers determined that the requested service was 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 nephrology 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: Overturned Decision of Health Plan

The parent of the patient has requested authorization and coverage for Absorica (isotretinoin) 30 mg, two capsules twice daily. Acne vulgaris is the most common disease of the skin, affecting up to 80% of patients at some time in their lifetime. Acne vulgaris is a chronic condition with substantial negative psychological, social and emotional impacts. Females with facial acne typically respond more favorably to systemic antibiotic therapies than males. The combination of systemic antibiotics with topical therapies may show synergistic effects, thereby speeding up response and reducing duration of therapy. Absorica is a highly effective treatment option for moderate to severe acne, which acts by shrinking sebaceous glands. Absorica is appropriate for patients with acne resistant to other treatments, nodulocystic inflammatory acne, and acne fulminans. All told, the requested continued treatment with Absorica (isotretinoin) 30 mg, two capsules twice daily, 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 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

The patients parent has requested reimbursement for residential treatment center (RTC) services. Based on CALOCUS criteria, this patient meets the criteria for residential treatment. The patient was at serious risk of harm to others due to recent assault of peer at an inpatient facility, as well as impulsivity, history of self-harm, and history of suicidality. The patient demonstrated serious functional impairment, given his impulsivity, difficulties with anger, and refusal to adhere to expectations at RTC including maintaining his hygiene. The patient had significant comorbidities, considering his history of substance use, recent hand injury, and possible fetal alcohol syndrome. The patients recovery environment was mildly stressful as evidenced by peer conflicts and difficulties meeting expectations at school and home. The patients recovery environment was minimally supportive due to his mothers refusal to actively participate in treatment during the patients RTC admission. The patient demonstrated poor response to treatment, given his lack of response to prior inpatient and RTC treatment. The patients parent was adversarial with the patients treatment, due to his mothers refusal to speak with provider at RTC, participate in treatment, or allow release of information. This gives the patient a composite score that meets the criteria for medically monitored or medically managed residence based services, such as RTC. Given these findings, the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for subacute 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 including: (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. Per ASAM criteria, the patient met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services, such as RTC level of care. The patient required a safe and stable living environment in order to develop his recovery skills. Thus, the patient qualified for ASAM Level III treatment, such as RTC services. Given the severity of the patients illness, the subacute 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for Hyalomatrix dressing for a buttock wound developed after radiation treatment for metastatic rectal cancer. Wound care consists of silver alginate dressing, changed four to five times per day due to drainage. The enrollee was referred for hyperbaric oxygen chamber wound treatment. The provider also requested Hyalomatrix to assist with wound healing. At a wound clinic visit the enrollee indicated the wound had not changed in size or drainage pattern. He reported the excessive wound drainage negatively impacts his life. The physician assistant indicates the enrollee would like to avoid surgery and his wound has improved with the use of the Hyalomatrix dressing. Review of the medical literature indicates there is no scientific, evidence-based support for a significant benefit associated with the application of the Hyalomatrix dressing for this enrollees clinical condition. Studies that support the effectiveness of Hyalomatrix dressing use on wounds are anecdotal, which is the weakest level of evidence, and have not been shown to be more beneficial than other standard therapies. Most studies regarding Hyalomatrix are related to burn patients, and they do not address the complexity related to buttock wounds. Unlike hyalomatrix dressing, other treatment modalities, such as vacuum seal, have studies that looked specifically at its use on the buttock and the perianal areas, and the contribution of bacterial load to infection and the healing rate/process. To date, studies on hyalomatrix dressing are not specific to this patient's case; which is a buttock wound secondary to radiation therapy for his rectal cancer. Thus, this treatment modality is not clinically comparable to other treatment modalities for his buttock wound.   There are no studies in the medical literature to support the safety and efficacy of the requested Hyalomatrix dressing in this clinical setting. Final Result: Three of three medical experts decided that the requested treatment was not likely to have been more beneficial than any other available standard treatment for the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in Vascular Surgery 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: Overturned Decision of Health Plan

The parent of an enrollee has requested reimbursement and authorization and coverage for 40 hours per week of home health care services.The peer-reviewed medical literature related to care of children with severe static encephalopathies that include cerebral palsy confirms that skilled nursing may be medically necessary for children with complex medical problems that relate to profound intellectual disabilities and grossly impaired motor functions. Medical literature reports a systematic review and meta-analysis of multiple databases and found that there is increased risk for malnutrition, dehydration, aspiration pneumonia, and poor quality of life in persons with cerebral palsy. In this case, the patient has both profound intellectual disabilities and grossly impaired motor functions, she is at constant risk for aspiration, and because she is not mobile, she is also at risk for integument breakdown as well. If the patients deficits were less profound, than perhaps family members could assume these responsibilities, but the patients deficits are significant and her risks of malnutrition, aspiration and pressure sores that could lead in turn to systemic infections are very high. Under these circumstances, 40 hours of home health care services per week were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services 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 neurology with special qualification in child 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for hip arthroscopy with femoroplasty. This patient presented with a history of right hip pain. On physical examination, the patients pain was associated with tenderness and some restriction of motion, particularly abduction and internal rotation. X-rays revealed 1 mm narrowing of the right hip joint space compared to the left. Magnetic resonance arthrogram demonstrated hypertrophic labrum, subchondral cyst formation in the acetabulum, and denting of the head and neck junction, indicating cam and pincer impingement. The patient underwent a complex right hip arthroscopy. Femoroacetabular impingement is a clinical syndrome, characterized by abnormal cam or pincer type morphology in the hip that alters the biomechanical, forces causing rapid progression of osteoarthritis and chondral and labral tearing. Early arthroscopic surgical intervention can provide symptomatic relief and delay the onset of osteoarthritis. Imaging findings of femoroacetabular impingement are oftentimes subtle, as in this case. Surgery was appropriate due to persistent pain, functional limitations, and lack of response to conservative treatment. In light of the foregoing, the hip arthroscopy with femoroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the hip arthroscopy with femoroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying the CALOCUS guidelines, this patient meets the criteria for intensive outpatient program (IOP) services. The patient is at some risk of harm (score 2) due to impulsivity and substance use, possible past suicidal ideation without any current suicidality or homicidal thoughts. The patient has demonstrated mild functional impairment (score 2) given the reported conflict with her parents, occasional skipped classes at school, and concerns about school performance. The records document significant comorbidity (score 3) due to depressed mood, ADHD, and cannabis use. The patients recovery environment is mildly stressful (score 2) considering the recent end of a romantic relationship, conflict with her brother, and struggles in school. Her recovery environment is supportive (score 2) due to her parents active participation in the program. The patient has shown moderate response to treatment (score 3). The providers state that the patient continues to have difficulty with maintaining sobriety in the program, and struggles to follow expectations and IOP rules about school attendance. The patient has been obstructive in treatment (score 3) as she continues to exhibit problem behaviors and struggles to meet program expectations. This gives the patient a composite score of 17, which is consistent with high-intensity community based services, such as IOP. Continued treatment at the IOP level of care will provide structure, family support, and individual and group treatment to address the patients substance use and other mental health issues. Therefore, the IOP 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an epidural steroid injection. The American Society of Interventional Pain Physicians (ASIPP) concluded that for lumbar disc herniation with radiculitis, the evidence is good for short-term and long-term relief with local anesthetics with steroids. Evidence is superior in contained disc herniation. Epidural steroid injections (ESI) have a clinically established role in the short-term management of low back pain when the pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations, and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. In this case, the patient developed radiating back pain into the left buttock, thigh and calf area associated with numbness. The physical was notable for diminished sensation in the left thigh and calf area. Her magnetic resonance imaging (MRI) reveals a new corresponding new disc herniation compressing the L3 nerve root on the left. Her conservative treatment to this point included non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, opioids and steroid burst with no benefit or improvement. She attempted physical therapy but was unable to participate due to pain. Based on the available medical records for review, the requested epidural steroid injection is medically necessary for the patients lumbar radiculopathy.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 anesthesiology subspecialty 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: The patient has requested reimbursement and prospective authorization and coverage 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 LOCUS, this patient met the criteria for prior RTC services for five days of treatment. The patient has been at low risk of harm (score 1) as there are no reports of suicidal ideation or safety concerns. The patients functional status has been moderately impaired (score 3). The patient has taken a leave from college and has become socially isolated. The records document that the patient has minor comorbidities (score 2), including bradycardia as a result of her food restricting, which has resolved with treatment. The patients recovery environment is minimally stressful (score 2). Her family is supportive, but she has limited social support. The patients recovery environment is supportive (score 2). The patient has an outpatient therapist and psychiatrist. The patient has demonstrated moderate response to treatment (score 3). The patient has been gaining weight and has been described as constructive in treatment (score 2). This gives the patient a composite score of 15, which is consistent with low intensity community based services. Overall, the records document that the patient became stable for transition to a lower level of care. Therefore, the RTC services were medically necessary, while future RTC services are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue were 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 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.