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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. Findings:  The physician reviewer found that the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. The clinical documentation submitted for review does not demonstrate the medical necessity of service delivery in a 24-hour supervised setting for the diagnosis of sedative, hypnotic or anxiolytic (benzodiazepine) use disorder during the dates in dispute. The patient presented with significant medical co-morbidity and complex chronic pain which represented the driving force for her treatment. However, she did not have a psychiatric condition that would have necessitated a residential treatment setting. She was married and had a supportive spouse and safe housing. She was reluctant to consider the notion that she had an addictive illness. There was no evidence of co-addiction with other substances. She had no history of complicated withdrawal, blackouts or seizures. She did not report recent overconsumption of the benzodiazepines, while neither medication was excessively dosed. Her last use of clonazepam was four days prior to admission and her last use of diazepam, which has a long half-life that facilitates auto-tapering in many instances, was three days prior to admission.  Upon presentation to the treatment facility, the patient was non-distressed and afebrile with a blood pressure of 120/88 and heart rate of 73 beats per minute. During the episode of illness, the patient had no prior history of chemical dependency treatment such as community programming, outpatient counseling or detoxification efforts, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. Current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In addition, there is a lack of evidence to suggest that comprehensive, evidence-based chemical dependency services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician 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 parent of an enrollee has requested reimbursement for residential treatment for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The family therapy note noted that the patient had developed insight into the nature of his problems and expressed good motivation to continue to do therapeutic work. He had already developed some coping strategies, was doing well in school and had a good pass with his father.  Based upon the records provided, the patient did not meet criteria for continued treatment in a 24-hour facility during the period in dispute. He was highly motivated towards his ongoing recovery and was not experiencing any behaviors or actions that could not be managed outside of a 24-hour setting. Final Result: The reviewers 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services.  Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with worsening, persistent and localized abdominal pain. The patient reported pain with ambulation, a common presenting sign of peritonitis. The patients white blood cell count was elevated, prompting CT imaging to rule out acute infectious process. Diverticulitis without abscess was identified. Only after abscess was ruled out could the patient be safely released with appropriate antibiotics. The patients persistent, worsening abdominal pain is consistent with an emergency medical condition. Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of her cardiovascular risk. Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk have been established and these guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), apolipoprotein B, sub-classifications of LDL, high density lipoprotein (HDL) subclasses, lipoprotein (A), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing at issue was 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for diastasis recti and fascial defect repairs (CPT code 15847 and 15830) for treatment of the enrollees chronic abdominal pain or back pain.   Findings:  The physician reviewer found that the patient reports chronic abdominal pain with pulling and weakness in the abdominal wall and loss of core strength. Diastasis repair and fascial defect repair will not relieve the patients abdominal symptoms. The proposed services could result in cosmetic improvement in the patients abdominal appearance but would not improve the patients medical/functional complaints. There is a lack of evidence demonstrating diastasis repair and fascial defect repair relieves chronic abdominal pain and weakness. Further, diastasis repair and fascial defect repair are not standard treatments for back pain. In the medical literature, according to the American Society of Plastic Surgeons (ASPS), true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty. Abdominoplasty with wide abdominal rectus plication has been shown to be beneficial for some patients with back pain. However, the research cautions that the procedure is contraindicated in the presence of a negative abdominal compression test. Although these reports suggest that abdominoplasty may improve back pain, there is a lack of prospective, controlled, randomized clinical trials that support diastasis recti repair as an acceptable treatment for back pain. This patients records do not include any evidence of improved back pain with a brace and do not document a positive abdominal compression test. Preoperative testing to determine if the procedure will be helpful has not been done. Moreover, the records do not report that a radiologic work-up for back pain or an evaluation by a spine surgeon have been performed. Thus, the requested surgery is not supported as medically necessary for treatment of this patients medical condition. Diastasis recti is a common finding in women post pregnancy. The rectus muscles separate to accommodate the enlarging fetus. As such, diastasis recti is not an abnormal structure. Rather, almost all women post pregnancy have some element of diastasis recti. Final Result: The reviewer determined that the surgery is not medically necessary for treatment of the patients medical condition or reconstructive in nature. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric services provided. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the date of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.Based on the documentation submitted for review, the patient did not receive emergency medical services on the date of service at issue. In this case, the documentation submitted for review does not show an evaluation was performed on the date of admission to residential treatment. The standard of care for emergency inpatient programs is for new patients to be evaluated, and treated by a provider within 24 hours. From tthe patient documentation provided, this was not done. Moreover, there was no documentation demonstrating that the patient was acutely suicidal at the time of admission, was psychotic, manic, medically ill or had any other acute condition that required emergency treatment. Therefore based on the information provided, the patient did not receive psychiatric emergency medical services.  Final Result: The reviewers determined that the patient did not receive psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: EE requested authorization and coverage bilateral removal of gynecomastia. Findings:  The physician reviewer found that the request for bilateral removal of gynecomastia is medically necessary for treatment of the patients medical condition. The patient presents with bilateral symptomatic gynecomastia without resolution despite attempted weight loss. Work-up of the bilateral masses and possible correctable causes had been evaluated. The photographs submitted for review demonstrate Grade III/IV gynecomastia. In addition, the photographs are supportive of a significant abnormality. Therefore, based on the documentation submitted for review, the request for bilateral gynecomastia surgery is medically necessary.  Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: an enrollee has requested authorization and coverage for Xeljanz XR. Findings:  The physician reviewer found that there is currently a lack of large randomized controlled clinical trials recommending switching from Xeljanz twice daily to once daily Xeljanz in a patient who has responded so favorably. Final Result: The reviewers 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: Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for lamotrigine 25 mg tablets, four times per day and gabapentin 100 mg, eight times per day. Findings:  The physician reviewer found that Lamotrigine was approved for bipolar maintenance therapy in 2003 and has since developed a niche among clinicians for bipolar depression. There is evidence in the medical literature also supporting its use in treatment-resistant unilateral depression.  The dose range of lamotrigine is typically 50 mg to 200 mg, and in some cases, up to 400 mg daily.  There is good support for gabapentin in anxiety and substance use disorders, and clinicians commonly prescribe this medication when anxiolytic pharmacologic intervention is necessary, but benzodiazepines are not an option. Up to 3600 mg of gabapentin can be administered daily in divided doses. Final Result: The reviewer determined that the requested medication quantities 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 removal of a fatty lump in the neck. Findings:  The physician reviewer found that Tte medical records document a mass of the right neck which is consistent with a probable lipoma. Although this may be a benign condition, there are several indications for removal. The mass is noted to be increasing in size, and the size is relatively large at 2 x 4 x 3 cm, especially considering the anatomic location of the upper neck above the level of the platysma.  Per the medical evidence, as the mass is both large and enlarging, surgical resection to confirm the diagnosis is medically reasonable. Additionally, the requested services are reconstructive in nature.  A lipoma or fatty mass is not a normal structure of the body.  This abnormal structure can be classified as a tumor.  Although there does not appear to be a functional impairment, the large size of the mass and its anatomic location of the upper neck contributes to an abnormal appearance.  In this patients case, the requested services are likely to create a normal appearance to the extent possible.  Given the size and its anatomic location, the requested services are likely to provide more than a minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the reviewer number two 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study test for evaluation of her history of daytime somnolence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient presented with a clinical presentation that was suggestive of a sleep-related breathing disorder.  In this case, the patient had significant malocclusion, dental crowding and a large tongue.  Malocclusion has been linked to sleep-disordered breathing in recent publications.  The presence of an enlarged tongue is also considered to be a potential risk factor for sleep-disordered breathing. There is sufficient evidence that correction of these anatomical abnormalities can lead to improvement/resolution in sleep-disordered breathing.  Based on this patients anatomical presentation combined with her complaints of excessive daytime sleepiness, there was a clinically reasonable basis to suspect that she may have had obstructive sleep apnea.  Polysomnography is the standard diagnostic test in this clinical setting.  Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of continued residential treatment level of care.  The patient did not have a comorbid psychiatric or medical condition that would have necessitated continuation of the residential treatment setting. He was motivated in his quest for sobriety. He had not been using substances every day. He had employment and safe housing available to him in the community along with engaged parents.  The patient had completed family week. He was looking forward to a family visit that Sunday.  Up to that point, he had completed three-and-a-half weeks of residentially-based treatment that included a full range of recovery services.  His anxiety was well-controlled.  Per the records, the patient had not received any previous chemical dependency treatment during the episode of illness.  He had no prior history of community programming, outpatient drug and alcohol counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. This is significant in this case for two reasons.  First, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that comprehensive, evidence-based services provided at a less restrictive treatment setting would have been insufficient or inadequate after a three-and-a-half week course of residential placement. 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 number two 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.