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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% patch and magnetic resonance imaging (MRI) of the hip joints. The records provided for review document that this patient presents with a history of complex regional pain syndrome (CRPS), thoracic fractures with malunion, and post-traumatic thoracolumbar kyphosis with progressive low back and hip pain. In a letter, the provider noted that the patient has not experienced sufficient improvement, or been able to tolerate, treatment with Lidoderm. The records do not demonstrate that the patient is likely to respond well to lidocaine patches given her lack of response to treatment with Lidoderm. Moreover, there is a lack of support for the requested MRI of the hips. The patient has a history of chronic widespread pain attributed to chronic regional pain syndrome and thoracic malunion. However, there is no report that an MRI is indicated for further evaluation of her chronic medical conditions. All told, the requested lidocaine 5% patch and MRI of the hip joints are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 orthopedic surgery with subspecialty certification in sports 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for an Intracept procedure (intraosseous basivertebral nerve ablation). Current medical literature supports the use of the requested services in this clinical setting. Truumees and colleagues reported significant improvement in pain and function in patients with vertebrogenic-related chronic low back pain treated with minimally invasive radio frequency ablation of the basivertebral nerve. Markman and colleagues noted an association between functional benefit from basivertebral nerve ablation and reduced opioid use. In this case, the requested service is an outpatient procedure that would allow the patient to avoid more invasive alternatives such as fusion and or artificial disc replacement while maintaining the structural integrity of the spine and allow to patient to avoid or reduce opioid use. Therefore, an Intracept procedure (intraosseous basivertebral nerve ablation) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. Kaushik and Lebwohl note that treatment regimens for psoriasis patients should be tailored to meet the specific needs based on disease severity, the impact on quality of life, the response to previous therapies, and the presence of comorbidities. Zakhem and colleagues note that systemic dermatologic medications may have effects on male fertility. In this case, the documentation reflects that the patient has psoriasis affecting about 11% of his BSA that has not improved with topical steroids. Given the patients history of hypercholesterolemia and as he is considering pregnancy with his wife, the provider has recommended Otezla. In this clinical setting, the requested medication is medically indicated. Therefore, Otezla is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for silicone partial finger prosthetic. Kuret and colleagues concluded that a silicone prosthesis for finger amputation of the upper limb plays an important role in the process of adaptation to amputation. The authors found that these devices provided aesthetically satisfying results, which influences overall quality of life. This patient is being treated for acquired absence of left finger. She sustained a left traumatic finger amputation via torque injury at the third distal interphalangeal (DIP). However, as noted in the prosthetic evaluation, the requested prosthetic was recommended for cosmetic restoration. The patient has returned to work without documentation of any issues performing her usual duties. Upon further examination, the provider noted that the finger has minimal sensitivity, and the patient has been able to perform activities of daily living without difficulty. Physical assessment revealed normal right and left hand dexterity. Given these findings, the requested silicone partial finger prosthetic would not improve the patients level of function. For these reasons, the requested silicone partial finger prosthetic is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological evaluation services (CPT codes 96132 x 2, 96133 x 2, and 96137 x 1) provided by Massachusetts General Physicians Organization, Inc. In the management of children with autism spectrum disorder (ASD), Hyman and colleagues do not  suggest neuropsychological testing for the ongoing care of patients with ASD. In clinical practice guidelines for the assessment and treatment of children with anxiety disorders, Walter and colleagues do not list an indication for a neuropsychological evaluation. In this case, the patient underwent initial neuropsychological testing in February 2018. The patient has diagnoses of ASD and anxiety, and a history of tics. The records did not document concerns regarding a deterioration in cognitive ability. Given the lack of support in current medical literature for neuropsychological testing in the management of children with ASD and anxiety, the services at issue were not medically indicated. Therefore, neuropsychological evaluation services (CPT codes 96132 x 2, 96133 x 2, and 96137 x 1) provided by Massachusetts General Physicians Organization, Inc. were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee have requested reimbursement for hospital bed (Safety Sleeper enclosed bed) with accessories purchased.Sleep is an essential part of life, health, and wellbeing, and is a crucial part of mental health/behavior and immune function. Typically developing children who do not get adequate sleep have difficulty with executive functions such as problem solving and concentration, difficulty with self-control and coping, and increased risk of mental health problems. A study found states that although cognitive abilities may be different in children with developmental disabilities such as Smith-Magenis syndrome, adequate sleep in a safe environment allows such children to optimize their abilities and function at their highest level. Additionally, a study found states that the use of enclosure beds is a reasonable intervention in children whose behavioral challenges can impact safety. In this case, as part of this patients genetic condition, she awakens frequently at night. The patient was at risk of significant injury if in a bed with siderails, and she was at great risk of elopement if she was not contained in a safe environment. In the absence of some type of restraint system or an all-night aide to monitor her activities, there were no alternatives to a specialty bed to maintain her safety and allow her to get the sleep that was medically necessary for her health and behavior. The requested Safety Sleeper bed was ideal because it provided a safe sleep environment as a soft enclosure to prevent injury and elopement. Therefore, the hospital bed (Safety Sleeper enclosed bed) with accessories purchased was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for consultation with a nephrologist and kidney function test/renal function test (KFT/RFT). The records document that this patient presents with multiple diagnoses including thalassemia, prediabetes, iron deficiency anemia, and ventricular septal defect. The patients medical conditions require a multidisciplinary approach to appropriately plan and administer her care. The patients caregiver has requested a consultation with nephrology. Leung and colleagues noted that, Although proteinuria is usually benign in the form of transient or orthostatic proteinuria, persistent proteinuria may be associated with more serious renal diseases. The presence of proteinuria supports an indication for the requested KFT/RFT. Given this patients elevated long term-risk for end stage renal disease and risk of renal disease complicating other problems, evaluation and treatment by a nephrologist is appropriate. All told, the requested consultation with a nephrologist and KFT/RFT are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certification in nephrology 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 consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides. According to Kwo and colleagues, a workup for underlying liver disease is appropriate given the risk of eventual cirrhosis with untreated metabolic liver disease, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. However, the patient does not have an indication for consideration of liver transplantation, and there is no evidence of liver disease on extensive laboratory testing. For these reasons, the requested blood tests are medically necessary for the evaluation of the patients medical condition. However, the consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services are 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for a mastectomy (CPT code 19300).At issue is whether the requested mastectomy is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Bellini and colleagues stated, In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision. The American Society of Plastic Surgeons notes that excision of gynecomastia may be indicated when malignancy is suspected, when grade III or grade IV gynecomastia is present, and when there is pain and discomfort due to the distention and tightness from the hypertrophied breast. In an evaluation of pain, objective physical findings are needed to substantiate the subjective physical complaints. Additionally, fatty breasts do not generally cause the distention and tightness that are caused by glandular hypertrophied from gynecomastia. In this case, malignancy is not suspected. Bilateral breast enlargement is present, which is consistent with pseudogynecomastia in view of the mammography showing that the breasts were almost entirely fatty. Based on the medical information received for review, the patients symptoms are more in line with pseudogynecomastia and not true gynecomastia. Therefore, the requested mastectomy is not medically necessary for the treatment of the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Gynecomastia constitutes an abnormal structure of the body due to a developmental abnormality. In this patients case, mastectomy would be performed to improve function. The surgery will improve function by relieving pain. Accordingly, the requested mastectomy (CPT code 19300) is reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for diapers. In this case, the patient has diagnoses of spastic quadriplegic cerebral palsy, global developmental delay, and seizures. The records note that the patient is unable to sit independently, walk, and is not toilet trained. Given that the patients severe delay, the patients lack of toilet training is due to incontinence rather than delay in training and it is not clear if the patient has the physiologic or cognitive ability to achieve this typical milestone of childhood. In this clinical setting, the requested supplies are medically indicated. Therefore, the requested diapers are medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested supplies medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for any or all 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. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to passive suicidal ideation without intent or plan a history of self-harm. The records noted an escalating pattern of substance use, resulting in loss of self-control without demonstrated ability to abstain from use, causing her psychiatric symptoms to decompensate. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to dropping out of college and an inability to maintain any employment due to her symptoms. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of significant and uncontrolled substance use, posing a barrier to recovery from her co-occurring psychiatric disorders. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment due to being in an environment with easy exposure and access to alcohol and substances. With regard to level of support of the recovery environment, the records support a score of 3 due to limited social and family support. The records noted that the patient was engaged in family therapy with her mother, appeared to distance herself from her father, and was close to her brother. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management, as outpatient therapy had not achieved remission of symptoms. With regard to treatment acceptance and engagement, the records support a score of 4. The patient was ambivalent about seeking treatment. Thus, the patient has a total score of 25. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient met LOCUS 5b extended stay criteria. Therefore, RTC services were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 45 mg/0.5 mL. Medical literature describe ustekinumab (brand name Stelara) as a human monoclonal antibody that binds with high specificity and affinity to the P40 subunit of both interleukin 12 (IL-12) and interleukin 23 (IL-23), thereby suppressing IL-12 and IL-23 mediated inflammation associated with psoriasis. Researchers note that for systemic medications for psoriasis, ustekinumab and secukinumab had the lowest rate of adverse events for several of the system organ classes, with a statistically significant decreased rate ratio (incidence rate ratio less than 1), whereas cyclosporine and infliximab had the highest, with an increased rate ratio (incidence rate ratio equal or greater than 5). In this case, the patient has a history of psoriasis and has tried and failed topical steroids, Protopic and salicylic acid. As the patient was noted to have elevated liver function tests, methotrexate and cyclosporine, which are metabolized by the liver and may cause liver toxicity, are not recommended. Given that current medical literature supports the use of ustekinumab in this clinical setting, the requested medication is medically indicated. Therefore, Stelara 45 mg/0.5 mL is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.