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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three-dimensional (3D) breast mammography (breast tomosynthesis). The National Comprehensive Cancer Network (NCCN) recommends annual mammogram for the surveillance of patients who are at increased risk for breast cancer and possible tomosynthesis in certain clinical settings. Rafferty and colleagues reported that the addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. Given this patients personal history of triple negative breast cancer at age 50 and family history of breast cancer, she is considered high-risk. In this scenario, the pee-reviewed medical literature supports the utility of tomosynthesis. Therefore, the requested 3D breast mammography (breast tomosynthesis) is medically necessary for 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 certifications in medical oncology and hematology 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. 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. Using CALOCUS, 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) developmental, medical, substance use 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. Applying the CALOCUS framework the patient met the criteria for the RTC services. The patients composite score is consistent with medically monitored residence based services. Given these findings, the RTC services were medically necessary for the 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 residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3 criteria for RTC 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. As the patient has met the six ASAM dimensions, the RTC level of care 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: Upheld Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for individual dialectical behavior therapy (DBT) twice a week. A Cochrane review of therapeutic interventions for addressing self-harm in children and adolescents concluded that there have been relatively few investigations into interventions for children and adolescents who engage in self-harm. The review concluded that there is little evidence on which to draw conclusions on the effectiveness of interventions for self-harm in this population. While there were some very limited positive findings regarding DBT-A (DBT for adolescents), mentalization, and therapeutic assessment, the review concluded that these approaches require further evaluation before any definitive conclusions about their use in clinical practice can be made. In this case, the patients diagnoses include depression and anxiety, and her symptoms include suicidality and self-harm. Given the lack of evidence that dialectical behavior therapy (DBT) is effective for patient's diagnoses and symptoms, including depression, anxiety, and self-harm, the requested individual dialectical behavior therapy (DBT) twice a week is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for facial feminization revision surgery (scalp advancement, forehead feminization, osteotomy, reconstruction and rhinoplasty, upper lip shortening primary, chin and jawline revision, trach shave primary with submental fat reduction and a chin tuck) performed during one surgery (as opposed to two surgeries). In this case, the estimated surgery time of 6 hours for the listed procedures in a single stage approximates the fastest that the surgery could be expected to be carried out by a surgeon with extensive experience, with the published procedures requiring up to 8 hours and 15 minutes. The surgery in this patient is almost all revisionary, and revision rhinoplasty, in particular, requires significant additional time as compared with primary rhinoplasty, because of adherent tissue and post-surgical scarring. The use of more than one surgical stage over a period of no less than 6 months is accepted scheduling and treatment of facial feminization. Under these circumstances, the requested facial feminization revision surgery performed during one surgery (as opposed to two surgeries) is not medically necessary. Accordingly, the requested facial feminization revision surgery (scalp advancement, forehead feminization, osteotomy, reconstruction and rhinoplasty, upper lip shortening primary, chin and jawline revision, trach shave primary with submental fat reduction and a chin tuck) performed during one surgery (as opposed to two surgeries) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the performance of the requested services during one surgery (as opposed to two surgeries) is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery 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 budesonide extended release, 3 mg. The American Association for the Study of Liver Diseases (AASLD) support treatment with budesonide as a first-line corticosteroid therapy for patients with autoimmune hepatitis. The AASLD guidelines cite a lower risk of systemic side effects such as myalgias with budesonide than prednisone. This patient has a contraindication to prednisone as the risk of tuberculosis reactivation dramatically increases with systemic corticosteroid use. Moreover, she is not an ideal candidate for treatment with prednisone due to side effects including myalgias. Current data have shown that budesonide is effective with or without azathioprine for the treatment of autoimmune hepatitis, and the AASLD guidelines support corticosteroid monotherapy when azathioprine is contraindicated. The patients provider has recommended that she avoid azathioprine due to the presence of latent tuberculosis. For these reasons, the requested budesonide extended release, 3 mg 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 internal medicine with subspecialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto 97-103 mg twice a day. The current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines support an indication for treatment with Entresto for this patient with reduced ejection fraction, as defined as 40% or less. The records document that this patient has class C, stage II congestive heart failure with a reduced ejection fraction. The patients ejection fraction on recent testing was 40%, which improved from 20-30% before starting optimal therapy with Entresto. Solomon and colleagues reported Entresto was effective at reducing heart failure in patients with an ejection fraction up to 40%. In addition, this patient has been on chronic Entresto therapy for years and has improved symptomatically and with an improved ejection fraction. All told, the requested Entresto 97-103 mg twice a day 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 internal medicine with subspecialty certification in cardiovascular 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 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 Fasenra (benralizumab, SQ) injections. Fasenra is U.S. Food and Drug Administration (FDA) approved and supported by medical evidence for the management of eosinophilic asthma in patients with persistent asthma symptoms and peripheral eosinophilia who have tried and failed inhaled asthma therapy, including inhaled corticosteroids and inhaled long-acting beta-agonist. Based on submitted records, this patient presents with eosinophilic asthma. The provider has recommended continued treatment with Fasenra for the management of the patients eosinophilic asthma, especially given the patients positive response to this treatment. The patient had a peripheral blood eosinophil count of 714 cells/uL, and persistent asthma symptoms despite inhaled corticosteroids and inhaled long-acting beta-agonists. Given her eosinophilic phenotype, treatment with Fasenra is within the standard of care for the patients condition. For these reasons, the requested Fasenra injections are 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 internal medicine with subspecialty certifications in pulmonary disease and 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural injections (CPT codes 64483 and 64484). Lumbar spinal stenosis is associated with neuroforaminal and central stenosis commonly related to degeneration of the spine with aging. Lumbar epidural steroid injections under fluoroscopic guidance are safe and effective for the treatment of low back and lower extremity radicular pain, as well as neurogenic claudication caused by spinal stenosis. Rivera reported that data shows that these procedures are relatively safe and effective, especially for the short-term treatment of radicular pain. In this case, the patient has symptoms and findings consistent with spinal stenosis associated with radiculopathy and corroborated by the imaging studies. Given the support in the medical literature, the requested epidural injections (CPT codes 64483 and 64484) are medically necessary for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left lumbar radiofrequency ablation at L4-5 (CPT 64635). Researchers reviewed concluded that radiofrequency ablation was safe and effective for patients with facetogenic chronic low back pain. The authors noted that ideal patients with lumbar facetogenic chronic low back pain experienced greater than 80% relief of pain with two comparative lumbar medial branch blocks prior to radiofrequency ablation. Researchers concluded that there is Level II evidence demonstrating the long-term effectiveness of lumbar radiofrequency neurotomy and lumbar facet joint nerve blocks in well-selected patients. This patient presents with a four-month history of low back pain radiating into the hip and thigh. He reports functional limitations in his ability to perform activities of daily living and work duties. Clinical examination findings are consistent with facet-mediated pain, with no neurologic deficits. There is reported imaging evidence of disc degeneration and facet arthropathy at L4-5 and L5-S1, and annular tear at L5-S1. He has failed to improve with reasonable and comprehensive conservative treatment. He underwent a facet joint medial branch block at left L4-5 and L5-S1 with 60-70% improvement of his left-sided low back pain, which lasted approximately 12 hours. Current evidence based medical literature supported lumbar facet joint radiofrequency treatment as safe and effective for chronic facetogenic chronic low back pain when the patient experienced greater than 80% relief of pain with two comparative lumbar medial branch blocks. In this case, the patient has not demonstrated a response to medial branch block that meets current literature criteria and has not undergone two comparative lumbar medial branch blocks. The patient reported that he obtained about 12 hours of 60-70% improvement of his left-sided low back pain with one lumbar facet block. Therefore, the requested left lumbar radiofrequency ablation at L4-5 (CPT 64635) is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tub labor and delivery. The records provided for review document that this patient is pregnant and she has requested a tub labor and delivery. However, there is no documentation that the patient cannot undergo safe and effective care with conventional labor and delivery despite the COVID-19 pandemic or her language barrier. The medical literature does not support the patients preference for a water birth with a midwife. Researchers noted that there are concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS) with water immersion labor and birth. All told, the requested tub labor and delivery is not medically necessary for 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 upheld. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with gender dysphoria. The patients therapist reported the patient socially transitioned to male in January 2018 and began hormone treatment in August 2018. The provider noted the patient would benefit in his transition process by having gender-affirmative surgery. The patients plastic surgeon noted the patient is an excellent candidate for a transgender mastectomy. It was noted the patient experiences chest dysphoria and binds his chest daily. The patients parent has requested authorization and coverage for chest reconstruction (CPT 19303 - simple complete mastectomy, 19350-50 or 15200-50 - nipple reconstruction). The Health Plan denied the request and reported the requested surgery is not medically necessary for the treatment of this patient. At issue in this case is whether chest reconstruction (CPT 19303 - simple complete mastectomy, 19350-50 or 15200-50 - nipple reconstruction) is medically necessary for the treatment of the patients medical condition. Coleman and colleagues reported, Chest surgery in female to male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. Researchers reported, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient was noted to experience chest dysphoria and binds his chest daily. He socially transitioned to male in January 2018 and began hormone treatment in August 2018. The patients providers have noted he is an excellent candidate for transgender mastectomy. The medical evidence supports the requested surgery in this clinical setting. Therefore, chest reconstruction (CPT 19303 - simple complete mastectomy, 19350-50 or 15200-50 - nipple reconstruction) is medically necessary for the treatment of this patient. 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 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.