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 microvascular decompression brain surgery. Several of this patients complaints are consistent with a diagnosis of trigeminal neuralgia since his pain is described as unilateral, generally sharp, electrical, and brief, with triggers such as touching the face. The patient has been treated with carbamazepine, which is considered first-line medical therapy for the treatment of trigeminal neuralgia. When medical management fails to adequately control a patients pain due to trigeminal neuralgia, surgical options include percutaneous rhizotomy, microvascular decompression, or stereotactic radiosurgery. Microvascular decompression has been demonstrated to have the best long-term success in actually addressing the cause of trigeminal neuralgia. Given this support, the requested microvascular decompression brain surgery is medically necessary for treatment of this patients medical condition.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 neurological 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 authorization and coverage for Remicade (infliximab) injections every eight weeks.Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohns disease, thiopurines are not recommended as primary monotherapy, and tumor necrosis factor (TNF) inhibitors such as Remicade are recommended. These recommendations are corroborated by the American Gastroenterological Association guidelines. For patients with moderate to severe Crohns disease, guidelines do not recommend alternative therapy, such as aminosalicylates, corticosteroids, and antibiotics, as long-term primary therapy as they are unlikely to prevent complications. American College of Gastroenterology guidelines also recommend Remicade as primary monotherapy for the induction of remission of Crohns disease. In this case, the patient is unlikely to respond to conventional alternatives, such as immunosuppressants, corticosteroids, and 5-aminosalicylate therapy. The patient has been on Remicade since 2005 and failed thiopurine therapy. The patient is at risk for Crohns disease complications such as fistula, stricture, hospitalization, and need for surgery if induction and maintenance of remission is not effective. Therefore, Remicade (Infliximab) injections every eight weeks are medically necessary for the treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total knee replacement of the left knee.The current medical evidence supports the requested service in this clinical setting. According to Price and colleagues, knee replacement surgery is one of the most commonly performed musculoskeletal surgical procedures. The surgical indications include osteoarthritis with knee pain, reduced function, and reduced quality of life. In this case, this patient already has a total knee replacement on the contralateral side and is satisfied with the outcome. Imaging studies have revealed osteoarthritis in the patients left knee, and the patient reports a loss of function. The patient needs the procedure to enhance his quality of life. Additionally, there is no contraindication to this surgery. Therefore, the requested total knee replacement of the left knee is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: An enrollee has requested authorization and coverage for continued physical therapy and occupational therapy services.Treatment options for Parkinsons disease include dopaminergic pharmacotherapy, various exercises, formal rehabilitative interventions, and deep brain stimulation. Researchers hypothesize that exercise may improve gait in Parkinsons disease through multiple mechanisms, but methodological limitations of the existing literature limit the clinical applicability of the findings, and further research is required to evaluate the potential for specific exercise interventions for improving symptoms over time. Researchers state that benefits may be achieved through maintenance programs with high levels of repetitive practice. While formal physical and occupational therapy evaluations and programs may have a role in the management of functional deficits related to Parkinsons disease, the optimal intensities, frequencies and duration parameters for these interventions are unclear. In this case, the patient underwent physical and occupational therapies in the skilled nursing facility and progressed to a contact guard assistance level for her basic mobility, but continued to require assistance for her self-care, particularly for lower body self-care. There were no indications that she had potential to increase her independence in a clinically significant manner. She was transitioned to a long-term care facility setting with plan for maintenance exercises via restorative nursing services, which can meet her basic exercise needs. Therefore, the continued physical therapy and occupational therapy services are not medically necessary for the treatment of this patients medical condition.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 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 authorization and coverage for Marinol (dronabinol 2.5 mg capsules) purchased. Researchers describe anorexia nervosa as a psychiatric disorder with a high mortality and unknown etiology, and effective treatment is lacking. The authors further note that while cannabis has been known to cause physical effects on the human body, including increasing appetite, which may be beneficial in the treatment of anorexia nervosa, there are few studies. Per the authors, more research on cannabinoids in anorexia nervosa is warranted, especially regarding its effects on psychopathology. Researchers found that no psychotropic medication has proved efficacious in terms of weight gain in patients with anorexia nervosa, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Researchers note that there are currently no approved pharmacological options for anorexia nervosa, although study results for olanzapine and dronabinol are promising. Researchers note that standard treatment for anorexia nervosa consists of nutritional rehabilitation and psychotherapy, which are supported by far more evidence than pharmacotherapy. In this clinical setting, current medical literature does not support the use of the requested medication as superior to standard treatment focusing on nutritional rehabilitation and psychotherapy. Therefore, the purchased Marinol (dronabinol 2.5 mg capsules) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Marinol (dronabinol 2.5 mg capsules) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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: An enrollee has requested authorization and coverage for a mastectomy procedure for removal of gynecomastia on both breasts.At issue is whether the requested mastectomy procedure for removal of gynecomastia on both breasts 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?The American Society of Plastic Surgeons notes that excision of gynecomastia may be indicated when malignancy is suspected, when grade II or grade IV gynecomastia is present, or when there is pain and discomfort due to the distention and tightness from the hypertrophied breast. In this case, the patient has 1.5 centimeter retroareolar masses which appear to be consistent with grade I gynecomastia. Malignancy is not suspected. He does not complain of pain and discomfort due to distension and tightness from the hypertrophied breast, although he complains of pain while wearing his body armor as a police officer. Therefore, the requested mastectomy procedure for removal of gynecomastia on both breasts is not medically necessary to treat 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, excision of the gynecomastia would be performed to improve function. Per the submitted documentation, the recurrent gynecomastia causes pain when the patient wears a bulletproof vest as a necessary part of his employment as a police officer. Accordingly, the requested mastectomy procedure for removal of gynecomastia on both breasts is reconstructive in nature. Final Result: The reviewer determined that the requested service 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 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: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the pelvis and abdomen. Findings:  The physician reviewer found that Prolonged postoperative pain after recurrent inguinal hernia repair can represent technical failings of mesh movement or other anatomic abnormality. Per Andresen and Rosenberg, The optimal management of chronic pain following inguinal hernia surgery should begin with a thorough clinical examination to rule out other causes of chronic pain and to rule out a recurrence. This patients records document a history of recurrent inguinal hernia. The patient underwent surgical repair of the hernia. However, he then presented with postoperative pain. Treatment included medical therapy and a local nerve block without substantial control over his pain. Given the efforts at medical as well as interventional treatments without improvement, evaluation with MRI was indicated to rule out a technical or anatomic abnormality. Therefore, the MRI of the pelvis and abdomen was medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for food specific immunoglobulin G (IgG) allergy panel (CPT 86001 x 11). This patient underwent IgG level testing to help assess food allergy response and to direct treatment. However, the use of food specific IgG level testing has not been demonstrated to predict true food hypersensitivity and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. In addition, IgG4 is generally increased in patients who have successfully undergone oral immunotherapy for milk or peanut allergy. Thus, food specific IgG should not be used as a tool to diagnose food allergy and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. IgE Immunoassays have demonstrated high positive predictive accuracy in children for several of the major food allergens. In conclusion, the food specific IgG allergy panel (CPT 86001 x 11) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three of the three physician reviewers found the food specific IgG allergy panel (CPT 86001 x 11) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in allergy and immunology, and rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and is 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 parent of an enrollee has requested reimbursement for oral surgery (tooth extraction).There is sufficient support for the service at issue in this clinical setting. Management of an unerupted tooth can prevent complications, such has development of cysts and resorption of adjacent teeth. The treatment provided was indicated for development of a harmonious dental arch and dental occlusion. Per the American Association of Oral and Maxillofacial Surgeons, an impacted tooth is one that cannot erupt into normal position or function and is considered to be pathologic. In this case, the patient had an unerupted tooth with ectopically positioned supernumerary tooth. Given that the tooth failed to erupt, treatment was necessary with the goal of preventing future pathology and optimizing dental and occlusal status. Thus, the oral surgery (tooth extraction) was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 oral facial and maxillary 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 surgical procedure (modified zero depth vaginoplasty in which the penile tissue is not resected or reshaped, but to include bilateral orchiectomy and shaping of scrotal skin into labia, and with no vaginal canal creation). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) supports certain interventions for patients that can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Zero depth vaginoplasty, or vulvoplasty, is an increasingly common option for genital surgery in the treatment of patients with gender dysphoria. However, the WPATH SOC requires two mental health assessments to be considered for genital surgery. The records provided for review do not include documentation from providers that the requested surgery is a medically necessary procedure to address gender dysphoria in this patient. Therefore, the requested surgical procedure (modified zero depth vaginoplasty in which the penile tissue is not resected or reshaped, but to include bilateral orchiectomy and shaping of scrotal skin into labia, and with no vaginal canal creation) 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 psychiatry with expertise in transgender health 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 eight units of additional physical therapy. Total knee arthroplasty is the definitive treatment for highly symptomatic end stage knee arthropathy that has failed to resolve with conservative management. Direction and oversight of a trained physical therapist for a rehabilitation program is initially clinically appropriate.  Strengthening and functional activities are advanced on an individual basis, depending on factors such as other impairments, comorbidities, tolerance, and goals. Large, randomized clinical trials, meta-analyses and reviews, nonetheless, have not demonstrated a significant benefit of intensive or prolonged standard formal therapy programs in this clinical setting, even for patients considered to be at high risk for poor outcomes. Arthrofibrosis, a pathological stiffening of a joint, is incompletely understood but occurs not uncommonly following total knee arthroplasty. Range of motion loss at the knee can be significantly functionally impairing. Prevention and treatment for post-TKA arthrofibrosis includes controlling pain and inflammation as optimally as possible to encourage rehabilitation participation and mobility. A relatively aggressive range of motion program is critical, requiring a high level of patient commitment and compliance. In the present case, the patient underwent a total knee arthroplasty, which was followed by physical therapy. His postoperative knee range of motion was severely compromised. He developed arthrofibrosis, and he underwent manipulation under anesthesia, where right knee range of motion was found to be 120 degrees. The next day, he had 78 degrees of flexion. He continued therapy and made range of motion gains on a steady but slow and incremental basis. At this juncture, there is no expected marginal benefit with respect to clinical course or outcomes from ongoing physical therapy over a continued conservative management program of appropriate exercise and modalities that can be performed independently. Overall, the patient has maximized the benefit he is expected to derive from an individually tailored and supervised outpatient therapy program following his elective knee arthroplasty. All told, the requested eight units of additional physical therapy 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 physical medicine and rehabilitation 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.