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

An enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. The submitted documentation supports that Intensive Outpatient Program (IOP) services were medically necessary. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. The patients composite score indicates that the patient would have qualified for a Level 4: Medically Monitored Non-Residential Services level of care during the period under consideration. This more intensive level of care rating supports that Intensive Outpatient Program (IOP) services were medically necessary. Accordingly, Intensive Outpatient Program (IOP) services were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for magnetic resonance imaging (MRI) of the breast. The enrollee underwent magnetic resonance imaging scan of the breast. The enrollee reports she has a history of atypical ductal hyperplasia and is at high risk for breast cancer. Literature reports atypical ductal hyperplasia is now a common diagnosis, with wide variation in diagnosis and treatment. After a diagnosis of atypical ductal hyperplasia is confirmed by biopsy, a proportion of enrollees are upgraded to carcinoma after removal; however, the remainder are over-treated. A study of women with atypical hyperplasia who underwent magnetic resonance imaging, and another 79 women who did not, found that cancer developed after a negative magnetic resonance imaging finding in one woman; whereas cancer developed in two women who were not screened with magnetic resonance imaging. The study authors concluded there was no benefit in magnetic resonance imaging screening.Final Result: Three of the three reviewers determined that the requested services was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for positron emission tomography - computed tomography scan. The enrollee has a dermoplastic malignant melanoma in the mid-portion of his back. A sentinel node biopsy was not possible due to the size of the surgical resection. A positron emission tomography scan was normal. A follow- up positron emission tomography  computed tomography scan was normal, except for faintly seen gallstones. A follow-up visit showed no evidence of recurrence or metastasis. The enrollee reports the positron emission tomography was ordered for restaging, and as a comparison to a prior scan. Researchers report that follow-up involves a comprehensive history and physical every six to twelve months for two to five years, and then decreasing follow-ups to annually. No imaging is recommended as part of the routine follow-up. Researchers recommended against surveillance imaging for asymptomatic enrollees with stages 1A, 1B, and 2A.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for high dose rate (HDR) brachytherapy combined with external radiation. The National Comprehensive Cancer Network (NCCN) guidelines state that low dose rate (LDR) or HDR brachytherapy can be added as a boost to external beam radiation therapy plus androgen deprivation therapy in patients with high-risk prostate cancer being treated with curative intent to minimize acute or late toxicity while improving biochemical control. Similarly, the European Association of Urology (EAU) guidelines recommend external beam radiation therapy with LDR or HDR brachytherapy boost in combination with long-term androgen deprivation therapy for patients with high-risk localized prostate cancer. As this patient has a diagnosis of Gleason 3+4=7 prostate cancer with an elevated prostate specific antigen (PSA) of 44.4, the requested treatment is consistent with the NCCN and EAU guidelines. All told, HDR brachytherapy combined with external radiation is medically necessary for the treatment of 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 urology 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 intensity modulated radiation therapy (IMRT). IMRT may be considered in the treatment of breast cancer when conventional techniques are inadequate to meet dose volume constraints for critical normal structures. In this case, on review of the medical records, there is no indication that standard dose metrics cannot be met with standard dose planning techniques using 3DCRT treatment planning methods. The routine use of IMRT to deliver adjuvant breast radiation is not supported by guidelines or professional organizations because conventional three-dimensional conformal radiotherapy (3DCRT) or field-in-field techniques are generally able to meet treatment-planning goals. Accordingly, the requested IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be 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 radiation oncology 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

The patient has requested authorization and coverage for orthopedic evaluation of the right knee, left knee, or both knees. This patient presents with a history of chronic bilateral knee pain with associated locking and giving way. The provider recommended that the patient should lose weight prior to surgery. The records provided for review do not include documentation that the patients knees require further examination by an orthopedic surgeon. There is no evidence of a recent physical examination of the knees by the patients primary care physician. Moreover, there is no indication that the patient is ready to proceed with knee surgery at this time. There is no compelling rationale to support the medical necessity of a referral to an orthopedic specialist when continued conservative management of these complaints is within the armamentarium of the primary care physician. Therefore, the request for referral to an orthopedic specialist for the right and/or left knee is not medically necessary for evaluation of the 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Stelara syringe 90 mg/mL every four weeks. Current medical literature supports continued dose escalation of Stelara at 90 mg every four weeks in this case. The patient had active disease symptoms on Stelara 90 mg every eight weeks. Researchers reported on a large randomized controlled trial demonstrating the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease resistant to anti-tumor necrosis factor (TNF) therapy. This patient has reportedly failed anti-TNF therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. One study showed Stelara dosing at 90 mg every four weeks is frequently used to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four. In this case, the patient has failed multiple conventional and biologic alternatives, and failed Stelara every eight weeks. He did have a response to Stelara, but routinely loses response at four weeks after injections in the setting of a low Stelara level. A return to dosing every eight weeks or a change to another medication may result in complications. For these reasons, the requested Stelara syringe 90 mg/mL every four weeks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication dosage is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for matrix-associated autologous chondrocyte implantation (MACI). The patient presents with a history of patellofemoral pain in the right knee. Arthroscopy revealed a full thickness chondral lesion of the trochlea. This defect is surrounded by healthy articular cartilage and there is no evidence of osteoarthritis in the remaining knee. The patient has tried and failed conservative treatment including NSAIDs, physical therapy, and a home exercise program. The provider has recommended MACI of the right knee for long-term durable cartilage repair. Focal chondral defects are common in the patellofemoral joint and can significantly impair a patients quality of life with pain and loss of function. MACI has been demonstrated to be safe and effective in this clinical setting. Given this patients localized defect in the patellofemoral joint surrounded by healthy cartilage, the requested procedure is supported by the current peer-reviewed medical literature. For these reasons, the requested MACI is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an enrollee has requested reimbursement for the inpatient psychiatric treatment program level of care 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 children needing mental health treatment. The patient had a composite score which corresponds with a Level 4: Medically Monitored Community Based Services level of care, the patient scores for both his risk of harm and his functional status constitute independent criteria that would require admission to Level Five: Medically Monitored Residence-Based Services. Neither the patients composite score nor his individual dimension scores; however, correspond with the necessary scoring to qualify for an inpatient psychiatric treatment program level of care, Level Six, during the period at issue. Accordingly, the inpatient psychiatric treatment program level of care provided during the period at issue was not medically necessary to treat the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the brachytherapy. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including electrodessication and curettage, elliptical excision, or Mohs micrographic surgery. Brachytherapy may be an option for shallow, widespread lesions, or lesions at anatomic sites that lie immediately above structures vulnerable to irradiation. There are significant limitations in the use of brachytherapy for treatment of basal cell carcinoma. Specifically, the tumors that respond best with the lowest rates of recurrence are primary, superficial, and small. Most studies have found that adequate radiation dosage with brachytherapy cannot be delivered at depths much greater than 2 mm, making the treatment of infiltrative tumors impractical. This patient has a history of basal cell carcinoma with a prior history of skin cancer. The peer-reviewed medical literature does not support the use of brachytherapy for treatment of this patients basal cell carcinoma. In conclusion, the brachytherapy was not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The enrollees parent is requesting authorization and coverage for male chest reconstruction. The enrollee is transgender male with gender dysphoria. He began taking testosterone and has helped lessen his gender dysphoria and anxiety, but he still has anxiety about his chest and binds it daily. The enrollees counselor reports the enrollee has participated in individual counseling. The enrollee is confident in his gender identity and participates in all domains of his life as a male. The counselor reports he meets all criteria for gender dysphoria. There are no psychiatric contraindications to chest masculinization surgery. He is intelligent and thoughtful and has demonstrated the ability to make informed decisions about his care. He has the support of his parents to consent for h0-is care. This surgery will positively impact his persistent gender dysphoria related to his chest, provide him with greater gender congruency and add great quality to his life.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested reimbursement for the SpaceOAR Hydrogel procedure. The enrollee has prostate cancer. He elected radiation therapy and a SpaceOar Hydrogel was placed prior to radiation therapy. This SpaceOAR Hydrogel is a biodegradable gel that is inserted between the prostate/rectum, by means of ultrasound guidance. The gel solidifies at body temperature, and then slowly degrades over several months. Its purpose is to shield the rectum from the radiation therapy which is directed at the prostate gland. At the current time, there are no similar products on the market that are approved by a governmental body. It has been shown to reduce the risk of rectal toxicity following external beam radiation, and it has no current competitors for this purpose. Scientific evidence in peer-reviewed literature supports a reduced rate of high-grade rectal complications with the use of SpaceOAR hydrogel; therefore, there is an improvement in health outcomes.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for removal of a benign mole on the right cheek.Although common congenital and acquired melanocytic nevi are largely benign, they are one of the most common indications for cosmetic surgery encountered by dermatologists. Melanoma is uncommon in the pediatric age range. Only 1-2% of skin tumors excised in children turn out to be malignant when examined histologically. Some benign skin tumors of childhood tend to regress spontaneously within a few years but may cause complications at particular locations and when multiple. In this case, records indicate that the patients congenital nevus was noticed since kindergarten, that it has been growing over time, and that it is larger in size. Accordingly, the warning signs of malignancy are not present in this case. Under these circumstances, the requested removal of a benign mole on the right cheek 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; or (2) to create a normal appearance, to the extent possible. In this case, the patients congenital nevus of the face does not constitute an abnormal structure of the body. It is a common and largely benign indication for cosmetic treatment. Therefore, the requested removal of a benign mole on the right cheek is not reconstructive in nature 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. The reviewer also determined that the patients benign mole on the right cheek did not constitute an abnormal structure of the body and that the requested services were thus not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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.