Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld 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 did not meet Level 3.5 criteria for clinically managed high-intensity residential 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. Applying the ASAM criteria, the patient was not in withdrawal or at risk for acute or subacute withdrawal. The records suggest that the patient could have transitioned to a sober living environment, which would have provided safety and support for relapse prevention with regular daytime participation in a lower level of care. For these reasons, the RTC services at issue were not medically necessary for treatment of this patient. 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 expertise 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous implantation of neurostimulator electrode array epidural (CPT code 63650). Researchers performed a review of the available literature evaluating the efficacy and safety of dorsal root ganglion stimulation for the treatment of various forms of neuropathic pain. The authors reported successful use in treating a wide range of indications including postsurgical pain, CRPS, and phantom pain. The authors also analyzed the effects of dorsal root ganglion stimulation on the treatment of chronic neuropathic pain. The authors found that patients reported that dorsal root ganglion stimulation improved patients pain by 56% at one-year post-implantation. In this case, the patient has tried and failed multiple neuropathic agents, opioid therapy, and lumbar sympathetic blocks without substantial benefit in his pain. He continues to use physical therapy, osteopathic care and Pilates to manage his pain with mild benefits. The provider document that the patient underwent a successful seven-day trial for dorsal root ganglion stimulation for his CRPS with 90% relief of his lower abdomen and groin pain. The patient reported that his pain relief allowed him to tolerate wearing pants for the first time in several years, which represented a significant improvement in his quality of life. The peer-reviewed medical literature has demonstrated the safety and efficacy of dorsal root ganglion stimulation in cases of CRPS. Based on the current medical literature and this patients positive response to the dorsal root ganglion stimulation trial, the requested percutaneous implantation of neurostimulator electrode array epidural (CPT code 63650) is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 referral to a nephrologist. The records provided for review document a recurrent problem of unclear etiology involving the genitourinary system. The patient is noted to have UTIs as well as hematuria. She is noted to take non-steroidal anti-inflammatory drugs (NSAIDs). A nephrologist is most familiar with several conditions including papillary necrosis related to ibuprofen intake, medullary sponge kidney, and loin pain hematuria syndrome. Further, issues such as neurogenic bladder related to comorbid conditions should be ruled out. The nephrologist has a role in the diagnosis of recurrent UTIs. 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: The patient has been diagnosed with osteoporosis. The provider noted that the patient sustained a left hip fracture, a right distal radius fracture, and a right femoral neck fracture in. All fractures occurred after falls. The patient has not received prior therapy for osteoporosis. The provider noted a dual-energy x-ray absorptiometry (DEXA) scan revealed a distal radius T score of -2.3. The patients vitamin D level was noted to be 41. The patient has requested authorization and coverage for romosozumab (Evenity) injections. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether romosozumab (Evenity) injections are medically necessary for the treatment of the patients medical condition. Researchers reported, Romosozumab is a monoclonal antibody that binds to and inhibits sclerostin, increases bone formation, and decreases bone resorption. The authors noted, The U.S. Food and Drug Administration (FDA) approved Evenity (romosozumab) for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Authors reported, Clinical trials demonstrated that romosozumab markedly increased bone formation and therefore bone mineral density, and suppressed vertebral fractures compared with a placebo in postmenopausal women with osteoporosis. In this case, the patient has been diagnosed with osteoporosis with a recent history of a right femoral neck fracture. The medical evidence supports the requested medication in this clinical setting. Therefore, romosozumab (Evenity) injections are 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 been diagnosed with a uterine fibroid and a left ovarian mass possibly representing a dermoid. A pelvic mass risk assessment revealed an OVA1 of 4.3, which was noted to be low risk.  A pelvic ultrasound revealed a 1.9 cm anterior uterine fibroid and a stable 2.6 cm echogenic mass in the left ovary, which was noted to possibly represent an ovarian dermoid. The patient has requested authorization and coverage for a total hysterectomy (CPT 58571). 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 a total hysterectomy (CPT 58571) is medically necessary for the treatment of the patients medical condition. Borah and colleagues reported, Uterine leiomyomas are a benign and very common gynecologic condition in reproductive-aged women and are associated with significant morbidity including menstrual disorders, anemia, and adverse reproductive outcomes. The authors also noted, The fact that menstrual disorders were associated with higher odds of having uterine-sparing procedures compared with hysterectomy is in line with the current understanding of the effectiveness of uterine-sparing procedures for leiomyoma symptoms. In this case, there is no documentation to support anemia from the patients menstrual periods to indicate surgery as the next step. The patients fibroid is small and located in the anterior uterus. She has not had an assessment of her uterine cavity with endometrial sampling. She has no other factors suggestive of malignancy or high risk for malignancy. The medical evidence does not support the requested surgery in this clinical setting. Therefore, a total hysterectomy (CPT 58571) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery is 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 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

An enrollee has requested authorization and coverage for testosterone 1.62% transdermal gel. The submitted documentation supports the requested medication in this clinical setting. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, and depressed mood and fatigue. For these reasons, providers often treat patients with hypogonadism when their testosterone level is less than 350 ng/dl. There are a variety of testosterone preparations currently on the market, and injectable and transdermal testosterone preparations are currently the most widely used in the United States. In this case, the patient was unable to tolerate intramuscular testosterone injections. Under these circumstances, testosterone 1.62% transdermal gel is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 endocrinology, diabetes and metabolism, 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 patients parent has requested reimbursement and prospective authorization and coverage 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 composite score is then used to determine the level of care needed. Applying CALOCUS, this patient does not meet the criteria for RTC services provided. The patient has been at significant risk of harm (score 3) due to her history of suicidal behavior and excessive alcohol use. The patient has shown moderate functional impairment (score 3) given her conflict with her peers. The patient has significant comorbidity (score 3) considering her alcohol use disorder, PTSD, and depression. The patients recovery environment is moderately stressful (score 3) given her experienced with online harassment by her former best friend. The patients recovery environment is supportive (score 2) considering her parents engagement with treatment. The patient has exhibited poor response to treatment (score 4) with continued symptoms after over one year of outpatient therapy and medication management, followed by nearly two months of IOP treatment. The patient has been incompletely engaged in treatment (score 3) as her providers documented that she minimizes her alcohol use and depressive symptoms. This gives the patient a composite score of 21, which is consistent with medically monitored community based services. Per CALOCUS, services in this level of care include partial hospitalization, (and) intensive day treatment. In this case, patient does not meet eligibility criteria for a RTC level of care. Accordingly, the RTC services were not and are not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 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 an oral appliance. The patient was diagnosed with obstructive sleep apnea (OSA). Researchers reported that oral appliances (OA) have emerged as an alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) treatment. Researchers also noted that the mandibular advancement appliance (MAA) is the most common type of a dental device in use today. The device makes the mandible protrude forward, preventing or minimizing the upper airway collapse during sleep. A significant variability in the patients response to treatment has been observed, which can be explained by the severity of sleep apnea at baseline and duration of treatment. In some trials, patients with mild OSA show a similar treatment effect after the use of CPAP or MAA. It is worthwhile to give it a try with an oral appliance of MAA type in snoring, mild-to-moderate sleep apnea, and in individuals who are intolerant to CPAP treatment. In this case, the patient has been diagnosed with OSA and was intolerant to CPAP. The medical evidence supports the device at issue in this clinical setting. Therefore, an oral appliance was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device 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 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

The enrollee requested coverage for the medication hydroquinone. The enrollee has been diagnosed with hyperpigmentation of the skin on her face due to acne. She has a history of treatment for acne. She reported she has used Hydroquinone in the past with good results. On examination, the physician reported pustular acne on the face with some scarring and hyperpigmented patches on her chin, cheeks, and neck. The enrollee reports that she has heavy acne with dark spots and the only medications that help treat her acne are hydroquinone and tazoratene and without these two creams her acne will never heal. According to the American Academy of Dermatology Acne Guidelines and dermatology literature, hydroquinone is not medically necessary for the treatment of the enrollee's post-inflammatory hyperpigmentation. The evidence-based literature is consistent. After review of the medical record provided, there is no documentation that would justify the enrollee requiring treatment with hydroquinone.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 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. This gives the patient a composite score which is consistent with high intensity community based services. Given these findings, the RTC 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has tried and failed other conservative treatments for patellofemoral chondromalacia including physical therapy and injections in the past. The patient is refusing additional corticosteroid injections and requesting viscosupplementation. The patients degenerative changes are also not severe enough to warrant surgery. Under these circumstances, the requested Orthovisc injections in both knees are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are 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 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.