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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery for reattachment of tendon. Findings:  The physician reviewer found that the documentation does not support the medical necessity for the requested procedure in this clinical setting. Current peer-reviewed literature indicates that flexor tendon injuries remain a challenging condition to ensure optimal outcome and restoration of function following zone 2 repairs. Ongoing clinical and basic research have improved understanding of flexor tendon mechanics and physiology for surgical repair and rehabilitation after a zone 2 flexor tendon repair. Yet, the ideal surgical repair technique that includes sufficient strength to allow safe immediate active motion of the finger, without excessive repair stiffness, bulk or rough surfaces resulting in excessive resistance to flexion, does not exist. After optimizing the repair, the surgeon and therapist team must select a rehabilitation plan that protects the repair but helps to maintain tendon gliding. There are common secondary complications that include decreased range of motion and stiffness associated with tendon adhesions. This patient underwent left middle finger corrective osteotomy . Records documented that a zone 2 flexor tendon laceration was sustained during the procedure and the flexor digitorum profundus (FDS) tendon was repaired. The FDS tendon was cut at the time of the procedure. The patient has initiated occupational therapy with progressive active range of motion. She has requested reattachment of the FDS tendon. However, the medical necessity of additional surgery has not been established. This request would tend to result in surgical treatment without reasonable substantiation for same, and would likely result in increased pain and stiffness due to adhesions. Therefore, the requested procedure is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary An enrollee has requested authorization and coverage for Somatuline Depot (lanreotide) 120 mg/0.5 mL.  Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested medication. The patient presents with multiple metastatic carcinoid lesions. She has undergone resection of multiple lesions in the liver, jejunum, mesentery and lymph nodes. There are persistent lesions in liver. The patient has fecal urgency and pancreatic insufficiency. There is adequate medical literature demonstrating the efficacy and benefits of lanreotide in patients with neuroendocrine tumors and carcinoid syndrome . Somatuline Depot is highly effective in controlling the symptoms associated with carcinoid tumors  For patients who are symptomatic from carcinoid syndrome, initiating treatment with a somatostatin analog is recommended. Somatuline Depot is a long acting analog that is administered every four weeks, and it has been beneficial for this patients management for many years. Lack of treatment places the patient at risk for recurrence and further metastatic disease that can lead to carcinoid crisis. Carcinoid crisis is a life-threatening form of carcinoid syndrome that results from the release of an overwhelming amount of biologically active compounds from the tumor; it may be triggered by tumor manipulation (eg, biopsy, embolization, surgery) or anesthesia, and occurs mostly in patients with markedly elevated serum serotonin or urine 5-hydroxyindoleacetic acid (5-HIAA) . Therefore, Somatuline Depot 120 mg/0.5 mL has been established as medically necessary for treatment of the patients differentiated carcinoid tumor.  Final Result: The reviewers 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: Physician reviewer number one 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: An female enrollee has requested authorization and coverage for Lidocaine 5% patch. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medication in this clinical setting. In the documentation available for review, the patient reports mid-back pain that she is unable to place the Lidocaine gel on. It is unclear how applying a patch to the mid-back would be any easier than applying a gel in the same area. While there is some evidence to indicate that Lidocaine patches help for back pain, Lidocaine gel is equally effective. Also, mid-back pain can be treated with injections and other interventional procedures for pain from arthritic joints. Moreover, the patient reported that pain in the lower back was alleviated with the epidural injection and now the middle back pain is the main focal point of her pain. While the patient reported that multiple treatment options have been tried for her pain, it is not clear that physical therapy has been exhausted specifically for her mid-back pain. Also, the medical literature indicates that behavior therapy is an option for chronic pain and would help avoid medications and injections. Finally, not all medications classes have been optimized or tried for this patients mid-back pain. As such, the medical necessity of Lidocaine patches, as the next best step for this patients pain control in the mid-back, has not been established. For all these reasons, the Lidocaine 5% patch is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain 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: An enrollee has requested authorization and coverage for acupuncture treatment. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The records indicate that the patient has a history of chronic pain which flared during pregnancy as well as nausea. The patient reported throbbing in her hands, forearms, elbows, shoulder and upper back.  Per the records, Tylenol was ineffective.  There is sufficient support for the requested acupuncture treatment in this clinical setting.  Per the medical literature, an acupuncture trial for the patients musculoskeletal condition and nausea is appropriate. All told, the requested acupuncture treatment is medically indicated for the treatment of this patient.  Final Result: The reviewers 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: Physician reviewer number one is board certified in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX testing. Findings:  The physician reviewers found that the current medical evidence has not established the superior efficacy of the services at issue.  Oncotype DX testing has been shown to have prognostic value, but to date has not shown a predictive benefit to standard chemotherapies.  The clinical utility of the services at issue is uncertain.  Per the medical evidence, information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  There is insufficient data to recommend the use of multigene assays, such as Oncotype DX testing, to determine adjuvant therapy.  In this clinical setting, Oncotype DX testing has not been shown to be more beneficial than the standard of care of evaluating risk based on prognostic information from the pathology. In sum, Oncotype DX testing performed was not likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for residential treatment center for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the RTC services were medically necessary for treatment of the patients medical condition. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient does meet the criteria for residential treatment. The patient was at a significant risk of harm with extreme distress and a history of suicidal behavior. Her functional status was seriously impaired as she consistently had conflictual or disrupted relations with others. In addition, she had significant comorbidity of both substance use disorder and anorexia. She demonstrated poor resiliency and a poor response to treatment and was ambivalent, avoidant and distrustful in her relationships. In this clinical setting the RTC services at issue were medically indicated. For the reasons provided, the RTC services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in psychiatry with sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient was not in withdrawals. However, she was on methadone upon admission. Her use of Dilaudid was reported to be 2-3 times per week, not daily. She underwent an Ativan taper, with a methadone taper being planned for two weeks.  This pattern of use and detoxification plan did not require 24 hours per day at 7 days per week monitoring.  She was not a danger to herself or others.  She was not gravely disabled.  She was medically and psychiatrically stable.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.   There was no evidence of a high degree of agitation, mania, hallucinations, or any other significant symptom that would interfere with her care.  She was motivated, cooperative, and appeared to be working the program.  Although she required further treatment to help deal with her emotions and develop coping skills, this did not require the structured environment of a residential setting.  She could have received treatment at partial hospitalization program level of care. Therefore, residential treatment provided during the dates of service in question was not medically necessary for the 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 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 intensity modulated radiation therapy (IMRT) for treatment of the enrollees breast cancer. Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. IMRT may be considered medically necessary in the treatment of breast cancer when conventional techniques are not adequate to meet dose volume constraints for critical normal structures. In this case, the patient requires treatment to the internal mammary nodes because she was node positive before receiving chemotherapy. The internal mammary nodal group sits adjacent to the heart. Conventional treatment planning with three-dimensional (3D) conformal planning typically results in excessive volumes of heart and lung tissue in the field when the internal mammary nodal chains and the bilateral chest wall must be treated. In this clinical setting, IMRT is medically necessary to limit dose to critical normal structures including the heart compared to standard techniques. 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 radiation oncology 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 opiate pain relieving medication, Norco. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medication in this clinical setting. Chronic pain that has no hope for a cure is considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In the documentation available for review, not all non-opioid treatment options have been utilized. There was no mention of behavior therapy despite much research to support its use. Moreover, given the documentation of a history of emergency department visits for pain, psychiatric history, and use of illicit substances, continuation of opioid medication should be under the direct guidance of a mental health professional . Also, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The Centers for Disease Control and Prevention also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible . The medical literature recommends consideration of alternatives to opioids as well as to be weaned to a lower dose of opioids or weaned off the medications entirely. In this patients case, there is a lack of objective treatment goals for pain and function for the requested medication. Finally, continuation of opioid prescribed at higher doses without proper treatment for the opioid use sets the patient up for higher morbidity and mortality. For all these reasons, the requested Norco is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.  Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy.  However, the records do not document that he has had a recent trial of conservative therapy.  The American Pain Society recommends a trial of conservative therapy before starting interventional therapy.  Conservative therapy includes physical therapy, chiropractic therapy or a home exercise program.  All told, the requested lumbar/sacral transforaminal epidural injection is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for labiaplasty. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient developed hypertrophy, hyperpigmentation and hyperkeratosis of her labia majora, with associated itching and irritation over an eight-month period.  This has all the signs of a dermatologic condition that may be allergic, irritant, or infectious in etiology.  This is not the typical history for labial hypertrophy, which generally refers to enlarged labia minora, not the labia majora.  The patient describes the labia as having more laxity, which would be more of a cosmetic issue.  She states she is having issues with keeping the labia clean, which would suggest that she may be cleaning or rubbing the tissue excessively, which could account for the hyperpigmentation and hyperkeratosis as well as the itching and irritation, a condition known as lichen simplex chronicus.  Surgery would not be the appropriate treatment for this condition, and healing could actually be impaired if surgery is done on her irritated tissue.  There are a number of treatments that could help resolve her symptoms, all of which are non-surgical.  Therefore, the requested labiaplasty is not medically necessary for the treatment of this patient. Based on the medical records, this patients condition does not constitute an abnormal structure of the body.  She has structurally normal, but irritated, labia majora.  This condition can be treated non-surgically.  The requested surgery will not improve function or create a normal appearance.  If the underlying dermatologic issue is treated, function and appearance are likely to improve.  Surgery is not appropriate for this condition.  Per the clinical documentation, the requested services will not offer more than a minimal improvement in the appearance of this patient.  In sum, the requested labiaplasty is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.