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

The patient has requested authorization and coverage for bilateral mastectomy. Researchers noted that in hypothyroidism and hyperthyroidism, gynecomastia is commonly resolved after euthyroid state restoration. The American Society of Plastic Surgeons (ASPS) recommend breast biopsy when malignancy is suspected. There should be unilateral or bilateral gynecomastia present that has persisted for more than three months after pathological causes ruled out and three months of unsuccessful medical treatment. Moreover, the patient should have symptoms such as pain and discomfort due to the distention and tightness from the hypertrophied breast. Based on the available documentation, malignancy is not suspected. Bilateral gynecomastia is present, but pathological causes have not been ruled out. There is no report of pain or tenderness due to the distention and tightness from the hypertrophied breast. Based on the medical information received for review, bilateral mastectomy is not medically necessary for treatment of this patient. 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. Bilateral gynecomastia is a developmental abnormality. There is no pain or tenderness, so functional issues are not present. The requested surgery would achieve a more normal appearance. However, the requested surgical intervention is not supported since the medical records do not include documentation that pathologic causes have been ruled out. For these reasons, the requested bilateral mastectomy is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 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. The patient was at risk of subacute withdrawal given his premorbid level functioning. The patients risk of subacute withdrawal symptoms was elevated due to comorbid obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for proton beam radiation therapy. Compared to standard radiotherapy with photon intensity modulated radiation therapy (IMRT), proton therapy features a Bragg Peak, which translates into decreased exposure of normal tissue in the low- to intermediate-dose range. For this patient, the clinical benefit of proton therapy is of critical importance. The patient received craniospinal irradiation, which involves radiotherapy to the entire brain and spine. Using a photon technique, there is significant exit dose going through all of the organs in front of the spine. Conversely, utilizing a proton approach, the Bragg Peak avoids almost most of the exit dose. Researchers compared acute toxicities between photon-based craniospinal irradiation and proton-based craniospinal irradiation. The authors found less weight loss, grade 2 nausea and vomiting, and less grade 3+ esophagitis in patients treated with photon therapy. Given its advantages over photon therapy, proton therapy was expected to substantially decrease the risk of radiation-induced secondary malignancies. All told, the proton beam radiation therapy was likely to be more beneficial for treatment of the patients medical 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 overturned. 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Xifaxan 550 mg three (3) times a day for 14 days. Xifaxan (rifaximin) has proven highly effective in the treatment of small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication had greater effectiveness with fewer side effects than antibiotic alternatives. Results are sustained for several weeks after treatment. In this case, the patient has small intestinal bacterial overgrowth that has not responded to treatment with over-the-counter medications. The provider has recommended Xifaxan at a dose and duration that is consistent with the regimens used in studies which support the use of this medication to treat small intestinal bacterial overgrowth. Under these circumstances, the requested medication Xifaxan 550 mg three (3) times a day for 14 days 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 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

An enrollee has requested authorization and coverage for quetiapine extended-release 150 mg tablets. The U.S. Food and Drug Administration has approved quetiapine XR as a monotherapy for the treatment of acute depressive episodes of bipolar disorder and acute manic or mixed episodes in bipolar I disorder based on two placebo-control trials. One study demonstrated that subjects on quetiapine XR showed a statistically significant decline in total Young Mania Rating Scale (YMRS) scores compared to placebo. In terms of the side effect profile, there is evidence that patients taking Seroquel XR experience less sedation than Seroquel IR. In this case, the patient has failed to respond to many antipsychotics and has been unable to tolerate the sedation side effects of Seroquel IR. Under these circumstances, quetiapine extended-release 150 mg tablets are 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 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

An enrollee has requested reimbursement for percutaneous coronary intervention (coronary revascularization). The 2017 Appropriate Use Criteria for Coronary Revascularization indicate that in patients with significant left main disease along with other involved coronary vessels, coronary artery bypass surgery is the preferred intervention. Furthermore, in the setting of 1, 2, or 3 vessel disease along with left anterior descending involvement, percutaneous coronary intervention (PCI) is less preferred, being associated with higher re-stenosis rates and re-intervention requirements including coronary artery bypass grafting (CABG). In this case, the submitted records show that the patient had severe left main disease also involving the ostium of the left anterior descending and left circumflex coronary arteries. In this circumstance, revascularization is preferred, especially with severe ischemia identified on stress testing. Given patient preference, however, PCI is a reasonable, though less effective, alternative. Therefore, percutaneous coronary intervention (coronary revascularization) was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 cardiovascular disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four months of residential treatment center (RTC) services, or any 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. Based on CALOCUS criteria, this patient meets the criteria for residential treatment. The patient has been at serious risk of harm to himself and others (score 4) as evidenced by significant impulsivity and physical aggression. The patient has shown poor judgment and insight and he endorses excessive substance use. The patient has demonstrated severe functional impairment (score 5) given his extreme deterioration in interactions with peers, adults, and family that include chaotic communication and assaultive behaviors with little or no provocation. The patient has significant comorbidities (score 3) due to a combination of depression, anxiety, and substance abuse. The patients recovery environment is mildly stressful (score 2) given his conflict with his mother. The patients recovery environment is supportive (score 2) as his mother has participated in treatment and treatment planning. The patient has shown negligible response to treatment (score 5) based on minimal response to past residential treatment. The patient has been non-collaborative (score 4) due to hostility and threats toward staff. The patient previously left the prior RTC without permission. This gives the patient a composite score of 25, which meets the criteria for medically monitored residence based services, such as RTC. However, due to scores of 5 on functional impairment and response to treatment, the patient meets the CALOCUS criteria for medically managed residence based services, such as inpatient psychiatric care, or a locked RTC program. Moreover, the patients providers at the prior RTC and patients current providers have recommended this level of care. Given patients resistance to treatment, dangerous behavior, and the failure to respond to a lower level of care, four months of RTC care in a locked facility that can manage patients who are at risk of leaving without permission is appropriate. Accordingly, four months of RTC services are 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 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: The patient has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation (CPT 78816). Erdheim-Chester disease most commonly manifests as multifocal sclerotic lesions of the long bones demonstrating sheets of foamy histiocytes on biopsy, with or without histiocytic infiltration of extra-osseous tissues. A patients baseline disease status, organ involvement, and requirements for ongoing treatment direct the frequency and mode of imaging. PET/CT is a preferred imaging modality in this clinical setting as it can assess extra-osseous involvement. Bone scintigraphy can demonstrate the iconic radiologic features but does not assess extra-osseous involvement. PET/CT is helpful to evaluate the cardiovascular system and allows visualization of the entire vascular tree during a single session. This patient has extensive disease involving the nodes and is on a clinical trial. A prior PET/CT showed stable innumerable bone lesions. The provider recommended a PET scan with CT for attenuation to track the patients progress and response to treatment. Given these findings, the requested PET with CT for attenuation (CPT 78816) is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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. The patient continues to have post-acute withdrawal symptoms including anxiety, agitation, irritability, and insomnia. The patient has been on a Librium taper. The patient underwent a hip replacement surgery. She reported ongoing pain that led to her abuse of opioids and alcohol. She has also exhibited poor ability to tolerate and cope with physical pain and discomfort. The provider noted that the patient has limited coping skills for managing her substance abuse. In addition, the patient has not been able to control substance use without 24-hour support. Her emotional and cognitive symptoms have distracted from her recovery efforts. The patient appears to have little understanding of the effects of substance use on coping and functioning. She was noted to attribute her substance use to her medical problems. The records documented that the patient has an impaired ability to make behavioral changes without structured motivational interventions to help her develop insight. The patient has been experiencing significant craving to use alcohol. The provider reports that the patient does not have the skills required to avoid relapse due to crisis. The patient lives alone and is socially isolated. She does not have a discharge plan regarding where she will live. She is still using a walker so her ability to access outpatient support is limited. Given these findings, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Behcets disease. The provider noted the patient was HLA-B51 positive. She has had three episodes of genital ulcers and two episodes of oral ulcers that spontaneously resolved. The patient reported arthralgia/myalgia in the joints of the back, cervical spine, ankles, and feet. The patient also reported fatigue, weakness, and weight loss. Ulcers were not noted on physical examination. The patient has requested authorization and coverage for Otezla. 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 Otezla is medically necessary for the treatment of the patients medical condition. Authors reported, Topical measures such as steroids should be used for the treatment of oral and genital ulcers. Colchicine should be tried first for the prevention of recurrent mucocutaneous lesions, especially when the dominant lesion is erythema nodosum or genital ulcer. Papulopustular or acne-like lesions are treated with topical or systemic measures as used in acne vulgaris. Leg ulcers in Behcets syndrome might be caused by venous stasis or obliterative vasculitis. Treatment should be planned with the help of a dermatologist and vascular surgeon. In this case, there were no objective findings of oral or genital lesions in the provided medical records to support treatment with Otezla. The patients symptoms included myalgia, arthralgia, fatigue, and weight loss. The medical evidence does not support the requested medication in this clinical setting. Therefore, Otezla is not medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty in rheumatology 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 authorization and coverage for Epclusa 400 mg - 100 mg tablets for 12 weeks. The patient has been diagnosed with hepatitis C. American Association for the Study of Liver Diseases and Infectious Diseases Society of America reported, The daily fixed-dose combination of sofosbuvir (400 mg)/velpatasvir (100 mg) for 12 weeks was approved by the U.S. Food and Drug Administration (FDA) for the treatment of genotype 3 infection in patients without cirrhosis or with compensated cirrhosis. The authors also noted, The phase 3 POLARIS-2 study evaluated 12 weeks of sofosbuvir/velpatasvir in genotype 3-infected, noncirrhotic patients who were either treatment-naive or interferon-experienced. Eighty-nine genotype three patients received the sofosbuvir/velpatasvir regimen and 97% achieved a sustained virologic response (SVR)12. In this case, the patient has documented hepatitis C, genotype 3 infection. The patient has begun treatment with Epclusa, which is consistent with the recommended guidelines. The medical evidence supports the requested medication regimen. Therefore, Epclusa 400 mg - 100 mg tablets for 12 weeks are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 in internal medicine with sub-specialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.