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

The enrollee is requesting authorization and coverage for the requested medication, Otezla, 30mg for moderate to severe psoriasis involving a total body surface area of greater than 10 percent. The record indicates lesions on her scalp, back, arms and legs. She had been treated with the topical agents, Taclonex and Clobetasol, but her condition was only partially alleviated. A trial starter pack of Otezla was provided to the enrollee and her psoriasis had completely cleared with Otezla. The enrollee was continued on Otezla, along with Fluocinonide. On a subsequent visit, mild, scaly psoriasis on the scalp and trunk are noted. At the next visit, the record indicates the enrollees psoriasis is now moderate in severity, and also developed along her scalp. The plan was for Enstilar topical foam and Otezla. Her provider indicates she has tried and failed high dose steroids. The enrollee has a history of moderately severe psoriasis. The plaques are on her arms, trunk and scalp and are symptomatic. She has tried and failed topical medications, such as steroids and Enstilar/Calcipotriene. Otezla was first prescribed several years ago and the enrollees psoriasis cleared with this medication. Although there are periods of remissions and flares, the Otezla has been most effective in relieving and improving her psoriasis. Stopping the Otezla now, after the extended length of time she has been on it, may potentially result in a disease flare up.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 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 enrollee is requesting authorization and coverage for removal of mammary implant material and the delayed insertion of breast prosthesis. The enrollee has a history of breast cancer and underwent bilateral mastectomy and breast reconstruction. She was evaluated for complaints of deformity related to wrinkling of the skin and an unaesthetic pectoralis animation deformity. Examination showed a slight deformity to the right breast and a discrepancy of the inframammary fold. There was age-related epidermal thinning and asymmetry in the right axillary region. The physician discussed revision surgery, including liposuction to the right axilla, a change in incision site, and a recommendation to downsize her implants. This enrollee underwent bilateral mastectomies with breast implant reconstruction. Her implants are too large and have wrinkling and pectoralis animation deformities.  Review of the record substantiates the revision of the reconstruction with implant exchange is medically necessary. The enrollee has continued abnormality of her breasts following breast cancer reconstruction. The abnormalities are due to breast cancer disease, and correction of the deformities is a stage of her reconstruction. The alleged abnormality constitutes an abnormal structure of the body that is due to disease. The requested surgery will help to create a normal appearance. The plastic surgery literature has several studies which show the outcome of breast reconstruction can change over time, due to age, and weight gain and loss.  The quality of the reconstruction can change and implants can rupture. Breast reconstruction is not a one-time procedure. Revisions are commonly required and can reasonably be considered a stage in breast reconstruction; which is now understood to be a multi-stage process, including revisions.  Implant exchange is a stage of her reconstruction to restore her breasts to her pre-mastectomy appearance and will provide more than a minimal improvement in the appearance of the enrollee.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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested wireless capsule endoscopy. She has a history of abdominal pain. She experienced constant pain between her shoulder blades and frequent eructation and epigastric discomfort to the left upper quadrant, which did not respond to proton pump inhibitors or over-the-counter simethicone. An upper endoscopy was normal. A computed tomography scan noted a seven millimeter structure the distal ileum, which may represent bowel or a polyp. The gastroenterologist recommended a colonoscopy to evaluate the area in the distal ileum, with a follow-up capsule endoscopy. The wireless capsule endoscopy noted no evidence of a small bowel lesion or polyp, but detected a small foreign body in the distal small bowel. The gastroenterologist indicates the procedure was necessary due to the lesion on the distal ileum noted on the computed tomography scan. A colonoscopy showed moderate diverticulosis. The colonoscope reached 30 centimeters into the distal ileum but no lesion was found. The physician believes only wireless capsule endoscopy could provide diagnostic imaging of the small intestine; an anatomic site that has proven peculiarly difficult to visualize.  This enrollee had a seven-millimeter structure noted on the computed tomography scan, which was investigated via a colonoscopy, but no lesion was found. The next evaluative step is a capsule endoscopy. The indications for video capsule endoscopy of the small bowel are evolving. The primary indications are to evaluate for small bowel bleeding in adults, for the diagnosis of suspected Crohn disease, and for the diagnosis of small bowel tumors.  The medical literature indicates guidelines recommend capsule endoscopy for patients with suspected, known, or relapsed Crohns disease when colonoscopy studies were negative in order to determine the presence of active Crohn's disease. It is also used for surveillance in patients with polyps other small-bowel cancers. Capsule endoscopy is described as a technology developed for the endoscopic exploration of the small bowel. This technology has been refined to provide the ability to view different parts of the gastrointestinal tract. This enrollee has a lesion, which could not be identified by colonoscopy. Video capsule endoscopy provides an expanded range of endoscopic examination of the small bowel. Final Result: Two of the three reviewers determined that the requested services are 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 gastroenterology 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

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. Applying the American Society of Addiction Medicine (ASAM) guidelines for the treatment of patients with substance use disorders, this patient meets the criteria for IOP services. ASAM notes that the treatment of cannabis use disorder is particularly suited to IOP level of care services. Although IOP may not be indicated for a patient with generalized anxiety disorder or oppositional defiant disorder, this patient has a comorbid substance use disorder, which supports treatment at this level of care. The presence of a substance use disorder in the setting of anxiety and oppositional defiant disorder supports the need for IOP, in order to successfully manage and treat the patients cannabis use disorder. Further, the records document that the patient has been able to maintain sobriety and he has been working with a sponsor. All told, the IOP 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 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 enrollee is requesting reimbursement for residential treatment center (RTC) level of care. He first started to smoke marijuana at a young age and smokes daily. He also started to use alcohol and consumes six to ten ounces of hard liquor on a daily basis. The enrollee used amphetamines and cocaine, four times intranasally. He had previous outpatient treatment for two months. The enrollee has an inconsistent appetite, unless he smokes marijuana and a sporadic sleep pattern. He had self-injurious behaviors during his teenage years, when he superficially cut himself once because of overwhelming feelings. He reports driving under the influence (DUI), lying, stealing and using substances at work. He has anxiety and loss of pleasure in previous activities. He denies feeling helpless and hopeless, suicidal/homicidal ideation, auditory verbal hallucinations or paranoia.  Mental status examination at the time of admission indicated the enrollee was alert and oriented, anxious and easily distracted. Admission diagnoses included amphetamine use disorder, severe; amphetamine withdrawal; alcohol use disorder, severe; alcohol withdrawal without perceptual disturbance; cannabis use disorder; cannabis dependence and withdrawal; unspecified anxiety disorder; unspecified depressive disorder; and post-traumatic stress disorder (PTSD). Review of the record supports the RTC level of care for two days. The patients Clinical Opiate Withdrawal Scale COWS was indicative of moderate withdrawal. The patient has a long history of substance use and uses alcohol daily.  His clinical opiate withdrawal scale score was consistent with severe alcohol withdrawal. After initiation of the lorazepam taper his scores dropped to moderate withdrawal.  The enrollee participated in all required activities and groups, including family therapy sessions with his father. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. This tool was used in this review. The enrollee demonstrates willingness to change. The enrollees composite LOCUS score correlates with medically monitored non-residential services. The enrollee had completed a lorazepam taper and was appropriate to transition to a lesser level of care for the dates in question following the initial two days.Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 dual diagnosis 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 including: (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. For dimension 1, the patient has demonstrated moderate CIWA scoring with symptoms including nausea, sweating, tremor as well as auditory and visual disturbance. The patient reported headaches, agitation, and a lack of motivation. The patient satisfies dimension 2 given his history of human papillomavirus (HPV), which has been untreated, with associated abdominal pain and nausea. For dimension 3, the patient has comorbid panic disorder and depression. The records support dimension 4, as the patient has been using for over 10 years and endorsed his last use was on the way to the RTC. The patient reported cravings, mood swings, irritability, and impulsivity. The patient has low accountability and is willing, but not yet able or ready. For dimension 5, the patient has symptoms of depression and anxiety that he has tended to self-medicate with substances and continued cravings. For dimension 6, the patient has limited support and structure outside of RTC has tended to isolate in bed. The patient requires a safe and stable living environment in order to develop his recovery skills and qualifies for ASAM Level III treatment similar to what patient has received at the current facility. Given the severity of the patients illness, the dual diagnosis RTC 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for resumption of hospice care services.The submitted documentation supports that the requested services are medically necessary. Glioblastoma multiforme, a high-grade glioma, is an incurable disease with a median survival of 18 months with treatment. Without treatment, or with progression, the median survival would be less than six months. In this case, the patient has survived nearly 24 months with a condition with a median survival of 18 months with treatment. In addition, the patient is currently bed-bound with symptoms of malaise/fatigue, weakness, and pain that is treated with Norco. The patient has a performance status of 50% or less, with recent nursing case manager notes indicating that the patient had a Palliative Performance Scale (PPS) level of 30% and remained total care with all activities of daily living. Under these circumstances, the requested resumption of hospice care services is medically necessary to treat 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 subspecialty certifications in medical oncology and hospice and palliative 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 requested reimbursement and prospective authorization and coverage for skilled nursing facility services including daily wound care and physical therapy. The specialized skill, knowledge and judgment of a skilled professional nurse has not been required to safely and effectively provide medically necessary and reasonable treatment to this patient. This patients wound care is not complex and does not require daily services at the SNF level of care. The patient does not have other skilled nursing needs. The patient has been at a functional level. All told, the skilled nursing facility services including daily wound care and physical therapy 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

An enrollee has requested authorization and coverage for continuing treatment with the Optune device and the medication Avastin.The patient has exhausted all treatment options involving surgical resection followed by radiation therapy with concurrent and adjuvant temozolomide. The submitted documentation includes two assessments from physicians caring for the patient that attest to his poor performance status, which would correspond with a grade of 4 on the ECOG Performance Status scale. The patients tumor is advanced, and the requested Optune device is not curative. Under these circumstances, continuing treatment with the Optune device and the medication Avastin is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that continued treatment with the requested device and medication 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 internal medicine, with subspecialty certification in medical 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

The parent of an enrollee has requested authorization and coverage for in-home speech therapy services.Researchers noted that the achievement of speech intelligibility by persons with Down syndrome facilitates their participation in society. Medical literature also describes that speech and language development in individuals with Down syndrome is often delayed and/or disordered and speech disfluencies appear to be more common.  Researchers also found that speech comprehensibility is malleable in school-age students with Down syndrome, and that speech therapy can significantly improve intelligibility of speech. The records document that this patient has Down syndrome, with mixed receptive and expressive language disorder. Ongoing speech therapy is medically necessary, but there is no documentation to support the need for home-based therapy. The documentation does not report any serious medical or mobility issues that would render home-based speech therapy medically necessary. Given these findings, the requested in-home speech therapy services are 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 neurology, with special qualification in child neurology, 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 been diagnosed with acquired hallux valgus, capsulitis, bilateral foot pain, and difficulty walking. The patient was noted to have bilateral bunions. The patient reported big toe pain, foot pain, and pain with range of motion of the great toe joint in bilateral feet. The physical examination revealed muscle strength rated as five out of five. No weakness or muscle imbalance was noted. A slight increase in the angle of the first metatarsal phalangeal joint with medial deviation of the bilateral hallux was noted. The provider noted an x-ray of bilateral feet revealed a bunion formation greater on the right side with midtarsal pronation. The patients parent has requested authorization and coverage for custom foot orthotics. Researchers reported that a hallux valgus (HV) deformity (bunion) is a common, potentially debilitating deformity consisting of lateral deviation of the hallux on the first metatarsal. Researchers also reported possible treatments include orthoses to improve support and alignment. Medical literature reported that conservative options for addressing the medial column include custom foot orthotics and bracing. In this case, the patient reported painful hallux valgus/bunion deformities bilaterally with x-ray confirmation of hallux valgus and midtarsal pronation. The medical evidence supports the requested equipment in this clinical setting. Therefore, custom foot orthotics are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatry 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.