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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with medial and patellofemoral compartment osteoarthritis of the  knee. The provider noted the patient received two weeks of benefit from a prior knee cortisone injection. The patient was noted to be attempting weight loss. Physical examination findings included knee medial femoral condyle tenderness. The provider noted a knee magnetic resonance imaging (MRI) revealed moderate medial and patellofemoral compartment osteoarthritis. The provider also noted x-rays revealed moderate knee medial compartment and patellofemoral osteoarthritis. The patient has been treated with knee arthroscopic surgery. The patient has requested authorization and coverage for a Synvisc-One injection in the knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in the knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients 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 patients options are limited. The patient has tried and failed other conservative treatments as well as arthroscopic surgery, with the alternative being knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the  knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.  Although the patient is age 18, the CALOCUS criteria will be used instead of the adult criteria, due to her developmental status as she was under the care of her parents and attending high school when her IOP treatment began, and continued to live at home during the course of her treatment. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to recent psychiatric hospitalization for suicidality and self-harm, and continued suicidal thoughts and urges to self-harm during IOP treatment. In terms of functional status, the records support as score of 3. The documentation noted moderate functional impairment, due to interpersonal conflicts and struggles with daily activities including sleeping and eating. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity, due to recent substance use, and diagnoses of depression and anxiety. In terms of the level of stress of the recovery environment, the records support a score of 2. The patient has a mildly stressful environment due to disruptions caused by the shelter-in-place orders, completion of high school, and pending transition to college. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate and/or equivocal resiliency and/or response to treatment, due to persistence of symptoms despite an extensive treatment history at various levels of care. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment, with some struggles in fully implementing the strategies learned. Thus, the patient has at total score of 18. In this case, the recommended level of care is high-intensity community-based services. This is consistent with the IOP level of care that the patient received. Therefore, IOP services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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 Facial Feminization Surgeries (CPT code 15824: rhytidectomy, forehead; CPT code 30410: rhinoplasty, primary, complete; CPT code 20926: tissue graft, other; CPT code 15829: rhytidectomy, SMAS flap; and/or CPT code 15876: suction assisted lipectomy).The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria, which the surgery does through harmonization with regard to other modified structures, achieving an aesthetic result beyond gender difference (Capitan, L., et al., 2020). The World Professional Association for Transgender Health (WPATH) has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. The WPATH has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition (WPATH, 2016). Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life (Ainsworth and Spiegel, 2010).In this case, documents indicate that the patient has a diagnosis of gender dysphoria. Progress notes indicate that the requested procedures are necessary in order to feminize the patients face. The progress notes explain that due to the patients gender dysphoria, accomplishment of the requested procedures will allow the patient an ability to appropriately assimilate into society as a female and will permit her to more fully self-identify as a female. Under these circumstances, the requested Facial Feminization Surgeries (CPT code 15824: rhytidectomy, forehead; CPT code 30410: rhinoplasty, primary, complete; CPT code 20926: tissue graft, other; CPT code 15829: rhytidectomy, SMAS flap; and/or CPT code 15876: suction assisted lipectomy) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollees parent has requested reimbursement and prospective authorization and coverage for food-tolerance induction program (TIP) with oral immunotherapy. Food oral immunotherapy may promote desensitization to food protein but it is has been associated with increased risk of adverse reactions. Oral immunotherapy with rush phase or build-up phase may improve peanut tolerance, but may also induce moderate-to-severe allergic response. This patient was started in food TIP due to cows milk and peanut allergy. However, the American Academy of Allergy Asthma and Immunology (AAAAI) guidelines do not recommend oral immunotherapy in this patients clinical setting due to uncertainty whether therapeutic benefit outweighs risk of treatment. Overall, there is a lack of consensus on the optimal protocol for oral immunotherapy as well as concern regarding the risks for anaphylaxis and other adverse reactions. Given these findings, the food TIP with oral immunotherapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is requesting authorization and coverage for Vemlidy 25 mg tablets.Findings: Guidelines recommend entecavir and tenofovir for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer incidence of side effects such as osteopenia and renal disease. However, the other guidelines also support the safety and efficacy of entecavir for the treatment of hepatitis B, and entecavir is not associated with these adverse effects. This patient does not have a documented contraindication to entecavir. For these reasons, the request for Vemlidy is not supported as 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 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

The patient has been diagnosed with right knee osteoarthritis, and is requesting authorization and coverage for Orthovisc injections in the right knee. Findings: Medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients 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 a history of benefit from prior viscosupplementation injections. The patient has also tried and failed other treatments, including previous surgical procedures on the right knee, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee are 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 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

The patient is a 57-year-old female who has been diagnosed with left knee osteoarthritis. On the provider noted the patient has been treated with a left knee cortisone injection approximately six weeks prior which was helpful for a short time. On 6/5/20, the patient reported left knee pain and swelling. Physical examination findings included tenderness over the left knee medial greater than lateral joint line. The provider noted an x-ray of the left knee revealed greater than 50% medial joint space narrowing. The patients body mass index was 44.28. The patient has been treated with Motrin and Nexium due to gastrointestinal side effects. The patient has requested authorization and coverage for Orthovisc injection in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients 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 patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the left knee are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) infusions with Privigen 50 grams administered over two days monthly for three months. This patient is status post kidney transplantation with rising serum creatinine in the setting of rising BK viremia (BKV) without clinical diagnosis of rejection. In the medical literature, reported on a study evaluating the safety and efficacy of IVIG in the treatment of patients with persistent BKV and BK virus-associated nephropathy (BKVN) following renal transplant. The authors found that IVIG administration appeared to be safe and effective in treating BKV viremia and BKVN and preventing graft loss in patients who had inadequate response to immunosuppression reduction and leflunomide therapy. Based on current data, IVIG is the standard of care as a first-line therapy for BKVN that can result in allograft failure. Given this support, the requested IVIG infusions with Privigen 50 grams administered over two days monthly for three months is medically necessary for 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 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics. There is a lack of clinical indication for the patient to remain admitted to the hospital in order to complete her antibiotic dosing. Such medications can be safely administered in a long-term care setting such a skilled nursing facility or another long-term care facility. Moreover, prolonged hospitalization increases this immunocompromised patients risk to other infections. As such, an infection such as a UTI is treated without inpatient care in an outpatient setting when possible. For these reasons, the requested continued hospitalization until her course of antibiotics is complete for her infection and her heart rate is stabilized is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for lifitegrast (Xiidra) 5% eye drops. Patients with Stuve-Wiedemann syndrome may require ocular treatment for conditions such as dry eye disease. Lifitegrast is an anti-inflammatory medication that has been shown to improve dry eye symptoms. In this case, given that the patients dry eye disease is not controlled with her current therapy, a trial of lifitegrast is medically indicated. Therefore, lifitegrast (Xiidra) 5% eye drops are medically necessary to prevent disease, disability, and other health conditions or their progression.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has serious risk of harm, due to self-harm prior to admission, and continued to demonstrate impulsivity and rule breaking at the RTC. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients conflict with parents and with peers at the RTC, without physical aggression. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of substance abuse. The patient reported using cannabis heavily at home, continued to test positive for THC at the RTC, and was reported trying to gain access to confiscated cannabis while at the RTC. The substance abuse contributed to other impulsive behaviors. In terms of stress of the recovery environment, the records support a score of 2. The patient has a mildly stressful environment due to struggles with performance expectations at home. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents active participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment. She demonstrated continued substance use and depressed mood despite multiple prior experiences with IOP, OP, and psychiatrist hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to her rule-breaking at the RTC. Thus, the patient has a total score of 22. Given the patients risk of harm, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient was and is receiving at the residential treatment center. Therefore, psychiatric RTC services were and are medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous (IV) Reclast 5 mg.  Findings:  The physician reviewer found that based on the available documentation, this patient has osteopenia on dual energy x-ray absorptiometry (DEXA) scan and her fracture risk score is 6.5%. Previous therapy has included IV zoledronic acid, which the provider noted the patient was able to tolerate. The patients clinical presentation is complicated by inflammatory bowel disease (IBD) and erosive gastritis. The medical records demonstrate gastrointestinal issues that prevent her from tolerating oral bisphosphonates. However, there is no history of contraindication to IV bisphosphonates or of chronic kidney disease. Given the patients presentation, the current National Osteoporosis Foundation (NOF) support treatment with IV bisphosphonates. Reclast is the preferred IV bisphosphonate for use when oral bisphosphonates are not tolerated, as in this case. Overall, the records indicate a need for bisphosphonate therapy via IV route. For these reasons, the requested IV Reclast 5 mg is medically necessary for 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 subspecialty certifications in allergy and immunology and 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.