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

Nature of Statutory Criteria/Case Summary: The patient is a 45-year-old male with a history of complicated inguinal hernia repair and continued pelvic and penile pain, which causes disability. Findings:  The physician reviewer found that he submitted documentation includes a record of magnetic resonance imaging (MRI) of the pelvis, which did not explain the cause of the patients pain. The patient has also tried neurostimulators with no success. The provider has requested authorization for lumbosacral plexus Magnetic Resonance (MR) Neurography at this time. The Health Plan has denied this request, stating that the requested services are not medically necessary for the treatment of the patients medical condition. At issue in this case is whether MR Neurography is medically necessary for the treatment of this patients medical condition. The submitted documentation supports that the requested services are medically necessary. This patient has a surgical history and clinical story that are suspicious for lumbar spine plexopathy, especially involving the genitofemoral nerve. MR Neurography, when performed on a 3-T magnet, has been surprisingly useful in diagnosing this condition and determines if there is a genitofemoral nerve entrapment due to extrinsic scar formation, mass, or intrinsic factors related to genitofemoral or inguinal nerves. This condition is uncommon, but when present, it is usually secondary to iatrogenic or traumatic causes. In this case, the patient has persistent symptoms, which alter his life, and routine testing and attempts at therapy have proven unsuccessful. MR Neurography would be the last remaining imaging test available to this patient. The American College of Radiology (ACR) appropriateness criteria support the use of MR Neurography in such a clinical setting. Under these circumstances, the requested Magnetic Resonance Neurography is medically necessary for the treatment of 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 diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Tazorac cream.Findings:  Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting. The treatment of palmoplantar psoriasis can involve targeted therapy with topical steroids and topical keratolytic medications. This patient has tried and failed therapy with clobetasol and urea 40% cream, as well as ammonium lactate 12%. She has failed therapy with intralesional steroids. The use of topical retinoid creams as a keratolytic agent is commonly used in dermatology to reduce hyperkeratosis and increase penetration of topical steroids. The requested medication is appropriate in this clinical setting. Therefore, Tazorac cream is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication is 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 dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient was evaluated by a pediatric endocrinologist for short stature. The patients initial evaluation included multiple labs that were normal, a normal physical exam, and a bone age that was two years delayed. Based on the patients initial evaluation, he underwent growth hormone (GH) stimulation testing with clonidine and arginine, which demonstrated a peak GH of 20 ng/dL (with clonidine). He was diagnosed with idiopathic short stature based on normal GH stimulation testing and a height that was 2.3 standard deviations (SDs) below the mean for his age. At issue in this case is whether the medication Genotropin is medically necessary for the treatment of the patients medical condition. Guidelines concluded that the impact of GH on idiopathic short statute remained unclear, and that the U.S. Food & Drug Administration approval should not obviate the need for a thorough investigation of the cause of the short stature. Updated guidelines stated that further studies are needed to clarify the benefits and long-term risks of GH treatment in the population of patients with idiopathic short stature.In this case, the patients response to GH stimulation was robust, ruling out GH deficiency. In addition, the patients delayed bone age suggests a combination of idiopathic short stature and constitutional delay of growth and puberty. The submitted documentation does not include any longitudinal height data prior to 2018, and one explanation for this patient having fallen further on the growth curve is that his peers are undergoing a pubertal growth spurt. Medical records suggests that the patients increase in height after starting GH was more likely secondary to a pubertal growth spurt than the use of recombinant GH. Under these circumstances, Genotropin is not medically necessary to treat the patients medical condition.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 pediatrics with a subspecialty certification in pediatric endocrinology 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 parent of an enrollee has requested authorization and coverage for a coordinated evaluation with a team of specialists who specialize in Shwachman-Diamond Syndrome (SDS), including a SDS specialist, allergist, gastroenterologist, endocrinologist, and pulmonologist in order to obtain a current treatment plan to best manage the enrollees condition. The submitted documentation supports the medical necessity of the requested services. SDS is a rare autosomal recessive disorder that affects multiple organ systems, and is characterized by exocrine pancreatic insufficiency, impaired hematopoiesis, and leukemia predisposition. There may also be skeletal, immunologic, hepatic, and cardiac abnormalities. SDS is classified as a bone marrow failure syndrome, and patients with this syndrome are at increased risk of developing myelodysplasia. Malignant transformation may result in acute myelogenous leukemia. These patients are susceptible to recurrent infections, particularly of the respiratory system, bones, and skin. Exocrine pancreatic insufficiency results in malabsorption, failure to thrive, steatorrhea, and decreased levels of fat soluble vitamins. Respiratory failure is not uncommon in the neonatal period as a result of rib cage abnormalities. There are a number of other abnormalities associated as well. Definitive therapy for bone marrow failure is hematopoietic cell transplantation. Even with hematopoietic cell transplantation, patients may experience graft failure/rejection, transplant-related toxicities, or relapsed leukemia. Due to the rarity of this disorder with its significant morbidity, multidisciplinary management is medically necessary. The current medical evidence supports the requested services in this clinical setting. Therefore, the requested coordinated evaluation with a team of specialists who specialize in SDS, including an SDS specialist, allergist, gastroenterologist, endocrinologist, and pulmonologist, is medically necessary in order to obtain a current treatment plan to best manage this patients 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 pediatrics with sub-specialty certification in pediatric critical care 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 coverage for weekly mental health therapy sessions. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. The Health Plan has indicated that a psychiatric evaluation is needed in order to determine the frequency of outpatient therapy sessions which are necessary. Per the Health Plan, the frequency of sessions will be recommended after this psychiatric evaluation. The majority of the documentation from November 2018 through January 2019 consisted of email communication which was largely related to disability benefits. The most recent clinical assessment completed by the provider was in November 2018. At that time, the clinical information did not indicate that the patient required weekly psychotherapy due to overall mild to psychiatric symptoms and stability. Based on the records, a face-to-face evaluation is medically indicated in order to determine the appropriate frequency of psychotherapy. There is no clear description of treatment goals for the patients requested therapy. The records do not describe clinical reasons for the requested frequency of therapy. The progress notes do not provide details regarding functional impairment. There is no clinical indication that this patients therapy needs to occur on a weekly basis. Therefore, weekly mental health therapy sessions are not medically necessary for the 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 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 is a transgender female with a history of gender dysphoria. The records noted that she has been on hormone therapy.  In a letter dated 12/6/18, the patients representative indicated the patient is seeking laser hair removal to alleviate gender dysphoria. The patient met with their medical provider to discuss laser hair removal, where it was determined by the provider it would be medically necessary to treat her gender dysphoria. The patients symptoms of gender dysphoria include persistent anxiety, depression, agoraphobia, and overall distress. On 9/18/18, the provider noted that the patient was a good candidate for laser hair removal. The patient has requested authorization and coverage for laser facial hair removal. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The submitted documentation supports the medical necessity of the requested services. Facial hair removal via laser is likely to enhance this patients psychological and social functioning. The patient has a documented history of gender dysphoria. She has been on hormone therapy. The World Professional Association for Transgender Health (WPATH) states that, in addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures include facial hair removal. This patients medical records document a history of gender dysphoria. Her mental health evaluation documents an exacerbation of gender dysphoria symptoms due to the presence of facial hair. The medical evidence supports the requested services in this setting. Therefore, the requested laser facial hair removal is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure 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 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 is a female with bilateral leg discomfort, swelling, and weakness; left leg greater than right. Per the records, she has used compression stockings. The patient has not had a deep vein thrombosis or arterial disease. A venous duplex ultrasound showed left great saphenous vein reflux and right deep venous reflux. The patient has hyperlipidemia. The records noted an elevated triglyceride level of 575 on. She has had elevated homocysteine levels and is pre-diabetic. The patient has been treated with fenofibrate. The patient has requested coverage for Vascepa and left great saphenous vein ablation. The Health Plan denied the requests and reported the requested medication and requested services are not medically necessary for the treatment of this patient. At issue is whether Vascepa and left great saphenous vein ablation are medically necessary for the treatment of the patients medical condition. The treatment for varicose veins due to greater saphenous vein incompetence and varicosities includes ablation or removal of the axial veins and interruption of significant non-axial accessory varicosities when conservative treatment fails. Clinical trial evidence suggests that radiofrequency ablation and endovenous laser treatments are as effective as surgery in the treatment of great saphenous varicose veins and have the advantage of a shorter recovery time. The American Heart Association and National Lipid Association define very high triglyceride levels as greater than or equal to 500mg/dL. This patient has this condition. Clinical practice guidelines recommend a fibrate as the drug of first choice.  In patients with severe hypertriglyceridemia, high-dose omega-3 fatty acids or niacin be initiated along with fibrate therapy. The medical evidence supports the requested medication and requested services at issue in this clinical setting. Therefore, Vascepa and left great saphenous vein ablation 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 general surgery and vascular 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: The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that RTC or similar care that is higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In addition, the American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce the risk of relapse. The RTC was in accordance with generally accepted standards of medical practice.This patients risks included her living alone without a support system in place. She required a safe and stable living environment in order to develop her recovery skills, and thus qualified for ASAM Level III treatment, which is consistent with the services provided at the RTC. Therefore, the RTC services provided from 12/12/18 through 12/16/18 were medically necessary to treat the patients behavioral health condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The diagnosis of a radial scar is associated with a low risk of malignancy. A study  noted that it may be appropriate for patients with a biopsy diagnosis of radial scar without atypia to forgo surgical excision in favor of imaging follow-up. In addition, the National Comprehensive Cancer Network (NCCN) guidelines report that there are no data on the benefit of risk-reducing mastectomy for women with ATM mutations, but this procedure may be considered based on family history. Based on peer-reviewed medical literature, risk reduction mastectomy for ATM gene mutation is not medically necessary in the absence of a positive family history. In this case, there is reference to a strong family history of cancer, including breast cancer. However, there is an absence of documentation of a family history of breast or associated cancer in first- or second-degree blood relatives. Based on the current medical evidence and peer-reviewed medical literature, this patients family history does not support the medical necessity of risk reduction mastectomy. Therefore, the requested prophylactic nipple sparing bilateral mastectomy and reconstruction (with implant) are not medically necessary for the treatment of this patient. Applying the California Reconstructive Surgery Statute, the requested prophylactic nipple sparing bilateral mastectomy and reconstruction (with implant) are not reconstructive in nature. The patients radial scar and ATM mutation do not constitute an abnormal structure of the body. Moreover, the presence of a radial scar and ATM mutation do not interfere with the patients ability to function. Furthermore, the requested surgery is not likely to provide the patient with a more than minimal improvement in appearance. All told, the requested prophylactic nipple sparing bilateral mastectomy and reconstruction (with implant) are not medically necessary or reconstructive in nature for treatment of this patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has chronic pain related to a motor vehicle accident. Records noted that the patient  was prescribed tizanidine and Tylenol #3. The Health Plan has denied this request and reported that the requested medications are not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested medications. The stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative setting. In this patients case, not all non-opioid treatment options have been utilized. There is no mention of the completion of behavior therapy documented, despite significant research supporting its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention states when opioids are started, clinicians should prescribe the lowest effective dosage. Moreover, the medical evidence supports muscle relaxants only for short-term use. Not all non-opioid medications classes have been optimized or tried. Therefore, Tylenol #3 and tizanidine are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology, 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.