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

Nature of Statutory Criteria/Case Summary: The patient is a 52-year-old male with symptoms of edema, fatigue, aches/pains, and cramps in the lower extremities. Findings:  The physician reviewer found that an ultrasound performed showed reflux of over 1000 ms in the greater saphenous vein (GSV) of the right and left legs, and a refluxing perforator vein in the right and left legs. The ankle brachial indices, pulse volume recording, and arterial ultrasound performed were all normal. The patient was prescribed compression stockings. On ------ the patient reported continued symptoms of edema, fatigue, and bulging veins. A repeat venous ultrasound of the legs showed the same findings as the study on -------. The patient has requested coverage for endovenous ablation therapy of incompetent veins right and left. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue is whether endovenous ablation therapy of incompetent veins right and left is medically necessary for the treatment of the patients medical condition. This patient had clinical symptoms consistent with venous hypertension of the lower extremities, including cramping and aching. The clinical work-up documented the absence of arterial disease and the presence of venous insufficiency as the cause of symptoms. There was no evidence of chronic deep vein insufficiency or thrombosis. Therefore, the clinical indications for superficial lower extremity vein ablation were met.  The records noted superficial venous insufficiency and a duplex scan documenting reflux greater than 0.5 seconds. Per the medical evidence, endovenous thermal ablations are safe and effective and are recommended for treatment of saphenous incompetence. Medical literature supports providing endovenous ablation for symptomatic venous insufficiency with documentation of reflux, as this patients medical history supports. Therefore, the requested endovenous ablation therapy of incompetent veins right and left is 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 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 presents with clinical symptoms of hypogonadism, including fatigue and dysthymia. Records noted low testosterone levels. The patient has requested coverage for testosterone. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. Low testosterone can lead to complications of reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. Providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The recommended therapy for men with symptomatic testosterone deficiency is to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism. Clinical guidelines recommend making a diagnosis of hypogonadism in men with signs and symptoms consistent with testosterone deficiency and unequivocally and consistently low serum testosterone concentrations, drawn while fasting in the early morning. This patients laboratory test was obtained in the afternoon rather than in the morning, as recommended by clinical guidelines. The medical evidence does not support the requested medication in this clinical setting. Therefore, the requested testosterone is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested service 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 a sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient was admitted for intensive outpatient program (IOP) services on 10/25/18. His diagnoses included: depressive disorder; oppositional defiant disorder; personal history of self-harm; attention deficit hyperactivity disorder; and cannabis use disorder. The progress notes indicate the patient has made minimal behavioral improvement and has engaged in recent self-harm and substance use. The patient was noted to continue to have stressful relationships due to lack of his ability to follow rules. The progress notes document minimal participation and investment in therapy. The patient continues to have some depression symptoms, substance use, and relationship issues. The progress notes indicate that the patient does treatment activities to appease others. It appears the continued group and individual therapy will be beneficial for the patient. It also appears that continued family therapy is crucial for recovery. 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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient has composite score of 19, which correlates with a treatment intensity level of three, which is for IOP services. Given this support, the IOP services provided from 1/16/19 forward were and are medically necessary to treat the patients behavioral health conditions.Final Result: The reviewer determined that the requested services 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for dopamine transporter imaging with single photon emission computed tomography (DaT-SPECT) that was provided on 3/2/18. The Health Plan has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. A review of the records indicates that the enrollee presented to his provider on 2/19/18. The provider noted that the enrollee had symptoms suggestive of rapid eye movement (REM) behavior disorder. The records noted a history of tremors, balance problems and other symptoms suggestive of dysautonomia. The provider recommended a DaT-SPECT scan to rule out striatonigral form of parkinsonism. The Health Plan indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Plan has denied reimbursement for the services at issue. One reviewer found that the DaT-SPECT scan provided on 3/2/18 was not likely to have been superior over other methods of evaluating this patient. Final Result: Two of the three reviewers determined that the requested procedure is likely to be more beneficial for evaluation 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 neurology 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 has been diagnosed with primary female infertility. The submitted documentation reflects that the patient has attempted to become pregnant on two separate occasions by intrauterine insemination (IUI) in 2014 and 2016. These attempts included two IUI and nine IUI cycles, respectively. The patient has stated that she and her husband have been unable to conceive naturally and that IUI is the only thing that has worked for her. At issue in this case is whether infertility treatments (including CPT code 58323 for sperm preparation, CPT code 58322 for intrauterine insemination, CPT code 99214 for office visit, and CPT code 76830 for ultrasound) received from 12/07/18 forward were medically necessary to treat the patients medical conditionPatient age has a statistically measurable impact on pregnancy rates, and logistic regression analysis of intrauterine insemination (IUI) patients shows a drop in pregnancy rates with increasing age. Researchers reported that pregnancy rates for IUI patients aged 40 years remained stable even after more than three cycles, up until six cycles. Six cycles are considered a maximum to determine efficacy, as rates of pregnancy significantly decrease with increasing IUI use. Maternal age is the predominant factor in determining fertility in women with advanced maternal age. Success rates are exceedingly low with IUI in women after 40 years of age. A study revealed that in patients over 40, in vitro fertilization (IVF) should be considered after one failed IUI cycle. In this case, the patient has already undergone 12 total cycles of IUI with the last cycle in December of 2018, and she is now above the age of 40. Due to waning efficacy, and failure as defined by six cycles of IUI, further IUI cycles are unlikely to result in pregnancy. Thus, intracytoplasmic sperm injection (ICSI) or in vitro fertilization (IVF) should be considered. Under these circumstances, the infertility treatments (including CPT code 58323 for sperm preparation, CPT code 58322 for intrauterine insemination, CPT code 99214 for office visit, and CPT code 76830 for ultrasound) received from 12/07/18 forward were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for hippotherapy. A review of clinical studies and research indicates that hippotherapy is a subset of animal assisted therapies that uses the characteristic movements of a horse to provide carefully graded motor and sensory input. The goal is to improve neurological function and sensory processing which can then be generalized to daily activities for patients with a variety of disabilities, including autism. However, a study found that the effectiveness of hippotherapy remains unsupported. Researchers evaluated all equine assisted activities and therapies, and found three studies suitable for meta-analysis. The authors reported the results of the meta-analysis indicated no statistically significant differences compared to control groups. The authors concluded that further research is needed. According to the National Autism Centers National Standards Project, behavior based techniques, such as applied behavioral analysis (ABA) therapy, are recommended for patients with autism. All told, the requested hippotherapy is not likely to be more beneficial for treatment of this patients autism spectrum disorder than standard available therapies.Findings:  Three physician reviewers found hippotherapy is not likely to be more beneficial for treatment of this patients autism spectrum disorder than standard available therapies.Final Result: The reviewers determined that hippotherapy is not likely to be more beneficial for treatment of this patients autism spectrum disorder than standard available therapies.Credentials/Qualifications: Physician reviewers 2 and 3 are board certified in psychologist and board certified behavior analyst,and are actively practicing. Physician reviewer 1 is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is 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: A patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that he Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested physical therapy. While the patient has had ongoing symptoms, there are no indications that she has any impairments that would preclude independent management, to include low impact aerobic exercise and gentle stretching for her fibromyalgia, wrist splint(s) for carpal tunnel syndrome, and general measures such as topical heat. These are the mainstays of management for her condition, and there is no proven marginal improvement in the clinical course or outcomes with prolonged formal physical therapy over these types of independent management strategies for the patient's conditions. In this case, the patient has had various chronic pain complaints and she has undergone extensive physical therapy to address and palliate her symptoms. The patients symptoms have persisted, and there is no indication that further physical therapy would be expected to positively impact her course clinically. Under these circumstances, the requested physical therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested physical therapy 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 physical medicine & rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request and reported that the requested services are investigational for the treatment of the enrollees knee pain. A review of the records indicates the patient has a history of lumbar disc herniation, lumbar radiculopathy, fibromyalgia, rheumatoid arthritis, and left knee osteoarthritis. Previous treatments for her left knee pain have included cortisone injection and physical therapy. On 10/2/18, the records noted that the enrollee experienced pain relief from a previous Euflexxa injection, and she was able to decrease her use of anti-inflammatory drugs. The provider recommended repeating Euflexxa injections into the left knee. The Health Plan indicates that the requested services are investigational for the treatment of the enrollees medical condition. Therefore, the Health Plan has denied coverage for the Euflexxa injections. One reviewer found that the requested Euflexxa injections are likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested Euflexxa injections are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 32-year-old transgender male to female with history of gender dysphoria, and cross-gender hormone treatment. The patient has been taking cross-gender hormone therapy since 2005. The patient has symptoms of persistent anxiety, depression, agoraphobia, and overall distress. The patient reports that consistently being mis-gendered due to the presence of facial hair exacerbates her symptoms of gender dysphoria. The patient was referred for gender affirming laser facial hair removal. Guidelines for the medical necessity of facial feminization surgery (FFS) from World Professional Association for Transgender Health (WPATH) provided guidance on gender reaffirming procedures. On the classification of laser hair removal, the WPATH states that, In addition to hormonal balancing, medically necessary gender affirming/confirming surgical proceduresinclude complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. This patient is noted to have a history of symptoms of persistent anxiety, depression, agoraphobia, and overall distress due to being mis-gendered on the basis of the presence of facial hair. Based on these findings, laser removal of facial hair is medically necessary for treatment of this patients gender dysphoria.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, 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

Findings:  The physician reviewer found that the enrollee has a history of osteoarthritis of both knees. She has failed other treatments, including physical therapy, weight loss attempts, nonsteroidal anti-inflammatory drugs, and corticosteroid injections. However, she benefitted from viscosupplementation in the past. She has recurrence of pain in both knees and the provider has requested repeat viscosupplementation with Hyalgan. Review of the recent literature with regard to use of viscosupplementation for management of osteoarthritis of the knees continues to support the use of viscosupplementation for osteoarthritis of the knees. According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. In addition, another research reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The researchers found that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Moreover, intra-articular hyaluronic acid results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the request for Hyalgan injections of both knees is medically necessary for treatment of this patients knee osteoarthritis.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.