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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testosterone injections. The submitted documentation supports the medical necessity of the requested medication. Low testosterone can lead to complications such as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment, in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. The patient has failed therapy with transdermal testosterone. The patient will benefit from intramuscular testosterone therapy. Therefore, the requested testosterone injections are medically necessary for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for transporting the enrollee back to the United States.Findings: Air ambulance is considered medically necessary under certain circumstances. These circumstances can include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport. Another circumstance would be when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one institution to another in order to receive specialized services such as trauma care or a burn unit. Patient conditions to be considered include: unstable vital signs, spinal cord injury, severe chest or abdominal injury, severe burns, or amputations. In such cases, air transport is medically necessary in order to transfer the patient to the closest facility capable of providing a higher level of care. In this case, the patient was described as stable upon arrival to Torrance. The documentation noted that the patients chest tube had no air leak on arrival in Torrance. The tube was clamped. The pneumothorax had resolved. The chest tube was removed. His vital signs were normal. He did not require an acute surgical intervention. Further, TMMC is not a trauma center. The submitted documentation does not establish that the patient could not have been appropriately treated in Costa Rica. As such, the documentation provided does not support the medical necessity for air ambulance transport from San Jose, Costa Rica to Torrance, California. Therefore, air ambulance services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 emergency 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 Orthovisc (hyaluronan) injection services. Hyaluronic acid injection for osteoarthritic knee pain has become an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term use, the injections have been confirmed to be safe with no severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can all have serious systemic side effects and may not be reasonable treatment options for some patients. This patient reports consistent relief with hyaluronic acid injections. Given this support, the requested Orthovisc (hyaluronan) injection services is medically necessary for treatment of this patients bilateral 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. Hyaluronic acid injection for osteoarthritic knee pain has become an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term use, the injections have been confirmed to be safe with no severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can all have serious systemic side effects and may not be reasonable treatment options for some patients. This patient reports consistent relief with hyaluronic acid injections. Given this support, the requested Euflexxa injections are medically necessary for treatment of this patients bilateral 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee replacement surgery. The submitted documentation supports the medical necessity of the requested services. Indications for joint replacement surgery generally include failure of conservative treatment, subjective findings of stiffness, nighttime joint pain, minimal pain relief with conservative care, current significant functional limitations, age over 50 years, body mass index less than 40, and weight-bearing x-ray findings of significant osteoarthritis. This patient presents with a history of chronic left knee pain. He has reported functional limitations with activities of daily living. His symptoms and clinical examination findings have been consistent with imaging evidence of severe osteoarthritis. Weight-bearing x-rays of the left knee demonstrated varus alignment, bone on bone findings in the medial compartment, decreased lateral and patellofemoral joint space, subchondral sclerosis, and osteophytes on the distal femur, patella, and tibia. Detailed evidence of long-term comprehensive nonoperative treatment and failure has been submitted. The medical evidence supports the requested services in this clinical setting. Therefore, the requested left knee replacement surgery 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epidural injection for treatment of the enrollees back pain. Findings:  The physician reviewer found that evidence based medical guidelines recommend lumbar spine epidural steroid injections with use in conjunction with active rehabilitative efforts. The literature supports these injections as a possible option for short term treatment of radicular pain, pain in dermatomal distribution with corroborative findings of radiculopathy. The criteria for the use of epidural steroid injections include documentation of radiculopathy with objective findings on examination and corroborated by imaging studies and/or electro-diagnostic testing, and initially unresponsive to conservative treatment. Current peer reviewed literature concludes that both epidural injections with steroids or with local anesthetic alone provide significant pain relief and functional improvement in managing chronic low back pain secondary to lumbar spinal stenosis. This patient presents with persistent moderate to severe low back pain radiating into the right anterolateral thigh to the anterior knee. Signs/symptoms are consistent with spinal stenosis. Clinical examination findings have documented motor deficits and reflex changes consistent with imaging evidence of multilevel lumbar stenosis and plausible nerve root compromise, most severe at the L3-4 and L4-5 levels. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Therefore, the requested injection is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injection 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential eating disorder treatment. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral issues.The documentation provided does not support the medical necessity of the services at issue in this clinical setting. Given that the patient was not medically compromised, there is data supporting that inpatient treatment such as a residential treatment center does not provide advantages over outpatient management. The standard of care is to treat patients in the least restrictive environment possible. A study found first-line inpatient treatment does not provide advantages over outpatient management, and that patients who do not respond to outpatient treatment do poorly on transfer to inpatient facilities. In the Handbook of Assessment and Treatment of Eating Disorders, it states that, A PHP [partial hospitalization program] is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight (e.g., greater or equal to 80% of ideal body weight) and maintain other evidence of medical stability. This patient was medically stable. The patient was motivated for treatment. The patient was cooperative with staff and participated in group sessions and individual sessions. The patient did not have any suicidal or homicidal ideation. She did not have any psychosis, hallucinations, or mania. Therefore, the medical necessity of the residential eating disorder treatment has not been established for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were 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 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: A patient has requested authorization and coverage for Ingrezza 40 mg capsule. Tardive dyskinesia is a serious side effect from antipsychotic medications characterized by involuntary movements. Ingrezza was approved in 2017 for tardive dyskinesia. The patients tardive dyskinesia was noted in progress notes and in the providers letter. Based on the available clinical data, Ingrezza is approved for the patients condition and is reasonably expected to improve the patients condition. Moreover, there is no available alternative treatment at this time. As such, the requested Ingrezza 40 mg capsule is medically necessary for treatment of this patients medical condition. 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 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 excision of excessive skin, tissue and suction assisted lipectomy in both upper extremities for treatment of the enrollees overgrowth of her upper arms and are not reconstructive in nature.  Findings:  The physician reviewer found that Based on the documentation provided, the patient has sufficient evidence of functional impairment related to severe excess soft tissue of bilateral upper arms.  The patient reports shoulder and neck pain that appears to be attributed to the excess soft tissue. This is supported by a review of the photographs submitted as well as the provider documentation. In addition, the record indicates that conservative management via physical therapy and medical management have not been effective. The patients excess soft tissue of the bilateral upper arms is a functional impairment. Accordingly, the requested excision of excess skin and tissue is medically necessary for treating this patients medical condition. However, suction assisted lipectomy is not medically necessary. Liposuction would not address functional impairment.With regards to whether the alleged abnormality constitutes an abnormal structure of the body, the patient has evidence of abnormal excess of skin and fatty tissue of the upper extremities as demonstrated by the photographs and documentation. The excess tissue was caused by obesity, which is considered a disease. The requested excision of excess skin and tissue (brachioplasty) will improve function and assist to create a normal appearance to the extent possible.  Moreover, brachioplasty will provide more than a minimal improvement in the patients appearance. However, this would not be the case with liposuction of the bilateral upper extremities. The functional impairment and abnormal appearance of her bilateral upper extremities should be adequately treated with resectional technique and not liposuction. Therefore, excision of excess skin and tissue in both upper extremities is reconstructive in nature.  However, suction assisted lipectomy does not meet the criteria under the expanded concept of reconstructive surgery.Final Result: The reviewer determined a portion of the requested services is medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.The submitted documentation fails to demonstrate the medical necessity of the requested medication. In the documentation submitted for review, there is a lack of objective treatment goals for pain and function. When starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting opioids. Additionally, when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  There was no medical evidence based rationale given for this high of a dosage. The medical literature is clear that dose escalation is not a long term plan, but a short term plan for the treatment of tolerance. Risk and benefit analysis must be performed to justify the requested dose. The records do not show clear objective goals with a higher dose of opioid have been established by the provider or the patient. There is no record of completion of behavior therapy despite much research to support its use. In addition, the medical literature indicates that the use of opioids has been linked to significant problems with treating headaches and may cause continued headaches. Finally, not all non-opioid medications classes have been optimized or tried.  For all these reasons, the requested authorization and coverage for OxyContin, has not been established as medically necessary for treating this patients medical condition.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 anesthesiology with 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.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for out-of-network services received. The services on 03/31/17 do not meet criteria for an emergency medical condition. The patient's symptoms were not sudden or acute in onset. She was not in severe pain. The patient had already been evaluated by a podiatrist and had undergone x-ray imaging. She had not sustained any new or recent trauma. Symptoms of the gradual onset of a painless bump on an extremity do not meet criteria for an emergency medical condition. The services provided on 7/19/17 meet criteria for an emergency medical condition. The patient was a contact lens wearer who had developed superficial punctate keratitis. She had been placed on topical medications and advised she needed follow-up exam. On the date in question, the patient was still symptomatic. Since keratitis may cause permanent vision loss, it was medically prudent for the patient to have a repeat eye exam. Persistent symptoms of keratitis would be considered an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on 7/19/17. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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.