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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services.   The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. Based on the LOCUS recommendations, this patient met the criteria for the PHP level of care services. The patient was at serious risk of harm to herself (score 4) given a recent injury with a knife and ongoing endorsement of desire to die as well as self-injurious urges. The records indicate the patient continued to struggle with severe mood lability as well as urges for self-harm and panic. The patient demonstrated moderate functional impairment (score 3) as she endorsed purging at least twice monthly and had difficulty completing activities of daily living. The provider noted that the patient was frequently social withdrawn and would have dissociative episodes. The records document that the patients family was actively involved in her treatment. The patients resilience and treatment history was poor (score 4) given that she tried to hang herself in the inpatient setting and continued to cut herself in the PHP environment. She demonstrated some minor improvement during PHP treatment, but remained at high risk for decompensation. The patient was constructive in treatment (score 2). The records report that the patient was accepting of her psychiatric illness and the negative effects on her functioning. She was motivated to change, but would regress at times and engage in unsafe behaviors. She did seek out staff for support during the episodes of regression. This gives the patient a composite score of 21, which is consistent with medically monitored residential services. Based on assessment with the LOCUS criteria, patient met the criteria for continued stay in medically monitored non-residential services or PHP. Therefore, the PHP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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: The patient has requested authorization and coverage for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS guidelines, the patient met the criteria for IOP services. The patient was at moderate risk of harm (score 3) due to recent suicidal ideation and impulsive behaviors. The records document that the patient expressed suicidal ideation due to conflicts with his family. The patient demonstrated moderate functional impairment (score 3), given his problems in interpersonal interaction and difficulty attending treatment. The patient had no major comorbidities (score 2) as he was overall medically stable without evidence of substance use. He continued to have symptoms of mental illness including depression and anxiety. The patients recovery environment was mildly stressful (score 2) due to a stable living environment but strained relationship with his family. The patient had limited support in his recovery environment (score 3) due to few supportive resources. The patient demonstrated moderate response to treatment (score 3) considering his recent treatment response in the IOP, but the presence of persistent symptoms. The patient was obstructive in treatment (score 3) due to fair cooperation in treatment but limited ability to accept responsibility for his recovery. The progress notes during the disputed period indicate that the patient was minimally cooperative in treatment. The patient showed some minimal commitment to therapy but also exhibited counterproductive behaviors. The patient demonstrated limited insight into his need for treatment, was late to treatment, and missed sessions. This gives the patient a composite score of 19, which correlates with high intensity community based services, such as IOP. All told, the documentation supports that the IOP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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:  The enrollees parent is requesting authorization and coverage for comprehensive orthodontic treatment of adolescent dentition. The enrollee has bilateral severely impacted maxillary cuspids, transversely constricted dental arches, a 100% deep and impinging overbite, and ankyloglossia with resultant tongue-thrust habit. The provider has recommended orthodontic treatment to provide the best chance of developing a healthy, functional occlusion; including attempting to successfully bring his ectopically impacted cuspids into proper occlusion. The provider indicates there is a possibility of root damage to the adjacent teeth due to the impacted cuspids, and a possibility the impacted cuspids could become ankylosed. Upon review of the record, it is evident the enrollee exhibits a significant malocclusion. The Handicapping Labiolingual Deviation (HLD) index is a tool to assess for severity of malocclusion. This index provides six specific conditions that automatically qualify a person for orthodontic care.  Additional criteria, utilizing a point system, apply if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 28 points is necessary. In this enrollee, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors (canines). The record supports this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. The validity of the Handicapping Labiolingual Index for assessing orthodontic need has been demonstrated through scientific scrutiny in peer reviewed journals. Reviews concludethis index is a valid and reliable determinant of need for orthodontic care.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prolotherapy (CPT code 0232T) in the left knee. There is a paucity of medical literature supporting the long-term safety and efficacy of platelet-rich plasma for treatment of knee pain. In addition to transient side effects such as post-injection swelling and pain, short duration nausea and dizziness, the incidence of side effects appears to be more common with multiple injection protocols. Short-term benefits, lasting from six months to over one year, have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. Filardo and colleagues performed a randomized controlled trial comparing platelet-rich plasma injections to hyaluronic acid injections in a 192 patients with 12-month follow-up. The authors reported significantly more post-injection swelling and pain in the platelet-rich plasma group with no significant differences in outcome. The authors concluded that platelet-rich plasma should not be preferred to viscosupplementation. This patient underwent prolotherapy with platelet-rich plasma injections on two occasions for symptomatic right knee osteoarthritis. Based on the peer-reviewed medical literature, platelet-rich plasma injections are not recommended for the treatment knee osteoarthritis over standard therapies. All told, the prolotherapy (CPT code 0232T) in the left knee was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the prolotherapy (CPT code 0232T) in the left knee was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment 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

The patient has requested authorization and coverage for compounded suppositories with Baclofen 4 mg and diazepam 5 mg. The documentation reviewed supports that this patient presents with chronic pelvic pain. She has been under the care of a pain specialist who recommended a compounded vaginal suppository medication of Baclofen and diazepam. While this is not the first-line treatment in pelvic pain, the compounded vaginal suppository medication of Baclofen and diazepam is an alternative treatment that has been studied and shown to be beneficial to patients with pelvic pain. Pelvic pain patients are difficult to treat with a goal of avoiding narcotic dependence. In this case, the use of this compounded medication is providing pain relief to the patient without using narcotics. It is medically necessary to manage this patients chronic pelvic pain so that she be able to conduct activities of daily living. Therefore, the requested compounded suppositories with Baclofen 4 mg and diazepam 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for eight transcranial magnetic stimulation (TMS). Leggett and colleagues concluded that the evidence available on the use of repetitive TMS (rTMS) for adults with treatment resistant depression suggests that, rTMS is approximately twice as effective as a sham procedure, although the optimal rTMS protocol remains unclear. The current evidence-based medical literature has not defined the exact number of maintenance TMS treatments needed for successful resolution of depression symptom. The data indicates that some patients require more than 30 TMS sessions to have successful resolution of their symptoms. The records provided for review document that this patient underwent 36 TMS sessions with a reported nearly complete resolution of her depression symptoms. The patient experienced a return in her depression symptoms around the same time that her provider recommended an additional eight TMS sessions. The provider noted that the patient tolerated TMS and the prior sessions administered were effective to alleviate the patients symptoms of depression. Given these findings, the additional eight TMS (CPT code 90868) treatments were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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

 Case Summary:  The enrollees representative is requesting authorization and coverage for the requested medication, Nutropin AQ Nuspin. The endocrinologist has prescribed growth hormone therapy for this enrollee. The enrollee is diagnosed with idiopathic short stature (ISS). The medical literature indicates classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency. The diagnosis of GH deficiency is based on auxological, biochemical and sometimes radiological findings. The auxological criteria upon which a biochemical evaluation is to be initiated include 1) severe short stature, defined as a height more than 3 SDS below the mean; 2) height more than 1.5 SDS below the midparental height; 3) height more than 2 SDS below the mean and a height velocity over one year more than 1 SDS below the mean for chronological age, or a decrease in height SDS of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2 SDS below the mean over one year or more than 1.5 SDS sustained over two years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml. Review of the record indicates the patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. FDA approval for this indication is for non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The record indicates the patient does not have a pre-treatment height less than or equal to -2.25 SDS. Therefore, the patient does not meet idiopathic short stature criteria. There is insufficient evidence in the record substantiating the patient meets any nationally accepted criteria for use of growth hormone. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for a prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) scan (CPT code 78813). The enrollee underwent a prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan to evaluate his response to therapy. His prostate specific antigen (PSA) was 0.3. The record indicates the enrollee has been receiving Lupron and abiraterone to control this disease, as well as radiation. To assess his response to treatment, a follow up scan was performed to compare to his last scan. His physician indicates the effectiveness of his current therapy needed an evaluation in order to decide if more aggressive treatment is needed. Current evidence-based guidelines for the management of prostate cancer were established using computed tomography (CT), magnetic resonance imaging (MRI) and bone scan. Prostate-specific membrane antigen (PSMA) positron-emission tomography (PET)/CT has higher sensitivity and specificity and can lead to changes in disease management. The literature for PSMA PET/CT is mostly in the setting of biochemical recurrence and primary staging of intermediate-to-high-risk prostate cancer. Lack of a globally accepted, standardized reporting system for PSMA PET/CT is a current limitation of this procedure. Such standardization is essential to incorporating this imaging process in clinical trials to assess its impact on outcomes; particularly when upstaging or downstaging conventionally-imaged disease. This would then lead to recognition by healthcare providers, incorporation into guidelines and routine use in clinical practice.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for proton beam therapy. Guidelines do not endorse the routine use of proton therapy in the treatment of breast cancer (Allen, et al.). However, in this patients case, the data submitted suggests that treatment with proton techniques was indicated to improve sparing of the heart compared to standard intensity modulated radiation therapy (IMRT) with photon techniques. While in the majority of cases, IMRT or three-dimensional (3D) conformal techniques with photons is able to achieve an acceptable cardiac and lung dose, for this patient, the heart abuts the chest wall more than normal and acceptable cardiac sparing was not achievable with standard techniques. The providers notes included comparative planning, which showed a significant drop in the mean heart dose from 8.0 Gy to 0.34 Gy. The typical constraint on the heart mean dose is less than 4.0 Gy, which was not possible with the IMRT treatment plan. Based on these findings, proton beam therapy was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of the keloid scar on the right ear lobe. Keloids arise after a disruption of skin integrity following superficial or deep injuries. Keloids are composed of mainly type III (early) or type I (late) collagen. Some of the symptoms include pruritus, tenderness, and pain. Although keloids have an aggressive growth pattern, they are generally benign tumors, as development of malignant cells in a keloid is rare. Tissue bulk can cause functional problems, and some keloids are symptomatic with associated itching and/or pain. In addition to symptoms such as tenderness, pain, and burning, keloids may lead to sleep disturbances, anxiety, depression, and disruption of daily activities. In addition, the cosmetic defect can progress to produce severe deformities and functional impairment that negatively impact the patients quality of life. Intradermal, extradermal, or systemic therapies may be used, although combination regimens are the most effective in treating keloids and preventing recurrences. The records provided for review document the presence of a symptomatic right ear lobe keloid measuring 2 cm. The patient reports that the keloid causes discomfort. Thus, the requested removal of the keloid scar on the right ear lobe is medically necessary. Moreover, the requested procedure is reconstructive in nature. The patients condition constitutes an abnormal structure of the body caused by disease. The requested removal of the keloid scar on the right ear lobe will create a normal appearance to the extent possible with more than a minimal improvement in the appearance of the patient. Given these findings, the requested removal of the keloid scar on the right ear lobe is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.