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

An enrollee has requested authorization and coverage for Xeljanz 5 mg tablets.The medication Xeljanz (tofacitinib) is off label for the treatment of alopecia areata. There are many peer reviewed studies regarding the use of this medication in the treatment of alopecia areata. Researchers conducted a study to compare the efficacy and tolerability of oral tofacitinib and conventional modalities for treating refractory alopecia totalis/universalis. They concluded that oral tofacitinib was more effective than diphenylcyclopropenone immunotherapy and more tolerable than conventional oral treatment after six months of treatment. In this case, the patient has experienced a rapid worsening of her disease process in the last three months. The patient has first line treatment with intralesional steroids, which she responded to initially, albeit slowly. The patients alopecia areata is affecting her quality of life and is impacting her eyes, as she has more irritation without her eyelashes. At this time, the patient is refractory to conventional treatment with worsening disease severity.  Under these circumstance, the requested medication, Xeljanz 5 mg tablets, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of bilateral knees. The patient reported bilateral knee pain. She reported little improvement with rest, ice, compression, elevation (RICE) therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). Bilateral knee corticosteroid injections were performed. In an undated letter, the provider noted that the patient had previously received hyaluronic acid injections (both Synvisc One and Euflexxa) for both knees and had shown great improvement/pain relief from these injections. The patient had also completed physical therapy in the past, with no improvement. The patient has requested authorization and coverage for Synvisc injections for both knees. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc injections for both knees are medically necessary for the treatment of the patients medical condition. Researchers reported, Intra-articular (IA) treatments were superior to nonsteroidal anti-inflammatory drugs, possibly because of the integrated IA placebo effect. A study reported, The American Medical Society for Sports Medicine recommends the use of hyaluronic acid (HA) for the appropriate patients with knee osteoarthritis (OA). In this case the patient has been previously treated with viscosupplementation injections that provided pain relief. She has tried and failed other conservative treatment, including NSAIDs, physical therapy, and corticosteroid injections. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections for both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that The requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for five (5) sessions of acupuncture treatment. The patient has been diagnosed with low back pain. The provider noted that the patient does not participate in regular exercise or any recommended home physical therapy. Physical examination findings included no tenderness to palpation over the spine. A straight leg raise test was negative bilaterally. Strength was full and sensation was intact. The provider noted that the patient has tried and failed physical therapy and chiropractic treatment. Researchers noted that the recommendations on acupuncture have discrepancies related to its use in patients with non-specific low back pain. The medical evidence does not support the requested services in this clinical setting. Therefore, five (5) sessions of acupuncture treatment are not medically necessary for 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with articular disc disorder of the temporomandibular joint (TMJ). The patient reported jaw clicking, neck pain, and ringing in the ears. Physical examination findings included no mandible deflection. Clicking was noted with opening and closing of the mouth. Muscle spasm and pain were noted in the craniofacial muscles. The patient has requested authorization and coverage for a mouth guard for the TMJ.  The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a mouth guard for the TMJ is medically necessary for the treatment of the patients medical condition. Zhang and colleagues reported, The results indicated that splint therapy increased maximal mouth opening (MMO) for patients with a MMO less than 45mm and reduced pain intensity measured using the visual analogue scale (VAS) for patients with temporomandibular disorders (TMD) without specific description (TMDSD). Splint therapy also reduced the frequency of painful episodes for patients with TMJ clicking. Ebrahim and colleagues reported, Although overall results are promising for the reduction of pain, establishing the role of splints for patients with TMDs will require large trials with stronger safeguards against bias. In this case, there is no medical etiology identified in the medical records for the patients symptoms. There was also no note of discomfort in the muscles of mastication or splint therapy attempts to alleviate the muscular aspect of the symptoms. The medical evidence does not support the requested device in this clinical setting. Therefore, a mouth guard for the temporomandibular joint is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed Doctor of Dental 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

The patient has requested authorization and coverage for monitored anesthesia care (MAC) to be performed during an authorized upper endoscopy procedure. The patient has a history of right upper quadrant abdominal pain. Researchers concluded the overall risk of complications after colonoscopy increases when individuals receive anesthesia services. The widespread adoption of anesthesia services with colonoscopy should be considered within the context of all potential risks. There is no documentation of previous problems with anesthesia or sedation. There is no documentation of any cardiac, pulmonary, kidney or liver disease. There is no history of alcohol or substance abuse. The medical evidence does not support the requested service in this clinical setting. Therefore, monitored anesthesia care (MAC) to be performed during an authorized upper endoscopy procedure 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested reimbursement for self-determination therapy (SDT) services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week) and prospective authorization and coverage for future SDT services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week). There are several established treatments for autism spectrum disorder. The National Autism Center has identified applied behavior analysis (ABA), and other behavioral interventions, as the most effective treatment modalities for patients with autism. In this clinical setting, the most effective treatments have been identified to be behavioral in nature, including behavioral and cognitive behavior therapy, and behavior activation therapy. However, SDT is not included in the recommendations for patients with autism. Researchers found that SDT is the only theory of motivation that explicitly identifies autonomy as a human need, that, when supported, facilitates more autonomous forms of behavioral regulation. The current data highlights that SDT is a lens to identify motivation that may affect treatment effectiveness, but is not an applied treatment. All told, the SDT services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week) and future SDT services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week) were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 a B.C.B.A, board certified in psychology, 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 patients parent has requested authorization and coverage for a wheelchair ramp (suitcase trifold 10-foot ramp by EZ-Access). The patient has been diagnosed with an arteriovenous malformation (AVM) rupture and equinovarus contractures of bilateral feet. The patients parents were noted to carry the patient and his wheelchair up and down three steps to the entry of their home. Researchers noted assistive technology systems can provide opportunities for children with physical limitations to interact with their world, enabling play, communication, and daily living skills. In this case, a portable ramp would enable the patient to safely and effectively enter and exit his home by self-propelling a manual wheelchair or driving a powered chair. Removing a physical obstacle and arranging his home is necessary to promote his health and participation in life. The medical evidence supports the requested equipment in this clinical setting. Therefore, a wheelchair ramp (suitcase trifold 10-foot ramp by EZ-Access) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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

The patients parent has requested authorization and coverage for mastectomy (chest masculinization). The World Professional Association for Transgender Health (WPATH) states that the surgery can be performed in patients under the age of 18 after ample time of living in the desired gender roles and after a year of testosterone treatment. Researchers noted that, chest dysphoria was high among presurgical transmasculine youth, and surgical interventions positively affected both minors and young adults. A psychological evaluation indicates that this patient is depressed from the presence of a feminine-appearing chest. Moreover, the patients providers support the requested procedure to address the patients distress related to gender dysphoria. Given these findings, the requested mastectomy (chest masculinization) is medically necessary for 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for residential treatment center (RTC) level of care services.  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) developmental, medical, substance use 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 patients composite score is consistent with medically monitored residence based services, such as RTC. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for tacrolimus 0.03% ointment. The long term safety and efficacy of topical corticosteroids have not been studied in infants with atopic dermatitis. Therefore, steroid sparing agents like tacrolimus are used to prevent the potential risks of steroids like thinning of the skin and striae. Tacrolimus, are used as steroid sparing agents and are often recommended by prescribers as first-line atopic dermatitis therapy for sensitive skin areas, because they cause neither epidermal barrier function impairment nor skin atrophy. In this case, the use of tacrolimus is supported by major publications and long term studies on TCI's, as published by the American Academy of Dermatology and Pediatrics. Accordingly, the requested medication, tacrolimus 0.03% ointment, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for genetic testing. Gene panels are currently within the standard of care in this patients clinical scenario. The records provided for review document that the patients family has a medical history of breast cancer and prostate cancer. The patient does not have a personal history of cancer. Medical literature notes that progress in next-generation sequencing (NGS) has enabled to identify huge number of genetic aberrations. Researchers also reported that based on sequencing results, patients are recommended to undergo targeted therapy or immunotherapy. The NGS technology offers an improvement in efficiency in comparison to sequential analysis. Given this support, the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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 genetics 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

The patient has requested reimbursement for genetic testing. Gene testing criteria for PTEN mutations supports testing for patients with a family history of a known PTEN gene mutation, meeting clinical diagnostic criteria for Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, adult Lhermitte-Duclos disease, autism spectrum disorder and macrocephaly, or two or more biopsy-proven trichilemmomas. This patient has a family history of breast and prostate cancer. Based on the available documentation, this patient does not meet the current testing criteria for the genetic testing performed. Given these findings, the genetic testing was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in genetics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for physical therapy. The goal of treatment in pediatric cavovarus deformities is to establish a well-balanced foot with optimal plantar pressure distribution, to prevent progression or recurrence of the deformity, and prevent or postpone development of ankle, midfoot, and hind foot arthritis. In this case, the patient has failed non-operative treatment and has worsening deformity and pain with extended duration of physical activities. Based on the patients presentation and treatment history, physical therapy is not likely to change the outcome or the functional limitation resulting from this deformity. There is a lack of medical studies demonstrating that physical therapy will provide greater benefits over surgical intervention or orthotics to prevent recurring or progressive deformity or arthritis for this patient. All told, the requested physical therapy is not medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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

The patient has requested authorization and coverage for bilateral mastectomy with chest reconstruction. In addition to studies demonstrating that obesity worsens surgical outcomes, the authors found that this study shows that moving from Class I obesity to Class II or even Class III progressively increase complication rates. This patient has a BMI over 40, which is referred to as Class III obesity or morbid obesity. Surgical complication rates from breast surgery in patients with Class III obesity are significantly elevated compared with the risk in patients with a lower BMI. This patients provider recommended weight loss prior to proceeding with chest reconstruction surgery. For these reasons, the requested bilateral mastectomy with chest reconstruction is not medically necessary for 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 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.