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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential care facility services from 11/10/15 through 1/13/16.Findings:  The physician reviewer found that residential treatment is considered the highest level of psychiatric care available.  Medical necessity guidelines and evidence-based practice indicate that psychiatric symptoms must be severe and present to the degree that this level of care is needed. While this patient did have some cutting behaviors during the disputed period (11/10/15 through 1/13/16), the progress notes indicate that she was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. Since the patient was cooperative in treatment, a less restrictive setting was appropriate for treatment during the disputed period. The functional impairment that the patient was struggling with may have been due to the patients borderline personality disorder.  One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy (DBT). This disorder can be treated in a less restrictive setting once patients are free from safety concerns, as indicated in this patients case.  A study notes, Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts. DBT is effective for the treatment of borderline personality disorder and is used on an outpatient basis on a regular basis. 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 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 parent of a female enrollee has requested authorization and coverage for bilateral inverted nipple repair utilizing a milk duct-sparring technique for treatment of the enrollees bilateral inverted nipples. Findings:  The physician reviewer found that there is sufficient support in the medical literature demonstrating the medical necessity of the requested services in this clinical setting. The medical studies support the preservation of lactiferous ducts in an attempt to preserve the ability to nurse and breast feed.  In this patients case, the records document evidence of bilateral inverted nipples which is considered a congenital or developmental breast deformity. As noted by colleagues, there is a functional deficit related to nursing, Inversion of the nipple presents a functional problem in that it interferes with effective nursing. In addition, it is an aesthetic disturbance that can cause psychological and emotional distress owing to its abnormal appearance. Moreover, nipple inversion is a source of repeated irritation and inflammation due to difficulties related to hygiene around the nipple-areola complex. As such, the restoration of an adequate projecting nipple together with an areola is the basic objective of inverted nipple operations. In another study by colleagues, they state, Inverted nipple, a mostly congenital condition, occurs when a portion or an entire part of the nipple is buried under the areolar surface. This anomaly can lead to functional problems in nursing, poor hygiene, and psychological concerns because of its abnormal appearance. These studies support the medical necessity of inverted nipple repair in this patient. Furthermore, with the re-emergence of the importance of breast-feeding during the last decade, the preservation of the lactiferous ducts is recommended for a patient who may want to breast-feed. Only for the most severe conditions would complete transection of the ducts be indicated. The documentation and photographs provided, confirm the presence of bilateral inverted nipples. Therefore, the requested bilateral inverted nipple repair utilizing a milk duct-sparring technique to preserve the lactiferous ducts (milk ducts) is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary and are 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 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 a magnetic resonance imaging (MRI) of the chest. Findings:  The physician reviewer found that the American College of Radiology (ACR) lists MRI of the chest in a patient with likely non-cardiogenic chronic chest pain as having a relative value of 2/9 which is low on the probability scale of being useful. In contrast a three phase radionuclide bone scan has a value rating of 4/9, which is somewhat improved. The records provided for review do not demonstrate that this patients symptoms are likely related to cardiogenic causes. In addition, there is no chest x-ray or rib series radiographic report in the submitted records. Based upon the information provided in the chart, the requested MRI of the chest is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left sacroiliac (SI) percutaneous joint fusion. Findings:  Three physician reviewers found that, as noted in the peer-reviewed medical literature, SI joint fusion is not considered a first-line treatment in the management of patients with low back pain. In addition, the long-term complications and outcomes remain unknown. More long-term outcomes studies are needed to establish the safety and efficacy of SI joint fusion. This patients records do not show any evidence of SI joint instability, fracture, or tumor, which may support an indication for the requested procedure. All told, the requested left SI percutaneous joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested service is 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: All three physician reviewers 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 parent of a 16-year-old enrollee has requested reimbursement for residential treatment center services provided.Findings:  The physician reviewer found that the residential treatment center services provided were medically necessary for treatment of the patients medical condition. A study recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. In this case, the patient continued to have unsafe behaviors and discharge to a lower level of care on the disputed date would not have been safe or effective. The patient was struggling with suicidal and homicidal ideation. She engaged in serious self-harm behavior that included smashing her head against a wall. She continued to have suicidal ideation during the dates in dispute and reported on several occasions a plan to harm herself. The patient had a significant risk of harm due to her repetitive suicidal ideation as well as self-harm including head banging. Moreover, she had minimal insight into her treatment needs, displayed poor boundaries and inappropriate with peers. Based on the records submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewers 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: Physician reviewer is  board certified in psychiatry with sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that the records provided for review document that this patient was not showing post-acute withdrawal symptoms and she was medically stable. She was not a danger to herself or others. She had a period of approximately five years in which she heavily used both methamphetamine and alcohol, and was unable to stop. Her use had effected employment and relationships. She was at high risk for relapse given these factors and required admission to IOP level of care. While in the program, she relapsed twice. After two weeks the patient reportedly began to make incremental improvements. She worked on assignments and steps, and developed a more healthy relationship with her mother. She completed most assignments, and met goals and objectives. Given these findings, the IOP services provided  were medically necessary for treatment of this patients medical condition.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 sub-specialty certification in addiction 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing provided. Findings:  The physician reviewer found that  in this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing provided  was not likely to have been more efficacious than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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: An enrollee has requested authorization and coverage for inferior turbinate outfracture. Findings:  The physician reviewer found that the submitted documentation does not support the requested procedure in this clinical setting. This patient has mild, but symptomatic, obstructive sleep apnea.  This patient is noted to have an arched narrow palate with resultant narrowing of the nasal airway. He is noted to have difficulty breathing through his nose while sleeping. While surgery may be the next treatment option for select patients who have failed CPAP therapy, in this patients case, the requested inferior turbinate outfracture, is not medically indicated. The documentation indicates that he had prior turbinate reduction and the examination notes state that there is no turbinate hypertrophy. Therefore, inferior turbinate outfracture, is not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 otolaryngology 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: An enrollee has requested reimbursement for the PuraPly graft provided.  Findings:  The physician reviewer found that most wounds have biofilm, which can prevent wound healing . The clinical indication for PuraPly is in biofilm reduction and wound stability. However, this patients biofilm could have been addressed with a more standard approach such as topical antibiotics or continued debridement . In addition, offloading was recommended as a key component in wound healing. The records indicate that the patient was not being compliant with his offloading boot. For those reasons, the PuraPly graft provided on the date of dispute was not likely to have been more beneficial as compared to standard approaches for treatment of this patients medical condition. Final Result: The reviewers determined that the service at issue was 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 upheldCredentials/Qualifications: Physician reviewer number one is board certified in family medicine and is actively practicing. Physician reviewer number two is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. Physician reviewer number three is board certified in dermatology and is actively practicing. All three 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: An enrollee has requested authorization and coverage for sildenafil 20 mg twice per day (BID), 60 per month for more than 12 months or indefinitely for treatment of her pulmonary hypertension and mixed connective tissue disease. Findings:  The physician reviewer found that the requested duration of sildenafil is not medically necessary for treatment of the patients medical condition. The Health Plan has authorized sildenafil 20 mg BID, 60 per month with 11 refills. The patient is seeking approval of sildenafil beyond 12 months or indefinitely. Approval of sildenafil beyond one year is not clinically indicated. The standard of care requires periodic follow-up evaluation of the patients symptoms in order to determine if continued treatment with sildenafil is appropriate. The patient will need to be evaluated for disease progression as measured by pulmonary function testing and spirometer. Final Result: The reviewer determined that the requested duration of 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 internal medicine with sub-specialty certification in rheumatology 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 Norco. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, the requested medication is not medically necessary for treatment of the patients medical condition. A study noted that short and long acting opioids have been found to be effective for chronic non-cancer pain. The authors also noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In this case, the patient has chronic neck and back pain that has persisted for many years. She has been treated with a multitude of therapies in the past for her pain. Although she reports that Norco has been effective for her pain, her provider does not recommend this medication due to her history of alcohol abuse. The Health Plans recommendation for a referral to pain management, physical therapy and behavioral health management is medically appropriate for this patient. Therefore, based on current medical literature and in consideration of the presented clinical records, the request for Norco has not been established as medically necessary for this patient. 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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: parent of the enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that based on the IOP records submitted for review, the patient has met the majority of the treatment goals. The remaining goals appear to be due to the patient's anxiety with transitions, rigid behaviors, following instruction, and listening to directions. These target behaviors are typical treatment goals of children with autism. In this clinical setting, the patients remaining goals can be appropriately treated with ABA. According to Myers and colleagues ABA methods are used to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. In addition, the patient is not having any current suicidal or homicidal ideation. The patient continues to have behavioral struggles at home as well as aggressive episodes with a sibling. The progress notes do not indicate that the patient is aggressive with children at school. It appears that the patient's aggression is isolated towards a sibling. The patient is also noted to struggle with anxiety. The peer-reviewed literature indicates that cognitive behavioral therapy based interventions are effective in reducing anxiety symptoms in individuals with autism. Cognitive behavioral therapy is routinely provided on an outpatient basis. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient has a score of 14, which correlates with a treatment intensity level of two which correlates with outpatient services. The patient has some episodic outbursts, and is not having active suicidal ideation. The patients functional status is mild, has no co-morbidities and has a stable housing situation. Moreover, the patient has a highly supportive family who is actively involved in treatment and attend family therapy sessions on a regular basis. In sum, the patient has stabilized and current behavioral issues are secondary to the chronic nature of the patient's autism and can be treated on an outpatient basis.  The patient is not suffering from symptoms that would warrant the intensity of an IOP. 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: physician reviewer is board certified in psychiatry with sub-specialty 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.