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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for septoplasty and rhinoplasty revision. It takes at least one year to recover from rhinoplasty, and in patients with thick skin, it can take longer. At this time, revision surgery is premature. Additionally, the operative plan is unclear. The patient was evaluated by two providers. The first provider noted the septum to be midline and the dorsum improved. The provider did not provide an operative plan or any indication of need for revision. The second provider noted valve collapse, a septal deviation and inferior turbinate hypertrophy. While correction of valve collapse has been shown to improve nasal breathing, the patient had been treated with nasal steroids and reported their breathing was improving in March 2018. Given these findings, the requested surgery is not medically necessary. Further, the requested surgery is not reconstructive in nature based on the available documentation. Although the patient reports that they are not satisfied with their  appearance, the records do not document the presence of an abnormal structure. In addition, there is a lack of documentation that the patient has a functional problem that would be addressed with revision surgery. Further, there is no indication that the requested surgery would result in more than a minimal improvement in the patients appearance. All told, the requested septoplasty and rhinoplasty revision is not supported as reconstructive in nature or medically necessary. Final Result: The reviewer determined that the requested surgery is not medically necessary and it not reconstructive in nature 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 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: A patient has requested authorization and coverage for gastric bypass surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients obesity. The submitted documentation does not support the medical necessity of the requested services. The records do not document an anatomic complication present for this patient. After a long period of time, dilation and stretching of both the gastric pouch and stoma can occur. Pouch and stoma reduction, whether operative (laparoscopic or open) or endoscopic, has not been shown to have durable efficacy or weight outcomes in any high-grade study. The documentation does not support that this patient had ongoing dietary or behavioral follow-up. The notes do not document a technical complication that would require revision of the patients previous gastric bypass surgery. Therefore, the requested gastric bypass surgery is not medically necessary for the treatment of the 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old female enrollee has requested reimbursement for the services provided by the Early Childhood Treatment Center. Based on the available documentation, the services provided by the Early Childhood Treatment Center were not medically necessary for treatment of this patients medical condition. There is no documentation to support that a less intensive treatment, such as home-based comprehensive applied behavioral analysis, was tried without successful improvement of symptoms. Moreover, there is a lack of data demonstrating that cognitive behavioral therapy  is effective to address anxiety and obsessive compulsive tendencies in a two-year-old patient with mild-to-moderate autism spectrum disorder. Published reports supporting the benefits are in children ages seven and older, and usually with high functioning autism. Abramowitz and colleagues reported that CBT can be ineffective for many patients with obsessive compulsive disorder. Moreover, Hybel and colleagues found that executive function determines the response to CBT for children with obsessive compulsive disorder. Overall, the medical literature suggests that a two-year-old patient lacks the executive function to adequately engage in CBT. Given these findings, the services provided by the Early Childhood Treatment Center were not medically necessary for 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 in pediatrics with special qualification in child neurology 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation fails to demonstrate the medical necessity of the services at issue. The standard of care is to provide treatment in the least restrictive environment possible. By the date in question, the records demonstrate this patient did not have any suicidal or homicidal ideation. Although the patient has a chronically elevated risk of self harm due to his prior suicide attempt, the documentation does not report the patient was an imminent threat to himself or to others. The patient was not aggressive. The patient did not have major psychiatric symptoms of psychosis, mania, hallucinations, or delusions. The patient did not have any co-morbid substance use problems. The patient was cooperative and would participate in activities and therapy. The patients parents were supportive of the patient. The patient was able to attend to his activities of daily living. The patient did not require 24 hour supervision by the date in question. The patient could have been treated in a partial hospitalization program (PHP), which is a less restrictive environment when compared to residential treatment centers. Therefore, residential treatment center services were not medically necessary for 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 in psychiatry with expertise 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Otezla 30 mg, one tablet by mouth twice daily. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients plaque psoriasis. The submitted documentation does not support the medical necessity of the requested medication regimen. This patient has had a trial of Otezla, with some improvement.  The patient has not tried and failed the preferred formulary agents, including methotrexate, cyclosporine, acitretin, Cosentyx, Enbrel or Humira. There is no medical documentation as to why the preferred agents cannot be used. The diagnosis of hyperlipidemia does not preclude the use of methotrexate, as there is no documentation of transaminitis due to statin therapy. In this clinical setting, there are alternative formulary agents that may be used for the treatment of this patient. Therefore, Otezla 30 mg, one tablet by mouth twice daily is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: A female enrollee has requested authorization and coverage for Orthovisc injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The researchers reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Given this support, the requested Orthovisc injections are supported as medically necessary for treatment of this patients medical condition.  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 Taltz 80 mg autoinjector. This patient has been stable on Taltz with good improvement in her symptoms for the past year. Taltz is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriasis and has shown good efficacy in the treatment of nail psoriasis. Given that this patient has experienced satisfactory results with Taltz, the risk of flare in stopping to switch to another agent is not appropriate. As treatment with Taltz has stabilized this patients medical condition, the requested Taltz 80 mg autoinjector is medically necessary. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program (IOP) services. The medical records provided for review do not support the medical necessity of IOP services. The patient was not suicidal or homicidal. He was not violent or aggressive. There were no emotional, behavioral, or cognitive barriers to step down to outpatient level of care. Other than chronic neck pain and the depression and anxiety, he was medically and psychiatrically stable. These diagnoses and his medication regimen could have been safely and adequately provided in the outpatient setting. The patient made little progress in IOP. Although his craving scores were low, his depression and anxiety remained in the moderate range, and motivation was poor. Given these findings, the IOP services provided were not medically necessary for 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 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 DecisionDX-Melanoma multi-variate gene expression assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees  cutaneous melanoma.Findings:  Researchers found the standard protocol for an intermediate thickness tumor, like the one this patient has, does not include a recommendation for a workup with molecular genetic testing. Although the testing has shown some promising results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. In addition, the protocol would be a wide local excision and possibly a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. Clinical studies are lacking at this time to indicate that the results of the molecular testing will make a difference in the treatment or morbidity or mortality of the patient. The only exception to this would be with discordant results. For these reasons, DecisionDX-Melanoma multi-variate gene expression assay provided was not likely to have been more effective than the available standard options of evaluating this patients medical condition.  Final Result: Two of the three reviewers have determined 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:  All three reviewers are board certified in dermatology and are 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 reimbursement for the residential treatment center (RTC) services provided by Hoag Hospital. The records provided for review indicate that the patient no longer met the American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care. The patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive or violent. His short-term memory impairment was not severe enough to require treatment in the residential setting. Although requiring prompting to perform ADLs, he was capable of independently performing them and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the residential level of care. He was medically and psychiatrically stable to the extent that he did not need a 24-hour facility to render the remainder of his care. There were no changes in his medication regimen, and he was not on any anti-craving medications. He was engaged in treatment and was seeking a sponsor. He had demonstrated the capability of prolonged abstinence previously and has had prior exposure to rehabilitation and the 12 step program. He was motivated and was working the program. He was cooperative and participating in his treatment plan. He did require continued treatment for his anxiety and depression, as well as the reported visual hallucinations at night, which could have occurred in the ambulatory setting. Given these findings, the RTC services provided were not medically necessary for 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 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 authorization and coverage for LINX surgical procedure. Findings:  Two of the three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The researchers concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. In sum, the requested LINX surgical procedure is not likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. The American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, their guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.