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

The patient is a male diagnosed with cannabis use disorder, Accutane induced psychotic disorder, and rule out bipolar II disorder. The patient endorsed using cannabis and alcohol use. The patient was prescribed Accutane for acne and was noted to have withdrawal symptoms including psychosis. The patient was treated at the residential treatment level of care from. He was started in an intensive outpatient program (IOP). The patients provider noted the patient appeared paranoid and suspicious of others. At issue in this case is whether IOP treatment from was and/or is medically necessary for the treatment of the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the patients score is 2 due to past suicidal ideation and substance use. For functional status, the patients score is 3 due to substance use with recent gains in functioning achieved while participating in structured treatment. For comorbidity, the patients score is 3 due to the patients previous paranoia and hallucinations. For recovery environment level of stress, the patients score is 2 due to a potential for exposure to substance use as his sibling is involved in substance use. For recovery environment level of support, the patients score is 2 due to parental involvement in treatment. For resiliency and treatment history, the patients score is 2 due to previous treatment at the residential level of care, and abstinence from drug and alcohol use. For acceptance and engagement, the patients score is 2 due to participation in treatment. For acceptance and engagement of the caretaker, the score is 2 due to parental support and involvement in treatment. The patients composite CALOCUS score is which corresponds to high intensity community based services. Therefore, IOP treatment was and is medically necessary for this patient. Final Result: The reviewer determined that the requested services were and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the Game Ready Pro 2.1 System and accessories was and the Med4 Elite Unit and their and their accessories are medically necessary for the treatment of the patients medical condition. The patient has been diagnosed with cerebral palsy (CP) congenital right spastic hemiparesis.  An examination revealed muscle strength in distal muscles of the right upper and lower extremities. The patient reports that one foot drags on certain occassions.There is a lack of scientific evidence to support the use of requested cold/heat compression devices requested in the care of this patient. The American College of Sports Medicine (ACSM) exercise recommendations for patients with chronic diseases and disabilities such as cerebral palsy and the American Academy of Pediatrics Committee on Children with Disabilities (AAPCCD) published recommendations serve as guidelines for families. There is no one specific cooling system modality included in the current recommendations. 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Otezla 30 mg tablets for plaque type psoriasis. The records indicate the enrollee has moderate to severe plaque type psoriasis primarily with psoriasis on the hands, palms, fingers and nails, as well as other areasof the body.  She has tried and failed topical corticosteroids.  She has been using Otezla with improvement.  The medical literature indicates biologic agents are considered the gold standard for moderate to severe psoriasis due to their favorable safety profiles and excellent efficacy.  Treatment recommendations depend on severity of disease and can include topical therapy alone or in combination with phototherapy and/or traditional non-biologic systemic therapy. The patient has no noted contradictions to taking methotrexate, cyclosporine, acitretin, Enbrel, Humira, or Cosentyx, which have been shown to have favorable safety profiles and efficacy. In addition, there is no medical reason noted as to why phototherapy was not tried.  Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee requested authorization and coverage for Proton Beam Radiation Therapy, 28 fractions for their medical condition of prostate cancer.  The use of proton beam therapy is not the current standard of care, requires further investigation and would therefore not be considered medically necessary in this case.  Specifically, there is no evidence that the IMRT plan cannot safely deliver the radiotherapy.  Quantec dose guidelines report that when individual loops of bowel are contoured, it is recommended to limit the V15 of the small bowels to 120cc.  There is no demonstrable clinical advantage to the proton beam therapy over IMRT based on the treatment plan comparison. Therefore, Proton Beam Radiation Therapy is not medically necessary. The health plans denial of coverage and authorization should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sacral nerve stimulation testing. According to the American Urological Association (AUA) guidelines, sacral nerve stimulation is considered an appropriate salvage therapy for patient with intractable irritative lower urinary tract symptoms including frequency and urgency incontinence. Sacral nerve stimulation is performed as a tertiary salvage procedure. With regard to this patient, there is no documentation demonstrating the patient has tried and failed first- and second-line treatment modalities for his irritative urinary tract symptoms. The provider noted the patient failed Myrbetriq. However, primary and secondary treatment options include bladder training, physical therapy, biofeedback, and medications. Prior to sacral stimulation therapy, the patient should be considered for second-line treatment options and modified pharmacotherapy. For these reasons, the requested sacral nerve stimulation testing is not supported as medically necessary for evaluation of this patients irritative lower urinary tract symptoms.Final Result: The reviewer determined that the requested services are 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 urology 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 requested reimbursement for a vitamin D screening assay (CPT code 82306), stress echocardiography (CPT code 93351), and carotid duplex ultrasound (CPT code 93880). The records provided for review document that this patient presented with symptoms of chest tightness and risk factors for coronary artery disease (CAD) including age, gender, and hypertension. Evaluation with a stress echocardiography was conducted as a diagnostic test for these symptoms and risk factors. The stress echocardiography revealed an upsloping ST segment depression, which is abnormal, and places him in an intermediate risk group for CAD. However, stress echocardiography is not supported by American College of Cardiology Foundation (ACCF) guidelines for use in this clinical setting. Based on the guidelines, the standard of care is evaluation with a plain treadmill test. The decision to use imaging modalities in lieu of a standard treadmill test is based on the appearance of the resting electrocardiography (EKG). The records do not report that a resting electrocardiography was performed to support an indication for the stress echocardiography. Given these findings, the stress echocardiography (CPT code 93351) was not medically necessary for evaluation of this patients symptoms and risk factors for CAD. With regard to vitamin D screening, researchers found that the current research does not support the use of vitamin D levels to help determine cardiovascular risk. The authors reported that meta-analyses of vitamin D supplementation trials have failed to show clear improvements in blood pressure, insulin sensitivity, or lipid parameters. Thus, the vitamin D screening assay (CPT code 82306) was not medically necessary for evaluation of this patient. Further, the ACCF states that a carotid duplex scan may be indicated if a bruit is audible or if there are symptoms of cerebral ischemia. This patients records do not report the presence of an audible bruit or symptoms of cerebral ischemia. Accordingly, the carotid duplex ultrasound (CPT code 93880) was not medically necessary. 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 internal medicine with subspecialty certification in cardiovascular disease 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 is diagnosed with obesity. The patient underwent laparoscopic gastric band placement with removal. The patient was subsequently diagnosed with breast cancer and underwent mastectomies with placement of tissue expanders. The patient reported that she gained weight due to chemotherapy treatment and endorsed pain caused by the tissue expanders. The patients provider requested the patient undergo laparoscopic sleeve gastrectomy for weight loss prior to undergoing breast reconstruction with flap surgery. She attended a bariatric support group. The patient also underwent a psycho-social and behavioral evaluation and was reported to be a good candidate for bariatric surgery. At issue in this case is whether a bariatric consultation is medically necessary for the evaluation of this patients medical condition. As noted by the American Society for Metabolic and Bariatric Surgery (ASMBS), patients with a BMI of 35 or greater with one or more severe obesity-related co-morbidity, including considerably impaired quality of life are considered potential candidates for bariatric procedures. The ASMBS support that disqualification from other surgeries as a result of type II obesity, as defined by a BMI of 35-39.9, is considered an indication for bariatric surgery. Overall, the evidence regarding reoperative surgery for failed weight loss and weight regain demonstrates improved weight loss and co-morbidity reduction after re-intervention . The patient reported pain related to her breast tissue expanders and breast reconstruction surgery was postponed until weight loss is achieved. Further, the patients provider recommended laparoscopic sleeve gastrectomy for weight loss prior to undergoing breast reconstruction. In addition, the patient demonstrated motivation for weight loss by attending bariatric support groups and was reported to be a good candidate for bariatric surgery by a psychological evaluation. Therefore, a bariatric consultation is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service 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 family practice 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for percutaneous arthrodesis of the sacroiliac (SI) joint. The Health Plan has denied the requested procedure as investigational for treatment of the enrollees SI joint dysfunction.Findings:  Two out of three physician reviewers found that SI joint degeneration is a common cause of chronic low back pain which is under-diagnosed. Minimally invasive fusion procedures have demonstrated successful pain relief for these patients. Recent medical literature has documented two-year follow-ups of these procedures, demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. The medical literature reports minimally invasive SI joint fusion using triangular titanium implants showed marked improvements in pain, disability and quality of life two years after fusion. One study noted that radiographic evidence of intra-articular fusion within the joint may take more than one year in many patients. In the absence of evidence of neural compression on MRI and in the presence of clinical findings of SI pain, which is relieved by injecting the SI joint, the requested procedure of SI fusion using the minimally invasive technique is likely to be successful in this patient. Thus, the requested percutaneous arthrodesis of the SI joint is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One physician reviewer found that overall, more research is needed to show the safety and efficacy of SI joint fusion. Long-term outcomes and complications remain ill-defined. Additionally, in this case, there is no documentation of SI joint instability, fracture or lesion.Final Result: Two out of three reviewers determined that the requested procedure is 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 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: Upheld Decision of Health Plan

An enrollee requested suction assisted lipectomy of bilateral knees. Findings:  The physician reviewer found that the clinical facts of obesity, bilateral knee pain and osteoporosis, type two diabetes mellitus, and obesity do not meet the criteria for liposuction. The available records did not document attempts at documented weight loss, a history of rashes, or of fungal infections. With regard to the reconstruction issue, the patients medical condition does not constitute an abnormal condition of the body. Those patients with fat legs associated with obesity should be counseled on modifying their lifestyles and be given the option of future cosmetic procedures if they are able to achieve sufficient weight loss to become better surgical candidates, which is typically considered after patients have lowered their body mass index below 30. In addition, the available records do not include objective findings regarding functional ability or a mobility deficit; thus, it is not clear that the requested liposuction would provide a significant improvement in the patients function. Moreover, the requested procedure would not provide a more than minimal improvement in the appearance 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 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: The enrolee has requested authorization and coverage for Otezla. Findings:  The physician reviewer found that the requested medication is not medically necessary for treatment of the enrolees medical condition. Therefore, the Health Plans denial should be upheld.  Dermatology guidelines for management of healthy adult males with chronic plaque psoriasis includes topical therapy as first line treatment. If UVB is not available, other first-line treatments include acitretin, Humira, cyclosporine, Enbrel, Remicade, methotrexate, and Stelara. The records provided for review do not document that the enrolee has been treated with acitretin or cyclosporine, which are considered the standard of care for psoriasis vulgaris. Thus, the requested Otezla is not medically necessary for treatment of this enrolees medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for proton beam radiation therapy.Findings:  Three physician reviewers found that the requested services are not likely to be more efficacious than other treatment options. Colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy, proton beam radiation therapy, and conformal radiation therapy for prostate cancer. In the comparison between intensity modulated radiation therapy and proton beam radiation therapy, intensity modulated radiation therapy patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between intensity modulated radiation therapy and proton therapy. A position statement released by the American Society of Radiation Oncology (ASTRO) in 2013 stated, At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, proton beam radiation therapy is not likely to be superior over other available 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 radiation oncology 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.