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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for partial hospitalization. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The records indicate the patient was cooperative in treatment and was free from withdrawal symptoms. She denied suicidal or homicidal ideation and denied psychosis.   The patient was noted to have gained insight into her need for treatment as well as express what triggers her to use substances. The records did not indicate that the patient had failed intensive forms of substance use or behavioral health treatment in the recent past.   In this patients case, the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (LOCUS) can assist in determining the necessary level of care. In terms of risk of harm, the records support a score of 2. The patient was not having active suicidal ideation. With regards to functional status, the records support a score of 3. The records noted functional impairment in relation to delinquent behaviors. With regards to medical, addictive and psychiatric comorbidities, the records support a score of 1. The documentation noted overall medical stability. In terms of recovery environment level of stress, the records support a score of 2. The patient had a stable living environment. With regards to recovery environment level of support, the records support a score of 1. The patients family was supportive and engaged in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had minimal to moderate treatment response overall. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in treatment and was able to identify triggers and emotional issues. In terms of acceptance and engagement of the parent, the records support a score of 2. Thus, the patient has a composite score of 16, which correlates with outpatient services. Therefore, partial hospitalization was not medically necessary for the treatment of this patient. 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 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: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The recent records indicate the patient was cooperative in her meal planning. She reported some binging behaviors, but her understanding of her need for treatment appeared intact. She was noted to be adherent to her medication regimen and was cooperative with psychiatric treatment. The progress notes did not document other severe psychiatric symptoms. It appears that she was exhibiting some purging behaviors, but her weight remained close to 100% ideal body weight.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services is an evidence-based, objective, instrument used to determine the necessary level of care for adults. With regards to risk of harm, the records support a score of 1-2. The records noted a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2. There were some problems with job performance. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of recovery environment, level of stress, the records support a score of 3. The patient had a stable living situation. With regards to recovery environment, level of support, the records support a score of 2. The documentation noted family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 3 due to recent success at the residential treatment level of care. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15-16. This score correlates with community based treatment in the outpatient clinic setting. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of eating disorders. All told, partial hospitalization program services were not medically necessary for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right knee injections with Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. There is a lack of support for the requested services in this clinical setting. Per the current medical evidence, hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. The medical literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports-related chondropathy has yet to be fully assessed. The ideal indication in the knee appears to be moderate femorotibial osteoarthritis without swelling.  This patient presents with complaints of right knee pain, swelling, and instability with difficulty in activities of daily living. Clinical examination findings have been generally consistent with x-ray findings of very mild spurring at the medial compartment, no significant joint space narrowing, and minor spurring around patella. There is evidence of long-term nonsteroidal anti-inflammatory drug use, prior physical therapy, and home exercise program, with reported insufficient benefit. However, the records documented mostly anterior right knee pain with a diagnosis of bilateral knee patellofemoral chondromalacia patella/osteoarthritis. Evidence-based medical guidelines and literature do not support the use of Orthovisc injections for patellofemoral osteoarthritis, or for very mild femorotibial osteoarthritis. Therefore, the requested right knee injections with Orthovisc 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 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 Vemlidy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases recommend alternatives for the treatment of chronic hepatitis B.  As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy is medically necessary for the treatment of this patients hepatitis B. Final Result: The reviewer determined that the 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 internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rituxan injection. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees myasthenia gravis.Findings: There is current literature to support the use of Rituxan (rituximab) in patients with refractory myasthenia gravis. Myasthenia gravis therapy has improved significantly and can be managed effectively. Many patients can achieve sustained remission and that is the goal. In general, rituximab has proven to be relatively safe in other autoimmune disorders as well as in myasthenia gravis. Myasthenia gravis is a common disorder of neuromuscular junction. The disorder is characterized by a fluctuating and variable combination of weakness in ocular, bulbar, limb, and respiratory muscles. Weakness is the result of an antibody attack directed at proteins in the neuromuscular junction. The diagnosis of myasthenia gravis can be established by clinical and serologic testing as it was in this patients case. The therapeutic approach is highly individualized for each patient depending upon the age of the patient, the severity of the disease, particularly dictated by respiratory or bulbar involvement, progression, and response to therapy. In this case, the patient has responded poorly to recognized standard therapy of prednisone, IVIG, and Mestinon. Rituximab is a monoclonal antibody against B cells. There is sound theoretical rationale as well as data supporting its use in patients with myasthenia gravis especially in individuals with MuSK antibody. Several studies show that rituximab is particularly effective for MuSK antibody subset of myasthenia gravis. In this patient, who has refractory myasthenia gravis and is on multiple standard therapies with poorly controlled myasthenia gravis, Rituxan has been demonstrated as 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopically assisted vaginal hysterectomy (LAVH). Findings:  The physician reviewer found that a hysterectomy is appropriate for pelvic pain after a comprehensive evaluation has been performed, including evaluation by pain specialist and mental health evaluation, as indicated. Furthermore, if investigations have not identified specific etiology of symptoms, individuals are encouraged to undergo uterine sparing treatments, hormonal treatment, or utilize gonadotropin releasing analogues, analgesics, antidepressants, and physical therapy.  In the case of endometriosis, a hysterectomy is appropriate when the endometriosis has been confirmed by histology, laparoscopic visualization, or identification of endometrioma.  the patient has been diagnosed with endometriosis as the cause of her pelvic pain.  However, the records do not support that this patient has exhausted conservative management options. Progestins such as oral progestins (norethindrone acetate and dienogest), Depo-Provera (intramuscular progesterone), and levonorgestrel intrauterine devices have been shown to be effective at treating pain associated with endometriosis. Gonadotropin releasing hormone agonists with add back therapy have also been shown to be effective at treating pain associated with endometriosis. For women with pain and endometriosis, suppression of menstrual cycles with gonadotrophin-releasing hormone (GnRH) analogues, the levonorgestrel-releasing intrauterine system (LNG-IUD) and danazol were beneficial interventions. There was no evidence of benefit with post-surgical medical treatment.Both the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine recommend hysterectomy as a treatment option for endometriosis only for patients who have completed childbearing and who have failed conservative surgical and medical management. The records provided do not indicate that this patient meets the recommended criteria for hysterectomy. The patient is 33 years of age and has not failed medical management. She has not tried either progesterone therapy or gonadotropin releasing hormone agonist therapy. Additionally, there is no documentation of uterine sparing surgical measures. Per the current guidelines by professional societies, this patient has not failed all conservative therapies. Therefore, LAVH has not been demonstrated as 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested authorization and coverage for implantation of the hypoglossal nerve stimulator system. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.Findings:  There is sufficient support in the medical literature for the requested services in this clinical setting. This procedure is U.S. Food and Drug Administration approved and recognized by the American Academy of Otolaryngology Head and Neck Surgery and also by the International Sleep Surgery Society. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three and four year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial demonstrated hypoglossal nerve stimulation to be safe and effective in a small subset of patients with OSA who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a BMI less than 32. Additionally, a recent study supports effective outcome in patients with higher BMI (up to 35) and a broader AHI range (between 15 and 65). This patient meets the recommended criteria with a BMI of 31.87, AHI of 21 and nonconcentric airway collapse. Furthermore, she has failed CPAP, which is the gold standard treatment for OSA and is at risk for untoward cardiac sequelae of untreated OSA. Therefore, implantation with a hypoglossal nerve stimulator is likely to be more effective than the available standard options for treating this patients medical condition.Final Result: Two of the three reviewers determined that services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in otolaryngology  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 authorization and coverage for implantation of cranial nerve neurostimulator electrodes and generator. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Per the medical evidence, there are significant limitations regarding this new therapy. There is a lack of studies demonstrating the efficacy of the requested services on patients with a BMI greater than 32 kg/m2. Per the medical evidence, it cannot be concluded that the requested services would be effective in this clinical setting. Multiple important clinical questions remain about the use of this therapy. Therefore, the requested implantation of cranial nerve neurostimulator electrodes and generator is 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 neurology with sub-specialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: The requested services are medically necessary for treatment of the patients medical condition in this clinical setting. Facial laser hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The patient was born with genetics to grow terminal hair on the face. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males. This would include the face and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial laser hair removal is medically necessary for the treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide a substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient. For these reasons, facial laser hair removal is reconstructive in nature. 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 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.