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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral brachioplasty revision surgery. According to the American Society of Plastic Surgeons (ASPS), buttock, thigh or arm lifts can be appropriate to treat functional abnormalities. Most often, these procedures are performed to improve appearance and are therefore cosmetic in nature. This patient reports no functional issues regarding her upper arms.Excess upper arm tissue is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The ASPS states that cosmetic plastic surgery includes surgical and nonsurgical procedures that reshape normal structures of the body in order to improve appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve functions but may also be done to approximate a normal appearance. Excess upper arm skin is not an abnormal structure of the body. Rather, it is a normal structural change that is an accommodative response to gain or loss of body mass. The patients excess arm skin is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Moreover, the requested procedure would not improve function or provide a more than minimal improvement in the patients appearance. All told, the requested bilateral brachioplasty revision surgery is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested surgery is not medically necessary and 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 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

The patient has requested authorization and coverage for trigger point injection, occipital nerve block injection, and peripheral nerve block injection. The American Headache Society noted that there is a paucity of evidence from controlled studies for the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. The consensus guidelines did not find evidence to support using occipital nerve blocks and trigger point injections for occipital neuralgia as the best evidence is for cluster headaches. Researchers found limited data on the efficacy of peripheral nerve blocks and trigger point injections for the treatment of headache syndromes. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block.In this case, the patient has been diagnosed with occipital neuralgia and myalgias related to a motor vehicle accident. An MRI of the brain revealed findings suggestive of a remote shearing injury consistent with whiplash. She is actively participating in occupational therapy and has undergone occipital nerve blocks and trigger point injections with an unquantified level of pain relief lasting for one week before her symptoms returned. There is a lack of documentation of significant efficacy or duration to warrant repeating the procedure when weighed against the risks of overexposure to steroids found in the injection material. Based on the available medical records for review and current guidelines, the requested trigger point injection, occipital nerve block injection, and peripheral nerve block injections are 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 anesthesiology with subspecialty certification in pain management 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 and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patients CIWA score supports mild to moderate withdrawal symptoms. For dimension 2, the presence of tremor and chronic fatigue syndrome may interfere with the patients ability to perform self-care. The patient meets the criterion for dimension 3 given the coexisting PTSD, MDD and GAD, which have been associated with worsening substance use disorders. For dimension 4, the patient has blamed others for his use behaviors and has demonstrated low accountability. This suggests that the patient is not ready for change. With regard to dimension 5, the provider noted that the patient is prone to immediate gratification and impulsivity, which supports that the patient is at high risk for relapse. For dimension 6, the patient has roommates who are heavy users and the patient lacks a strong support system. The patient requires a safe and stable living environment in order to develop his recovery skills. Thus, the patient qualifies for ASAM Level III treatment, similar to the services provided at the current RTC. Given these findings, the RTC services provided were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 expertise 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the eye, face, and neck before and after contrast. An addendum states that there was slight irregularity of the distal left optic nerve on one slice. The recommendation was for an ophthalmology examination and if clinically indicated, an MRI of the orbits with and without contrast. The provider diagnosed the patient with positional vertigo and found no objective evidence of organic visual disturbance. Specifically, the provider stated there was no clinical indication for MRI of the orbits. Detailed historical and physical examination revealed no sign of parasitic infection related to the orbits and no evidence of optic neuritis. The clinical examination conducted by ophthalmology stated that there was no indication for MRI of the orbits. Therefore, the requested MRI of the eye, face, and neck before and after contrast is not medically necessary for this patient. 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 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

An enrollee has requested authorization and coverage for right leg sacroiliac (SI) joint fusion. SI fusion may be beneficial as a last line of therapy as treatment for SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or SI pain due to severe traumatic injury. SI joint fusion is not recommended for mechanical low back pain, non-specific low back pain, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint-mediated pain. The North American Spine Society (NASS) supports SI fusion under limited conditions, if stringent diagnostic criteria have been met. The NASS recommends diagnostic intra-articular injections with local anesthetic resulting in at least 75% pain relief as a criterion for diagnosing pain related to the SI joint. A confirmatory injection is also recommended. Diagnostic imaging to rule out destructive lesions or inflammatory arthropathy of the SI joint, hip pathology, and/or neural compression or other degenerative condition of the lumbar spine that could cause low back or buttock pain are also recommended. A trial of at least one successful therapeutic intra-articular corticosteroid injection is then recommended. In this case, the patient has been diagnosed with right SI joint dysfunction. However, there are no objective imaging or laboratory findings to indicate the presence of SI joint infection, tumor, and sacroiliitis due to spondyloarthropathy or post-traumatic arthritis. Although NASS does note some evidence supporting SI fusion for SI joint-mediated pain, the quality of evidence is low. Given these findings, the requested right leg SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested right leg SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 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

The enrollee is requesting reimbursement for intensity-modulated radiation therapy (IMRT) services. This enrollee has a diagnosis of glioblastoma multiforme of the right temporal lobe, World Health Organization grade IV.  At a follow-up visit, the records indicate the enrollee underwent gross total resection of the right temporal lobe lesion. He had recovered from surgery quite well.  The enrollee does have a small left visual field deficit that has persisted. However, he reported his balance has improved.  He was not having seizures and there were no significant neurologic deficits.  The enrollee was alert and oriented with 5/5 strength to the upper and lower extremities. Clinically and radiographically, the enrollee was stable. Multiple published studies on IMRT for glioblastoma multiforme (GBM) have demonstrated that IMRT provides significantly improved radiation dose distribution to the tumor with sparing of adjacent normal brain tissues over a Three Dimensional (3D) conformal radiation therapy plan. With superior dose conformity to target volume and sparing of adjacent normal brain tissues with potential of decreasing risks of radiation related complications, such as brain necrosis, damage to optic nerve/chiasm and brain stem, IMRT has been accepted as a standard of care for enrollees with primary brain tumor in a clinical practice guideline for CNS (central nervous system) tumors. The record detailed this enrollees diagnosis of GBM and the literature supports conformal radiotherapy techniques including three-dimensional conformal radiation therapy and IMRT partial brain irradiation are recommended.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation oncology 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: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level criteria for Clinically Managed High-Intensity Residential Services. The records document the presence of a CIWA score consistent with mild to moderate withdrawal symptoms. The patient has comorbid PTSD and depression. The patient is in the early stages of readiness to change. The provider noted that the patient is reinvigorated and motivated to change. The patient continues to report cravings and his history of multiple relapses support that the patient is at high risk for future relapse. The patient has demonstrated prior difficulty maintaining sobriety in his recovery environment and will return to this same environment following discharge. The patient requires a safe and stable living environment in order to develop his recovery skills. The patient meets the criteria for ASAM Level III treatment, similar to the services provided at the current RTC. All told, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 expertise 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for liposuction and excess skin removal of the upper arms and excess skin removal of the legs. Researchers found that lipedema is a disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. Lipedema causes pain and is typically unresponsive to weight loss. This patients records do not support a diagnosis of lipedema in the upper arms or legs. There is no history of inability to lose weight, because the patient lost weight from approximately 400 pounds to as low as 149 pounds. The photographs reviewed show lax arms, which are typical of massive weight loss. There is no evidence of persistent fatty tissue in the arms. There is no report of functional issues from skin laxity or intertrigo. In addition, the patient has lax tissue of her thighs from massive weight loss.  There is no report of a recurrent rash underneath her skin folds. For these reasons, the requested liposuction and excess skin removal of the upper arms and excess skin removal surgery of the legs are not medically necessary to treat the patients medical condition. The patients excess arm and leg tissue is a normal structural change that is an accommodative response to loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. There are no functional deficits documented due to the patients condition. There is no report of a recurrent rash underneath her skin folds. There is no report of appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. The patient does not have a functional problem with a rash that has been demonstrated to be resistant to appropriate medical treatment. Furthermore, the requested procedure will not improve function or create a more than minimal appearance in the patient. Therefore, the requested liposuction and excess skin removal of the upper arms and excess skin removal surgery of the legs are not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and 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 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

The enrollee is requesting reimbursement for residential treatment center (RTC) services. The enrollee has a history of alcohol use disorder. She was discharged to the residential treatment center (RTC) with stable vital signs. The record indicates enrollee reports of short-term memory problems, sweating, blackouts and sleep disturbances. Her treatment plan included group therapy, individual counseling, 12-step meetings, psycho-social assessments, education, family meetings, recreational therapy, and life skills. The enrollee was compliant with the treatment plan, as well as daily homework assignments and breathalyzer testing. She is diagnosed with severe alcohol disorder, unspecified depressive disorder and insomnia. The physician ordered Trazodone at bedtime and ReVia in the morning. The patients composite LOCUS score corresponds to Level II. However, the record does not support the services at issue at the residential treatment center level of care.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting reimbursement for behavioral health inpatient services. The enrollee was treated in the emergency department for worsening depression for the previous five days. The enrollee was not compliant with her medications and had suicidal ideation without plan or intent. The enrollee declined outpatient, intensive outpatient program or partial hospitalization program services and requested admission to psychiatric inpatient hospital treatment because she would resume drinking immediately. The enrollee was admitted for inpatient behavioral health treatment. During her inpatient stay, she was compliant with treatment, denied suicidal ideation, did not have assaultive behaviors and denied symptoms of mania or psychosis. Her vital signs remained normal throughout the detoxification protocol. Upon completion of alcohol detox, the behavioral health team felt her mood had stabilized and were preparing to discharge her. The enrollee refused discharge, stating that if she were forced to discharge, she would resume drinking immediately. The team began searching for an appropriate residential rehab facility. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has been diagnosed with osteoarthritis of the knees. The patient received the fifth Supartz injection in both knees. In the application for independent medical review, the patient reported receiving Supartz injections to her knees for the previous eight years with relief. The patient has requested authorization and coverage for Supartz injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Researchers found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient reported lasting benefit from prior Supartz injections over the last eight years. Furthermore, the options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Supartz injections in 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.