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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that Vickers and colleagues state, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Additionally, Kelly and Willis state that for certain patients who are experiencing pain, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option. Moreover, a review by Zhang and colleagues found, There is growing evidence that acupuncture is just as effective and has fewer side effects than many of the standard pharmaceutical agents that are currently used. In this case, the patient has not undergone an acupuncture trial. Given the patient continues to be significantly symptomatic, with severe pain levels that remained unchanged despite prior treatment modalities, the requested acupuncture is medically reasonable and supported by the peer-reviewed literature. Therefore, acupuncture services are medically necessary for the treatment of the 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 oriental 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: The patient has requested authorization and coverage for a non-invasive ventilator. In this case, the provider notes that the patient has recovered from COVID-19 pneumonia. While an oximetry study shows frequent desaturation events, raising concerns for sleep disordered breathing, in this clinical setting, initiation of supplemental oxygen at night along with a formal sleep study to ascertain the etiology and optimal treatment for the patients condition is indicated. The records note that the patient is scheduled for a sleep study. Given that there is currently insufficient evidence of the patients sleep disordered breathing pending a formal sleep study, the requested service is not medically indicated. Therefore, a non-invasive ventilator is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 certifications in pulmonary disease and critical care 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: The patient has requested authorization and coverage for bilateral hearing aids. Findings:  The physician reviewer found that While hearing aids are helpful for patients with significant hearing loss, there is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In this patients case, the records document mild hearing loss that has been stable at 4,000 Hertz (Hz), with normal hearing in all other frequencies. Given that the impact of hearing loss at 4,000 Hz is minimal and would not affect speech recognition, the requested equipment is not medically indicated. Therefore, bilateral hearing aids are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a mastopexy (breast lift).At issue is whether the requested mastopexy is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?In this case, the patient has hanging breast tissue. The patient complains of a recurrent rash underneath her breasts, although physical examination at the end of January 2021 reported that no current or active rashes were noted under her breasts. The patient does not have a functional problem with the rash under her breasts that has been demonstrated to be resistant to appropriate medical treatment. Therefore, the requested mastopexy (breast lift) is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Breast ptosis does not constitute an abnormal structure of the body. It is a normal structural change that occurs with aging and as a result of the normal structural changes that are accommodative responses to gain or loss of body mass. Breast ptosis is not due to congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. The appearance is normal and consistent with the accommodative responses to gain or loss of body mass. The patient does not have a functional problem with the rash under her breasts that has been demonstrated to be resistant to appropriate medical treatment. The California reconstructive surgery statute does not apply in this instance. Therefore, the requested mastopexy (breast lift) is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition and not reconstructive in nature. 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:  An enrollee has requested authorization and coverage for a stairway chairlift. Findings:  The physician reviewer found that according to Siddiqi and Ruberg, the hallmark pathophysiology of cardiac amyloidosis is biventricular thickening and stiffening due to amyloid deposition, resulting in diastolic, then eventually systolic dysfunction. Other pathophysiology includes vessel infiltration, resulting in angina and myocardial infarction, and involvement of the cardiac conduction system, resulting in arrhythmias. Tuzovic and colleagues state that there is a risk of sudden cardiac death, often due to an electromechanical dissociation not amenable to restoration of cardiac function by defibrillation. Typical symptomatic manifestations of cardiac amyloidosis include dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea and lower limb edema. Treatment options include diuretics, sodium restriction, specific targeted therapy for different types of amyloidosis, consideration of pacemaker/defibrillator implantation, chemotherapy for specific treatable amyloid subtypes, and supportive/compensatory treatment. Siddiqi and Ruberg also state that standard cardiomyopathy pharmacotherapy such as beta blockers and angiotensin converting enzyme inhibitors are often poorly tolerated and generally avoided due to adverse effects such as hypotension and fatigue.Final Result: The reviewer determined that the durable medical equipment 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 physical medicine and rehabilitation 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 requested authorization and coverage for Stelara every four weeks. In this clinical setting, current medical literature supports a dose escalation of Stelara to 90 mg every four weeks. In a large randomized controlled trial, Sandborn and colleagues demonstrated the safety and efficacy of ustekinumab (brand name Stelara) for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. In a study of 38 patients with anti-TNF-resistant Crohns disease, Kopylov and colleagues noted a 73% initial clinical response to ustekinumab, and 80% of responders maintained remission for one year. Tuskey and Behm note that the mechanism of ustekinumab is entirely different than that of anti-TNF medications. Battat and colleagues noted the efficacy of ustekinumab therapy, at a dosing of 90 mg every four or eight weeks during maintenance. In this case, the patient has symptoms and colonoscopy findings consistent with active Crohns disease while on Stelara every eight weeks. They failed Remicade and Humira.  In this case, the requested medication regimen is likely to be more beneficial than continued dosage of Stelara every eight weeks or transitioning to another medication, which may result in worsening disease control with complications such as fistula, stricture, bowel obstruction, flare, or the need for hospitalization or surgery. Therefore, Stelara every four weeks is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication regimen is 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hammertoe correction surgery with intramedullary implants on the second and third toes of the right foot (CPT 28285 x 2). Researchers note that revision procedures of surgery of the lesser toes are challenging. One study likewise notes that the anatomy of the lesser toes is highly complicated and not yet well understood and that the high propensity of the metatarsophalangeal joint to develop hyperextension deformity should be recognized. The author further notes that a successful surgical result requires a well-planned procedure, accurate execution using proper techniques, and meticulous postoperative care and when complications do occur, surgeons should identify culprits so that proper treatment strategies can be successfully executed. In this case, the patient is status post hammertoe correction of her second through fifth toes on the right foot. She reported persistent pain and an examination revealed non-union of the second and third toes on the right foot with valgus deformities. In this clinical setting, given that a revision hammertoe surgery is recommended by the provider to relieve the patients pain and improve function, the requested service is medically indicated. Therefore, hammertoe correction surgery with intramedullary implants on the second and third toes of the right foot (CPT 28285 x 2) is medically necessary for the treatment of this patient.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 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: The patient has requested authorization and coverage for a tertiary level of care esophagogastroduodenoscopy procedure. Sheikh and colleagues note that duodenal neuroendocrine tumors are rare. Dewan and colleagues report that most cases of neuroendocrine carcinoma in the duodenum show rapid progression of the disease. Sato and colleagues explain that therapy for duodenal neuroendocrine tumors is based on tumor size, location, histological grade, stage, and tumor type. Herring and colleagues report that the academic tertiary cancer center that this patient is considering has a longstanding and specialized expertise in the diagnosis and treatment of neuroendocrine tumors. In this case, the patient had a rare neuroendocrine tumor with positive lymph node metastasis and is status post total pancreatectomy. In this clinical setting, given the potential for a remaining tumor in the duodenum and the difficulty in finding and identifying such a tumor, requiring the expertise of an endoscopist and pathologist, the requested service is medically indicated. Therefore, a tertiary level of care esophagogastroduodenoscopy procedure is medically necessary for the treatment of this patient.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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reduction mammoplasty.Cabral and colleagues state, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction.According to the American Society of Plastic Surgeons (ASPS), reduction mammaplasty may be recommended based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: chronic breast pain due to weight of the breasts; intertrigo unresponsive to medical management; upper back, neck, and shoulder pain; backache, unspecified; thoracic kyphosis, acquired; shoulder grooving from bra straps; upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area; headache; and/or congenital breast deformity.In this case, the patient reports back, shoulder and neck pain with shoulder grooving. She does not report chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Under these circumstances, the requested bilateral breast reduction mammoplasty is medically necessary to treat this patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The patient reports severe neck and back pain, and the requested breast reduction is to improve function by relieving this pain. Accordingly, the requested bilateral breast reduction mammoplasty is reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. 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: The patient has requested authorization and coverage for a cervical spine magnetic resonance imaging (MRI). Cohen notes that MRI is characterized by a high prevalence of abnormal findings in asymptomatic individuals but may be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment. In this case, the patients reported widespread pain symptoms in the head, neck, upper back, low back and upper and lower extremities do not correlate with a cervical anatomic source. The submitted records indicated that they had been evaluated by multiple specialists. While a letter from the patients chiropractor recommends a cervical spine MRI, the records do not document this recommendation by any of the patients other medical providers. Given that the submitted documentation indicates widespread nonanatomic symptoms that do not correlate with a cervical spinal source, and are without red flags of serious cervical pathology, the requested service is not medically indicated. Therefore, a cervical spine MRI is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for acupuncture services (twice a week for 5 months and once a week thereafter) and chiropractic services (twice a week for 5 months and once a week thereafter).According to medical literature, a full course of acupuncture is considered six treatments. Additionally, a study by researchers found that a positive, clinically significant number of chiropractic visits is nine to twelve visits. In this case, the patient has had both acupuncture and chiropractic sessions approved (at least 12 sessions of each type). The submitted documentation shows that the patient has had prior chiropractic treatment, with no change in symptoms. Additionally, there were no quantifiable improvements noted after past acupuncture treatments. Therefore, acupuncture services (twice a week for 5 months and once a week thereafter) and chiropractic services (twice a week for 5 months and once a week thereafter) are not medically necessary for the 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 oriental medicine and chiropractic 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.