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

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for ForeseeHome AMD Monitoring System.  The enrollee was referred to an ophthalmologist by his primary care physician for a bulging left eye.  Bilateral non-exudative (dry) age-related macular degeneration (AMD) had been diagnosed.   Eye drops, hot compresses, ultraviolet protection, and Ocusoft lid scrubs with pads or foam at night are recommended treatments.  The enrollee reports his vision is worsening.  The ophthalmologist has recommended the ForseeHome AMD Monitoring System, which is an at-home monitoring device for early detection of wet AMD.  Findings:  The physician reviewer found that according to the medical literature, choroidal neovascularization (CNV) is part of the spectrum of age-related macular degeneration, and threatens visual acuity. The ForeseeHome AMD Monitoring System (Notal Vision) monitors for the earliest signs of CNV.  A study proved its efficacy in a controlled clinical trial. Participants in the study were at high risk for developing CNV, with either bilateral large lipid deposits (drusen), in two study eyes; or in one eye (study eye) and advanced AMD in the other (non-study) eye, and best corrected visual acuity of 20/60 or better in the study eye(s). It was concluded early detection with the ForeseeHome AMD Monitoring System increases the ability to provide interventions that will lead to preserved visual acuity, which was significantly better at the time of CNV detection.  Monitoring to detect progression from dry to wet AMD is integral to preserving vision. Early detection, followed by immediate treatment is key to achieving the best possible outcomes. 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 ophthalmology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Applied behavioral analysis (ABA) services with a board certified behavior analyist (BCBA). As noted by the National Autism Center, the most persuasive evidence-based literature supports ABA as the standard of care for patients with autism. However, this patient does not appear to display deficits in line with the symptoms of autism. The only documented deficit related to autism the patient displays is a lack of social skills. The patients current concerns would best be addressed with the recommended medication management and counseling. The Behavior Analyst Certification Board (BACB) highlights practice guidelines for BCBA providers that include definitions and expectations of therapy. These guidelines state that BCBA providers should practice within the scope of their competence. Based on this patients issues, anxiety and depression are outside of the scope of training of a BCBA. ABA is not required to meet the essential needs of the patient. The patient is a high functioning individual. The patients needs are primarily psychoeducational in nature. At this time, the evidence does not support ABA for treatment of depression and anger management. Therefore, ABA services with a BCBA 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 psychology and is a board certified behavior analyst 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 is diagnosed with cranial/head somatic dysfunction, cervical somatic dysfunction, thoracic somatic dysfunction, rib somatic dysfunction, lumbar somatic dysfunction, sacral somatic dysfunction, pelvic somatic dysfunction, upper and lower extremity somatic dysfunction, abdominal somatic dysfunction, low back pain, neck pain, and foot pronation. The patient reported left shoulder pain. Physical examination findings included decreased range of motion in cervical spine flexion, side bending, and rotation. Thoracic spine range of motion was decreased in side bending and rotation. Scapular dyskinesia was noted with restrictions in the left pectoralis minor, left clavicle, and left biceps tendon. The therapy recommended by the provider included ligamentous balancing, diaphragm release, lumbosacral decompression, condylar decompression and cranial osteopathy. The patient has requested coverage for osteopathic manipulative therapy. 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 osteopathic manipulative therapy is medically necessary for the treatment of the patients medical condition. Manual therapy consists of manipulation and mobilization and can include many techniques. Mobilization involves assisted, low-force, low-velocity movement and manipulation involves a higher-force, higher-velocity with low amplitude action moving a target joint. Manipulation or mobilization of the lumbar, cervical and/or thoracic spine is recommended for short-term relief of pain or as a component of an active treatment program. Although support can be found for the use of thoracic manipulation for neck pain, function, and quality of life, results for cervical manipulation and mobilization are few and diverse. Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function, with transient minor musculoskeletal harms. Although manipulative therapy can be utilized for the treatment of acute back and neck pain, the record does not support that this was how the osteopathic manipulative therapy will be used for this patient. There is a lack of evidence on the clinical efficacy of cranial osteopathic manipulative medicine. Medical evidence does not support the requested services in this clinical setting. Therefore, osteopathic manipulative therapy is 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 internal 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: The enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy, including simulation and magnetic resonance imaging for treatment planning.  There is a lack of clinical evidence to suggest that proton beam radiation therapy will improve toxicities or improve local control compared to standard treatment with photons. There is a lack of phase 3 trials comparing outcomes of photon therapy versus proton beam radiation therapy for patients with cholangiocarcinoma. In this patients case, standard treatment with photon therapy is appropriate. Thus, proton beam radiation therapy, including simulation and magnetic resonance imaging for treatment planning was not and is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were not and 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a nerve conduction study. This patient has numbness in the left fourth and fifth digits. The differential diagnosis included ulnar neuropathy at the elbow, cervical radiculopathy, and lower trunk plexopathy. The documentation reveals that the provider suspected radiculopathy and performed a nerve conduction study. However, without needle electromyography (EMG), radiculopathy cannot be confirmed or excluded. There was no discussion of possible ulnar neuropathy or other compression neuropathy in the progress notes. Furthermore, without a thorough needle EMG, the provider may miss a diagnosis of a plexopathy. Additionally, the patient has shoulder pain and pain radiating into her arms. She was diagnosed with polymyalgia rheumatica but not with EMG. Without the needle EMG, the NCS alone is an incomplete study for this patients symptoms. There are no extenuating factors in the documentation such as upper extremity lymphedema, significant thrombocytopenia, or upper extremity infection where there could be a contraindication to needle EMG. Therefore, the nerve conduction study was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that 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:  One reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. One Reviewer is board certified in physical medicine and rehabilitation and is actively practicing.  One Reviewer is board certified in physical medicine and rehabilitation 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.
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 breast reduction. The current medical evidence does not support the requested services in this clinical setting. This patient reported back pain. There is no complaint of shoulder or neck pain, and other causes of skeletal pain have not been ruled out. Photographs show some mild erythema under a bra strap, but no bra strap grooving is visible. A view of the inframammary fold shows thin minimal erythema at the depth of the fold without evidence of acute or chronic intertrigo. She has received topical medication, but there is no report that she has intertrigo that has been unresponsive to medical management. There is no report of thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Therefore, the requested breast reduction is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries. Researchers acknowledge that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and, therefore, is much more medically necessary than for somebody without gender dysphoria. Researchers further state that although facial feminization procedures are generally labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Overall, FFS has been associated with improved mental health quality of life in transgender women who received the surgery, when compared with transgender women who have not undergone FFS procedures. This patient has undergone long-term care with at least four health care providers who support that she has gender dysphoria. These providers recommend FFS procedures to help alleviate the distress experienced related to her gender dysphoria. Therefore, the requested facial feminization surgeries are medically necessary for 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 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 Taltz injections. Taltz injections are not a standard treatment in this patients case. The standard treatment of rheumatoid arthritis includes both nonpharmacologic treatment and pharmacologic therapy. Medications for rheumatoid arthritis include nonsteroidal anti-inflammatory drugs, glucocorticoids and disease-modifying antirheumatic drugs (DMARDs). DMARDs encompass a heterogeneous group of antirheumatic medications, including interleukin-6 receptor antagonist antirheumatic medications. Taltz is an anti-interleukin 17A monoclonal antibody. Taltz has been approved by the U.S. Food and Drug Administration for the treatment of plaque psoriasis and has shown efficacy for psoriatic arthritis. The records do not document that the patient has psoriasis or psoriatic arthritis. This patient has diagnoses of rheumatoid arthritis and fibromyalgia. Taltz has not been approved by the U.S. Food and Drug Administration for the treatment of either rheumatoid arthritis or fibromyalgia. The current medical evidence does not support the requested medication in this clinical setting. Therefore, Taltz injections are not medically necessary for the treatment of this patient. 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 internal 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 enrollee requested authorization and coverage for arthroscopic surgery for the left knee. According to the medical record, the enrollee has a history of left knee pain, for which she had previous arthroscopic partial meniscus debridement. She presented for orthopedic evaluation as her left knee pain has been worsening.  Orthopedic examination of the left knee showed pain, swelling, and decreased range of motion. The orthopedist diagnosed left knee osteoarthritis and degenerative joint disease. X-rays showed mild joint space narrowing. According to the medical literature, the majority of studies do not support the use of arthroscopic partial meniscus debridement (APM) with osteoarthritis, and even when there is no osteoarthritis.  A review of the literature indicates a study of patients with arthroscopic partial meniscus (APM) compared to sham (fake) surgery in patients with mechanical symptoms.  They found that resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking. They concluded that the mechanical symptoms do not suggest a better outcome with APM over sham surgery. Second, a larger study performed by the same group concluded that even in patients without arthritis but with a degenerative meniscus tear, APM offered no benefit over sham surgery. Finally, a recent review found that APM was only of mild benefit in patients without any OA. Thus, given the evidence of mild OA on x-rays and moderate to severe OA on MRI, with swelling, there is limited data to support the benefits of performing an arthroscopic partial meniscus debridement, even with mechanical symptoms. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the medication, Otezla. According to the record, the enrollee has severe plaque psoriasis and hypertension. He has painful lesions with silvery scales on his trunk, upper and lower extremities, and genitals, which constitute 80% of his body surface area. Treatment with Triamcinolone, Fluconazole, Ciclopirox, Ketoconazole, Vanicream, and Prednisone has been unsuccessful. His physician indicates that he is not a candidate for light therapy due to his travel schedule and time restraints. The physician expressed concern regarding systemic therapies due to black-box warnings for methotrexate regarding liver damage, and for interactions between methotrexate and Lisinopril, the enrollees hypertension medication as interactions can worsen liver-damaging side effects. The physician indicated similar black-box and medication interaction concerns with the systemic use of cyclosporine for this enrollee. The enrollees dermatologist began a trial of Otezla (apremilast) following which skin lesions had improved enough to allow him to maintain his activities of daily life without pain. His dermatologist is recommending Otezla for relief of disease symptoms without the risk of side effects. Review of the record indicates the enrollee is on atorvastatin, which contraindicates the use of methotrexate and acitretin.  Cyclosporine is contraindicated since he has hypertension. Notes indicate compliance with phototherapy would be difficult due to the enrollees work/travel schedule. Per the medical literature, apremilast (Otezla) was approved for use in treating moderate-to-severe plaque psoriasis. A clinical study demonstrated that 29 percent of patients receiving 20mg of apremilast twice a day and 41 percent of patients receiving 30mg of apremilast twice a day achieved a 75-percent reduction in symptoms by week 16. Study participants receiving a placebo achieved a 6-percent reduction in symptoms. Apremilast also demonstrates efficacy for treating plaque psoriasis involving the male genitalia. The mode of action appears to diminish cellular inflammation and keratinocyte activation/proliferation. 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 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.