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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for diastasis recti repair surgery. At issue is whether the diastasis recti repair surgery was medically necessary for treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; 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?Current peer-reviewed medical literature has not established that abdominal rectus diastasis repair provides long-term relief of symptoms and improvement of function. Researchers suggested that surgical correction of abdominal rectus diastasis could improve functional ability and quality of life. However, the researchers did not report on any studies demonstrating that abdominal rectus diastasis repair provides long-term relief of symptoms, improvement in function, or increased abdominal wall muscle strength. Medical literature noted that the clinical significance of abdominal rectus diastasis remains inconclusive. Based on current literature and the medical information received for review, the diastasis recti repair surgery was not medically necessary.Applying the California Reconstructive Surgery Statute, reconstructive surgeries are 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: to improve function; or to create a normal appearance, to the extent possible. There is a lack of documentation that abdominal diastasis rectus repair corrects or materially improves a bodily function. The documentation does not suggest that the provider recommended the procedure to improve the patients function. Moreover, the preoperative photographs reviewed demonstrate a female abdomen that is not abnormal, but within the wide range of normal. Thus, diastasis recti repair would not have made a more than minimal improvement in the appearance of the patient. Therefore, the diastasis recti repair surgery was not medically necessary and not reconstructive in nature.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 conditio
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 units, two to three times per week, two vials per month, for one year. Sarcoidosis is a disease that can involve any organ, but most often affects the lungs. In cases of worsening sarcoidosis, steroids are the first-line of therapy. Of note, some patients are not responsive to steroids, as in this case. Also, steroids have many unwanted side effects. H.P. Acthar Gel is appropriate for the treatment of sarcoidosis. This medication has been demonstrated to be beneficial for patients with this condition. The potential benefits include increased six-minute walking distance, improvement in positron emission tomography/computed tomography (PET/CT) findings and lowering of the dose of chronic steroids. Therefore, H.P. Acthar Gel 80 units, two to three times per week, two vials per month, for one year are medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty certification in pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 100 mg.  Findings:  The physician reviewer found that Nucynta is an opioid analgesic that has been U.S. Food and Drug Administration (FDA) approved for the relief of moderate to severe acute pain in adults, when a continuous, 24-hour analgesic is needed for an extended period of time. Nucynta has been assessed in the management of acute pain associated with end-stage joint disease using doses ranging from 50 to 100 mg, every four to six hours. Lauche and colleagues performed a direct comparison on the efficacy of various common opioid pain medications. The authors included 13 randomized controlled trials and found that there is a lack of rationale to prefer one opioid or administration route over another given data demonstrating equivalency. In this case, the patient presents with pain four months status post total hip arthroplasty. The provider reports the patient experienced side effects with Percocet, hydrocodone, and MS Contin. Tramadol was reported to provide inadequate pain control. The specifics of the medication trials are not reported in the records provided for review. The patient reported paresthesias with Percocet and morphine. These are central nervous system side effects that may occur with Nucynta. Based on the patients records, the Health Plans formulary has options that have been proven to be effective in this clinical setting. There is a lack of evidence to support the use of one opioid medication over another. Therefore, Nucynta 100 mg is not medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lynparza 150 mg tablets. The National Comprehensive Cancer Network (NCCN) guidelines recognize that there is a lack of standard treatment options for recurrent anaplastic astrocytoma. Preliminary trials on the PARP inhibitor Lynparza have found efficacy with the use of Lynparza taken in combination with temozolomide. This patient has exhausted available standard therapies yet he retains a good performance status. Due to the IDH-mutant status, Avastin is unlikely to be effective. The data in the medical literature has demonstrated the efficacy and tolerability with the recommended regimen. Therefore, the requested Lynparza 150 mg tablets are medically necessary for treatment of this patient. 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 patients parent has requested reimbursement and prospective authorization and coverage for speech therapy. The speech therapy services provided were and are medically necessary for treatment of the patients medical condition. The patient has autism spectrum disorder with severe expressive and receptive language delays. He would be unable to state his name and address if lost, which poses a safety issue. Speech therapy is indicated to address his oral motor apraxia, which is impairing his expressive language. His condition is severe enough to result in inadequate oral intake of food and fluids, necessitating gastrostomy tube placement. This type of speech therapy is not provided in a school setting, where the emphasis is on speech for educational purposes. Colleagues emphasized the importance of the inclusion of speech therapy in the overall management of children weaning from tube feeding to oral feeding. Colleagues discussed the difference between the speech therapy typically provided in school, compared with that provided by a speech therapist who is an expert with augmentative and alternative communication (AAC) devices. The authors state that interventions provided to the children by general speech-language pathologists (who were not AAC experts) tended to be broader in scope, focusing on reducing underlying impairments. This patient is noted to have an AAC device. The authors found that interventions provided by AAC experts tended to focus on improving activities and participation and were oriented toward improving functional communication. As this patient does not have functional communication skills, the speech therapy 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 pediatrics and neurology with special qualification in child 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for placement on the liver transplant list. The American Association for the Study of Liver Diseases (AASLD) and American Society of Transplantation (AST) guidelines for evaluation for liver transplantation specify that alcohol abstinence for six months is recommended, and positive testing for alcohol is usually followed by delisting. However, this recommendation is not supported by adequate data regarding long-term graft and patient survival or recidivism rates. Ethyl glucuronide testing can be positive for up to 80 hours after consumption of small amounts of alcohol. Thus, exposure to ethanol-containing medications can result in a false positive test. The patient reported she took NyQuil for a cold prior to the positive test. NyQuil contains 10% alcohol. Based on the provided information, consumption of NyQuil close to testing may yield a false positive result on the ethyl glucuronide testing. The patients prior testing has been negative. One positive result in the setting of several negative tests suggest a false positive result due to NyQuil use. In this case, placement on the liver transplant list is appropriate for this patient who has decompensated cirrhosis of a hepatic allograft. Therefore, the requested placement on the liver transplant list is supported by guidelines and current medical literature.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 internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan. Current standards of practice recommend that patients with multiple sclerosis should be treated with a disease modifying therapy. Researchers noted that although one successful phase II trial reported positive results with Rituxan in treating patients with multiple sclerosis, the authors cautioned that the study had multiple limitations. Overall, there is a lack of clinical trials demonstrating the safety and efficacy of Rituxan in multiple sclerosis. Further, Rituxan is not U.S. Food and Drug Administration (FDA) approved for treatment of patients with multiple sclerosis. Moreover, the available data have not established that Rituxan is safer or more effective than standard multiple sclerosis therapies. In this case, the patient has been prescribed Rituxan as a disease modifying therapy for multiple sclerosis. This patient is noted to be treatment naive to disease modifying therapies that are considered within the standard of care for the treatment of multiple sclerosis. Therefore, the requested Rituxan is not medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for 45 days. The records document that the patients mental health has deteriorated over the last year with significant depressive symptoms, suicidal ideation and near attempts. The patient has engaged in self-harm and reports auditory hallucinations. The patient has demonstrated a decrease in her ability to function and has not been able to sustain a functional level outside of the hospital setting for a prolonged time and has required treatment in the emergency department due to suicidal ideation. The patient presents with symptoms of gender dysphoria that should be further evaluated. Based on the current practice parameter from the American Academy of Child and Adolescent Psychiatry (AACAP), RTC has been the appropriate and least restrictive treatment setting for this patient. Given the level of ongoing, difficult to treat depression, suicidal ideation, and mood lability mixed with auditory hallucinations, the patient requires the supervision and monitoring provided at the RTC level of care. The records document the patient has been treated with several recent admissions and discharges. This suggests that the patient decompensates quickly after discharge. Recent sessions from therapy show that although the patient is not expressing overt suicidal ideation, is not stable for care in a less restrictive setting than RTC. Therefore, RTC services being provided for 45 days 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for psychotherapy visits at a frequency of every two weeks. The record indicates the enrollee has anxiety, depression, and adjustment disorder and receives treatment with a psychologist every three to four weeks.  She has children with mental health issues and she takes care of her grandchildren.  Notes indicated the enrollee was overwhelmed as her child was in rehabilitation and attempted suicide, which was traumatizing to her and her family.  She has more difficulty navigating things, is not feeling better and verbally lashed out to family as she does not have the reserve to deal with these stressors.  She requested to schedule visits every two weeks rather than every three weeks.  Goals include improving coping skills, self-care, limit setting, boundaries, decreasing symptoms and improving mood.  She wants to continue therapy to be able to take care of herself. According to the medical literature, the core feature in the adjustment disorder diagnosis is clinically significant emotional or behavioral symptoms, as in this enrollee.  Standard treatment for adjustment disorder is psychotherapy to better deal with stressors, decrease symptoms and improve coping skills. This enrollee had reports of ongoing stress contributing to more distress and symptoms. Based on this, she requires more than the every three weeks psychotherapy given and increasing the frequency to every two weeks. The literature indicates that psychotherapy offers significant benefit.  Concerns persist that many adults with depression do not receive treatment that match their level of illness severity. Thus, it is important to strengthen efforts to align depression care with each enrollees clinical needs. This enrollee has been experiencing severe life stressors struggling with ongoing stress and related symptoms. 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for anesthesia services. A review of the record indicates the enrollee saw his physician for intermittent abdominal pain with occasional anal sphincter cramping with spasm. He did not report unintentional weight loss, nausea, or change in bowel habits.  History includes hypertension and hyperlipidemia. The enrollee underwent esophagogastroduodenoscopy and colonoscopy. Per the medical literature, monitored anesthesia care (MAC) is described as a specific anesthesia service for diagnostic or therapeutic procedures performed under local anesthesia along with sedation and analgesia, titrated to a level that preserves spontaneous breathing and airway reflexes. MAC alone or with local anesthesia accounts for a relatively high percentage of anesthesia services nationwide. MAC essentially comprises of three basic components: A safe conscious sedation, measures to allay patient's anxiety, and effective pain control.  Choosing the correct medications and doses depends upon an assessment of the individual patient and the degree of sedation required to adequately perform the intended procedure. Because the level of sedation required varies with patient characteristics and the procedure, it is important for the endoscopist to keep both of these considerations in mind when selecting the pre-procedure sedation plan. During endoscopic procedures performed with moderate sedation (formerly referred to as conscious sedation), the patient is able to make purposeful responses to verbal or light tactile stimulation. The patient underwent both an upper and lower endoscopy and achieving the appropriate level of relaxation is necessary. The patient would not be appropriate for the use of oral medication due to the possibility that the oral medications would not provide an appropriate level of relaxation since two procedures were performed. Full anesthesia would not be appropriate as the patient would then be too relaxed. The use of Monitored Anesthesia Care in this instance was appropriate. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.