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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization  coverage, and reimbursement, for mental health substance abuse partial hospitalization program (PHP) services. She entered a program for management of substance use disorder. The evaluating psychiatrist recommended starting low-dose Geodon for possible bipolar disorder. For risk of harm, the enrollees score is 3, due to binge behavior or excessive use of substances, resulting in potentially harmful behaviors without current involvement in such behavior. For functional status, the enrollees score is 3, due to significant disturbances in vegetative activities, such as sleep, eating habits, activity level, or sexual appetite, which do not pose a serious threat to health. The enrollee demonstrates significant deterioration in her ability to fulfill responsibilities and obligations to job, school, self, or significant others, and these may be avoided or neglected on some occasions. Chronic and/or variably severe deficits exist in interpersonal relationships, her ability to engage in socially constructive activities, and her ability to maintain responsibilities. For comorbidity, the enrollees score is 3, due to significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse affect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 3, due to a significant transition, causing disruption in life circumstances; such as job loss, legal difficulties or change of residence. There is danger in or near the habitat. There is easy exposure and access to alcohol and drug use. For recovery environment level of support, the enrollees score is 2, due supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, due to at least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For engagement and recovery status, the enrollees score is 2, due to the enrollee shows some recognition of her personal role in recovery and accepts some responsibility for it. The enrollees composite LOCUS score is 19, which correlates with high intensity community-based services. 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 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 patient has requested authorization and coverage for split-night sleep study with continuous positive airway pressure (CPAP) titration (CPT code 95811). This patients history of atrial fibrillation with symptoms of sleep apnea place her at an increased risk for central sleep apnea. A home sleep study is inadequate to detect central sleep apnea in this clinical setting. In addition, home sleep studies can underestimate the severity of sleep apnea. A split-night sleep study is indicated to evaluate the patients OSA, risk for central sleep apnea, and then to treat the patient with the appropriate pressure and mode of CPAP. The patients history of atrial fibrillation and her symptoms with the risk for central sleep apnea support a lab supervised sleep study. Therefore, the requested split-night sleep study with CPAP titration (CPT code 95811) is medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with expertise 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: The patient has requested reimbursement and prospective authorization and coverage for romiplostim. For chemotherapy-induced thrombocytopenia, thrombopoietin can provide benefit in the primary or secondary prophylaxis of thrombocytopenia. Clinical trials have shown improvement in patient platelet counts allowing for continued chemotherapy with use of romiplostim for this indication. In a case series of 20 patients treated with romiplostim for prolonged chemotherapy-induced thrombocytopenia, 19 patients demonstrated improvement in platelet counts, and 15 patients were able to resume chemotherapy at full doses. This patient has baseline thrombocytopenia. Without the use of romiplostim, the patient will not be able to continue chemotherapy. Therefore, romiplostim was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occupational therapy and physical therapy. Based on the available records, the requested occupational therapy and physical therapy are not medically necessary for treatment of this patient. The patient has undergone extensive therapy and been educated in a home exercise program. Documentation supports that the patients therapy has focused on upper and lower extremities with ankle and shoulder exercises. The records do not demonstrate that the skills of a professional therapist are required to facilitate this patients rehabilitation. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and deliver a program to maintain the patients current condition or to prevent further deterioration. All told, the requested occupational therapy and physical therapy 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. Per the records, he has been treated with Xanax, Ambien, trazodone and temazepam. The provider noted the patient had been seen by a psychiatrist in the past, but he did not want to take the medication that was recommended. The patient requested a refill of Xanax for daily use due to anxiety. The provider noted that daily use of Xanax was not an appropriate treatment for the management of anxiety. The provider prescribed Xanax 0.5 mg with a quantity of 10 to use as needed. The patient requested Xanax for chronic insomnia. He has requested authorization and coverage for Xanax 0.5 mg tablets, 30 tablets per 30 days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Xanax 0.5 mg tablets, 30 tablets per 30 days is medically necessary for the treatment of the patients medical condition. The British Psychological Society reported, A wide range of medicines with differing pharmacological properties can be effective in the treatment of generalized anxiety disorder (GAD). Traditionally, benzodiazepine drugs, such as diazepam, were employed for this purpose but it became clear that their use was commonly associated with the development of tolerance and dependence. For this reason, they are now recommended only for short-term use (two to four weeks). Kryger and Malhotra reported medications that may exacerbate obstructive sleep apnea (OSA) and theoretically worsen daytime sleepiness include benzodiazepine receptor agonists, barbiturates, other antiepileptic drugs, sedating antidepressants, antihistamines, and opiates. Wang and colleagues reported, recent benzodiazepine use (one to 30 days) increases the risk of adverse respiratory events and subgroup analysis suggested benzodiazepine use increased the risk of acute respiratory failure. In this case, the patient has been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. The patient requested Xanax for daily use due to insomnia and anxiety. The medical evidence does not support the requested medication in this clinical setting. Therefore, Xanax 0.5 mg tablets, 30 tablets per 30 days 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 psychiatry with sub-specialty certification in geriatric 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

The parent of the enrollee is requesting authorization and coverage for male gender-affirming chest reconstruction surgery. The enrollee has gender dysphoria and is requesting transgender top surgery to achieve a more masculine-appearing chest. The enrollee has been on testosterone. His therapist indicates the enrollee meets the symptom criteria and diagnosis for gender dysphoria and has approval from his therapist to proceed with transgender top surgery. Criteria in the medical literature for mastectomy and creation of a male chest in female-to-male individual requires the enrollee to demonstrate the existence of persistent, well-documented gender dysphoria, the capacity to make a fully informed decision and to consent to treatment. Additionally, the individual must have attained the age of majority, and any significant medical or mental health concerns must be reasonably well controlled. The guidelines for chest surgery in adolescents indicate chest surgery can be carried out earlier, preferably after the individual has had ample time to live in the desired gender role and after one year of testosterone treatment. This allows the adolescent the opportunity to experience and socially adjust to a more masculine gender role before undergoing irreversible surgery. However, different approaches may be more suitable, depending upon the individuals specific clinical situation and goals for gender identity expression. The enrollee meets these guidelines.  He has well-documented gender dysphoria and has the capacity to make an informed decision. His anxiety due to his female chest appearance has exacerbated his gender dysphoria. Mental health concerns are managed by his therapist.  His psychologist has recommended the mastectomies. The standard of care for adolescent top surgery is met.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: Upheld Decision of Health Plan

The patient has been diagnosed with knee osteoarthritis, peripheral neuropathy, low back pain, lumbar discitis, and breast cancer. The patient has been treated with knee replacements, multiple foot surgeries, and medications, including Norco, gabapentin, and Flexeril. In a power wheelchair evaluation, the patients gait was noted to be assisted with the use of a walker. She was noted to be a high fall risk. The patients upper and lower extremity strength was noted to be decreased. She was noted to be independent with basic activities of daily living and was capable of propelling a manual wheelchair. The patient has requested authorization and coverage for a power wheelchair. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. The Health Plan has approved a standard wheelchair. The medical evidence does not support the requested equipment in this patients case. A power wheelchair may be indicated for patients who have a health condition that causes significant difficulty moving around in the home. In order to support the medical necessity of a power wheelchair, the patient should be unable to do activities of daily living, even with the help of a cane, crutch, or walker. In this patients case, she was found to be modified independent with the use of a walker for household ambulation and activities of daily living. Per the records, she is capable of propelling a manual wheelchair. She has a manual wheelchair for community mobility to allow for participation in activities. The medical evidence does not support the requested equipment in this clinical setting. Therefore, a power wheelchair is not 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement for bilateral mastectomy. Chest surgery has been demonstrated to be a safe and effective treatment for gender dysphoria in transmasculine minors aged 13-17. Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affect both minors and young adults. Given these findings, professional guidelines and clinical proactive should consider patients for chest surgery based on individual need rather than chronological age. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges 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. WPATHs medical necessity statement states that chest surgery is often of greater practical significance in the patients daily life than reconstruction of genitals. This patient was assigned female gender at birth and has a nonbinary gender identity. The providers have documented that a bilateral mastectomy was indicated to address the patients distress associated with gender dysphoria. All told, the bilateral mastectomy was medically necessary for this patient.Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

The patient has requested reimbursement for upper left quadrant and lower right quadrant of periodontal scaling and root planing. The records provided suggest that this patients most recent routine care was four to five years ago. Periodontal charting provided showed generalized 2-3 mm probe depths with isolated 4 mm probing in the upper left and lower right quadrants with notation of some bleeding on probing in the posterior regions. The chart indicates that the patients gingival inflammation was likely attributed to the long lapse in care given the presence of bleeding on probing and periodontal probe depths. The AAP do not support scaling and root planing in the absence of documentation of attempts to assess and control the clinical condition with routine care or evidence of significant clinical attachment loss on the patients radiographs. All told, the upper left quadrant and lower right quadrant of periodontal scaling and root planing provided on were not medically necessary for 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 dentistry 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 for air and associated ground ambulance transportation. Kidney transplantation is the treatment of choice for most patients with end-stage renal disease. A successful kidney transplant improves quality of life for the majority of patients when compared with maintenance dialysis. Multiple studies comparing the survival rates between patients accepted for kidney transplantation who have undergone surgery with those accepted for transplantation but who have not yet received a renal allograft have found that patient survival is substantially improved with kidney transplantation than with dialysis. In this case, ground transportation would have prevented the patient from receiving the kidney transplant. Per evidence-based literature, due to increased morbidity from end stage renal disease, the air ambulance and associated ground ambulance transportation provided were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 nephrology 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

An enrollee has requested reimbursement for negative pressure wound therapy treatments. Negative pressure wound therapy has rapidly gained acceptance as a preferred approach to treating complex wounds in both diabetic and non-diabetic patients. In this case, the patient presented with a large wound on the right buttock where expedited healing is a priority. Although limited, the current medical literature has provided data showing accelerated and improved healing with negative pressure wound therapy for use in this patient. All told, the negative pressure wound therapy treatments were likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found that the negative pressure wound therapy treatments were likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the 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: Physician reviewers 1, 2, and 3 are board certified in 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.