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 treatment from a provider who is California Board Certified in both female pelvic medicine and reconstructive surgery, and obstetrics and gynecology. The records provided for review document that providers from urology and gynecology, as well as a female pelvic medicine have participated in the treatment of this patient. The providers documented a thorough review of her history, as well as comprehensive physical examinations and evaluations. The providers have established plans for ongoing care that are consistent with the patients previous successful treatment and the standard of care for her medical condition. The patient has required extensive management of her vesicovaginal fistula by urologists, as well as Botox treatment and pelvic floor physical therapy. The patients gynecologist is the appropriate specialist to monitor her for possible recurrence of her vulvar dysplasia and treatment of her vaginal atrophy and dyspareunia. A provider specializing in urology is appropriately trained to treat the patients bladder urgency issues. Given these findings, the requested treatment from a provider who is California Board Certified in both female pelvic medicine and reconstructive surgery, and obstetrics and gynecology is 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 obstetrics and gynecology 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 authorization and coverage for home health nursing assistance. Dystrophic epidermolysis bullosa is a subtype of epidermolysis bullosa that results in extremely fragile mucocutaneous tissues with complications including intractable ulcers, extensive scarring, recurrent corneal erosions, and malnutrition. The standard of care is symptomatic treatment with meticulous wound care and use of protective dressings to prevent severe wound infections. This patient requires daily skin cleansing and dressing changes, with judicious use of antibiotics for infected wounds or those that fail to heal. Treatment consists of a multi-step process involving cleansing the skin, lancing blisters, treating infected and poorly healing lesions with topical antibiotic, and applying multilayered wound dressings. Home health nursing can assist in managing the patients pain and anxiety related to wound care. In order to provide this patient with appropriate care, the requested home health nursing assistance is 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 pediatrics with subspecialty certification in pediatric critical care 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: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay. The DecisionDx-Melanoma Gene Assay analyzes the tissue genetics of an individual patients melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of DecisionDx-Melanoma on health outcomes. The National Comprehensive Cancer Network (NCCN) guidelines do not endorse routine use of the DecisionDx-Melanoma. This patient has a history of cutaneous melanoma. A dermatopathology report demonstrated Breslow thickness of 0.7 mm, no ulceration or perineural invasion, and staging consistent with pT1a. Overall, there is an absence of adequate data demonstrating improved health outcomes with use of the DecisionDx-Melanoma Gene Assay in this clinical setting. Therefore, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for percussion vest, mechanical tilt-in-space wheelchair, and custom gait belt. The requested percussion vest is not supported as medically necessary based on the available records. The patient was hospitalized with chronic obstructive pulmonary disease (COPD) and bilateral pneumonia. There is no documentation of a recognized indication for a percussion vest such as lobar bronchiectasis, bronchiectasis or neuromuscular disease with impaired ability to clear. A manual wheelchair with tilt-in-space may be appropriate for someone who is capable of spending a lot of time outside of bed, but is dependent for mobility and is unable to perform effective pressure relieving maneuvers. In this patients case, there is a lack of documented functional examination with respect to the patients mobility. In addition, there is no therapeutic indication for the therapy gait belt documented. Therapy gait belts are a tool that providers use during assessment and therapy treatment. Therapy gait belts are not appropriate for use by patients without training in their use and without general therapy training. The use of a therapy gait belt without proper training and supervision could result in unwarranted and unsafe attempts by caregivers to transfer or ambulate the patient. All told, the requested percussion vest, mechanical tilt-in-space wheelchair, and custom gait belt are not medically necessary, or medically necessary for the patient to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition, or medically necessary for the enrollee to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. 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 enrollee has requested authorization and coverage for brachytherapy. There is sufficient support for the requested services in this clinical setting. The records document that the patient has intermediate risk prostate cancer. Since his life expectancy is greater than 10 years, brachytherapy is a standard of care. Per the National Comprehensive Cancer Network guidelines, brachytherapy is a standard of care for men with intermediate risk prostate cancer and a life expectancy greater than 10 years. The medical evidence supports the requested services in this patients case. Therefore, brachytherapy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 medical 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 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 for transcranial magnetic stimulation (CPT codes 90867, 90868 and 90869). The submitted documentation supports the medical necessity of the services at issue. Researchers performed a systematic review and meta-analysis evaluating the efficacy of repetitive transcranial magnetic stimulation in patients with major depressive disorder who had failed two or more antidepressants. The authors noted, For major depressive disorder patients with two or more antidepressant treatment failures, repetitive transcranial magnetic stimulation is a reasonable, effective consideration. Authors noted, Repetitive transcranial magnetic stimulation is a safe, noninvasive neuromodulation therapy for major depressive disorder. Per the authors, The development of repetitive transcranial magnetic stimulation as an antidepressant therapy is supported by extensive clinical research. In this case, the Health Plan denied reimbursement for the services at issue on the grounds that the patient did not have a recent medication trial or recent psychotherapy. This statement was not supported by the clinical notes provided. The medical records indicate that the patient was currently taking Cymbalta 120 mg daily when she presented for transcranial magnetic stimulation treatment. Additionally, the records noted that the patient had received extensive CBT for major depressive disorder in the past, with little benefit. Given that the patient had tried and failed multiple medications and psychotherapy, the services at issue were medically indicated. Therefore, transcranial magnetic stimulation (CPT codes 90867, 90868 and 90869) was medically necessary for the treatment of 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 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 has requested authorization and coverage for Xeljanz 5 mg twice a day. There is a growing body of evidence that Janus kinase (JAK) inhibitors such as tofacitinib offer an effective treatment option for widespread and refractory dermatitis. Suga and Sato reported that, topical phosphodiesterase 4 inhibitors and JAK inhibitors are promising treatments for atopic dermatitis. Researchers found that, although it is still early in the study of JAK inhibitors for atopic dermatitis, evidence identifies JAK inhibitors as effective alternatives to conventional therapies. The records provided for review document that this patient has failed multiple therapies due to intolerance or lack of efficacy. Continuing Xeljanz for management of this patients atopic dermatitis and prurigo nodularis is consistent with the support in the peer-reviewed medical literature. Therefore, the requested Xeljanz 5 mg twice a day is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 5 mg twice a day 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 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 dermatology 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 patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. For dimension 1, the patient was at serious risk of harm (score 4) due to significant recent aggression with poor judgment and insight. The provider noted that the patients behavioral issues included property destruction, impulsivity, and substance use. The patient indicated that she has thought about harming the person responsible for her admission to the RTC. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her conflict with parents, recent school failures, physical altercations, and disregard for rules. For dimension 3, the patient has significant comorbidities (score 3) considering her coexisting substance abuse and mental illness. The patient reported that she likes to drink alcohol while on social media. For dimension 4, the patients recovery environment was moderately stressful (score 3) due to her parents difficulties with substance abuse and her history of abuse. In addition, the patients recovery environment provided limited support (score 3) due to her parents struggles to consistently participate in family therapy and their difficulty with co-parenting. For dimension 5, the patient has exhibited limited response and resiliency to treatment (score 3) given her inability to follow treatment recommendations and departure from the RTC against the recommendation of her providers. For dimension 6, the patient was non-collaborative in treatment (score 4) due to a lack of participation and elopement from the RTC against the recommendation of her providers. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Per CALOCUS, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services due to impulsivity, family conflict, academic failures, co-occurring substance abuse and mental illness, and parents struggles to respond to the patients needs. The typical length of stay at this level is up to 60 days. All told, the RTC services were medically necessary for treatment of 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to recent suicidality and self-harm, significant recent aggression, property destruction, impulsivity, and substance use. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict. With regard to comorbidity, the records support a score of 3. The patient had significant co-morbidity, due to the presence of substance abuse and mental illness. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to struggles with performance expectations at home and at school. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents efforts to arrange treatment for patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment. With regard to treatment acceptance and engagement, the records support a score of 4. The patient demonstrated initial reluctance to engage in residential treatment and prior rejection of multiple outpatient providers. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the residential treatment center. Therefore, the residential treatment center services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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 patient has requested authorization and coverage for left hip revision surgery.The goal of total hip arthroplasty is to restore the normal biomechanics of the hip joint, which includes the normal offset of the greater trochanter. The second goal is preservation or restoration of leg length equality, which is achieved while maintaining stability of the prosthesis. In this case, errors in the limb length and the femoral offset affected patient satisfaction after surgery, including function, pain, and the quality of life. Accuracy of the leg length and the high or low offset can be improved by using computer-assisted planning or surgery and the more recently introduced EOS imaging system. Femoral anteversion also needs to be carefully maintained. Attention should be paid to varus and valgus alignment. The most common errors are limb lengthening and a decrease in hip offset. In this case, there was an increase in the offset. Per the literature, when this causes symptoms, the hip needs to be revised. The requested services are medically indicated for management of the painful total hip arthroplasty. Therefore, the requested left hip revision surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for evaluation by a neurovascular specialist.An increased inter-arm systolic blood pressure difference is usually defined as 10 mm Hg or greater and can be found in up to 24% of healthy persons. Asymmetric blood pressure differences in systolic blood pressure (SBP) of 10 mm Hg or more or 15 mm Hg or more between arms have been associated with peripheral vascular disease and attributed to subclavian stenosis. An increased inter-arm systolic blood pressure difference is associated with an increased risk for incident cardiovascular events. In this case, the patient has had an extensive neurological work-up that did not show evidence of a stroke, aneurysm or blood vessel malformations that would warrant further evaluation by a vascular neurologist or neurovascular specialist. Asymmetric blood pressure can be associated with an increased risk of a cardiovascular event, however, asymmetric blood pressure itself is not an indication for a neurovascular evaluation. Under these circumstances, the requested evaluation by a neurovascular specialist is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat 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.