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

An enrollee has requested authorization and coverage for Orthovisc injection to the left knee. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a known history of excellent relief from viscosupplementation over at least three years with at least six to nine months of relief from each series of injections. Furthermore, the patients options are limited, with the alternative being a total knee arthroplasty. Under these circumstances, Orthovisc injection to the left knee is medically necessary for 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 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

An enrollee has requested authorization and coverage for a dual-energy x-ray absorptiometry (DEXA) bone density test.The patient had a DEXA scan performed one year ago that showed osteoporosis. Records reflect that she completed two years of anabolic agent teriparatide (Forteo) therapy this year. It is known that based on pharmacological mode of action, the effect of teriparatide may be lost after discontinuation of therapy, and, therefore, there are many studies that support sequential or intermittent therapy with an antiresorptive agent. Therefore, it is important for this patient to have a bone mineral density (BMD) study upon completion of therapy and prior to determining subsequent therapy. It would be misleading to require the patient to wait another year before performing a bone density test because of the bone loss that may occur in that period of time. Under these circumstances, a dual-energy x-ray absorptiometry (DEXA) bone density test is medically necessary for 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 internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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 psychiatric 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. Applying the CALOCUS framework, this patient met the criteria for RTC services. The patient was at significant risk of harm due to prior suicidality and self-harm, as well as multiple prior attempts and hospitalizations. Despite multiple prior psychiatric hospitalizations, she has only demonstrated recent gains in the RTC setting. The patient has been constructive with treatment, considering her positive engagement in treatment, and high extrinsic motivation, but lower intrinsic motivation, per the records. This gives the patient a composite score of 18. However, given the patients score for comorbidity, the appropriate level of care is Level Five, Medically Monitored Residence-Based Services, similar to the services provided at the RTC facility. Given this patients history of suicidality and self-harm, combined with continued body image concerns, 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

The patient has been diagnosed with atopic dermatitis. Physical examination findings included erythematous eczematous patches, lichenification, and hemorrhagic crusting distributed on the patients arms, hands, trunk, legs, and feet. The records noted that 30% of the total body surface area was affected. The provider noted that systemic corticosteroids were inappropriate for the patient. Per the provider, the patient is unable to be treated with phototherapy due to his work schedule. In an undated letter, it was noted that the patient had tried and failed treatment with clobetasol and triamcinolone acetonide topical creams. The patient has requested authorization and coverage for Dupixent. The Health Plan denied the request and reported that Dupixent is not medically necessary for the treatment of this patient. At issue in this case is whether Dupixent is medically necessary for treatment of the patients medical condition. This patient has been diagnosed with atopic dermatitis. Paton reported that dupilumab has been demonstrated to reduce the clinical manifestations of moderate to severe atopic dermatitis, thus improving quality of life. Dupixent (dupilumab) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe atopic dermatitis. In this case, the patient has tried and failed treatment with clobetasol and triamcinolone acetonide topical creams. Systemic corticosteroids were also noted to be inappropriate for the patient. The medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent is 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for DME, power seat elevator. The enrollee has paralysis, weakness and pain. She is unable to transfer, stand or walk. She cannot stand from a seated position, and she cannot shift her weight to manage pain and pressure relief. The enrollee cannot use a manual wheelchair due to pain, paralysis and poor grip. Her current power chair is broken. It is over five years old. The enrollees provider is requesting authorization for a seat elevator for the enrollees custom power wheelchair. Based on the diagnoses and the enrollees disabilities, the request for the power seat elevator is medically necessary. Literature shows the enrollees illness causes progressive weakness and and sensory loss; usually affecting the feet and legs at the beginning. It eventually affects the hands. Devices designed to improve mobility will improve the enrollees quality of life.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Euflexxa injections for the right knee. The enrollee has ongoing pain of the right knee. She has experienced benefit with hyaluronic acid (Euflexxa) injections in the past, but only temporary relief, lasting one week, with cortisone injections.  The enrollee reports she received Euflexxa injections previously and the effects lasted for a year.  The physician requested authorization for the injections again. Literature describes osteoarthritis as a common condition; resulting in pain, reduced mobility, and decreased function. Studies have shown corticosteroids short-term pain improvement and can be used for flares. Recent studies have shown hyaluronic acid (Euflexxa) injection demonstrates longer-term improvement in both pain and function. A professional society recommends intra-articular hyaluronic acid (Euflexxa) injection for the treatment of knee osteoarthritis for adults who do not respond to other treatment options. Literature supports hyaluronic acid injection for cases of osteoarthritis in situations where the individual declines surgical intervention.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has a history of depression and suicidal ideation. The enrollee entered a residential treatment center, with diagnoses of major depressive disorder, single episode, severe; cannabis use disorder, severe; alcohol use disorder, severe; oppositional defiant disorder, and inhalant use disorder; severe.  Upon admission, the enrollee endorsed passive suicidal ideation without plan or intent. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, due to no active suicidal or homicidal ideation exists, but extreme distress and/or a history of suicidal/homicidal behavior is present. For functional status, the enrollees score is 3, due to recent gains and/or stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched service. For comorbidity, the enrollees score is 3, due to recent substance use that has a significant impact on the presenting condition has been arrested, due to the use of a highly structured or protected setting or through other external means. For recovery environment level of stress, the enrollees score is 4, due to the threat of severe disruption in life circumstances, including the threat of imminent incarceration of either the caregiver or self, the lack of a permanent residence, or the immersion in an alien and hostile culture. For recovery environment level of support, the enrollees score is 2, due to family/primary caretakers are willing and able to participate in treatment if requested to do so, and have the capacity to effect needed changes. For resiliency and treatment history, the enrollees score is 4, due to previous treatment has not achieved complete remission of symptoms or optimal control of symptoms; even with intensive and/or repeated exposure to treatment. For treatment acceptance and engagement, the enrollees score is 3, due to an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. The enrollees composite CALOCUS score is 22, which correlates with Level 4, an intensive integrated service level of care without 24-hour psychiatric monitoring.Final Result: The reviewer determined that the requested service were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an amniotic membrane graft. This patient has a history of persistent neurotrophic keratitis in the right eye. The provider performed an in-office procedure to place an amniotic membrane over the cornea. The evidence for the efficacy of amniotic membrane for use in this clinical setting is limited. Although this patients condition did not substantially improve with Timolol ophthalmic solution, prednisolone acetate ophthalmic suspension, and Polytrim, there are remaining established therapies including Oxervate available for use in this patients care. All told, the amniotic membrane graft was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the amniotic membrane graft was likely to be more beneficial for treatment of the patients medical 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 ophthalmology 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

The patient has requested authorization and coverage for weekly individual behavioral health therapy sessions. This patient presents with depressive symptoms including mood disturbances, difficulty performing ADLs, and intermittent suicidal ideation. The continued stress of dealing with her gender transition has increased her mood, gender dysphoria and possible psychotic and dissociative symptoms. The American Psychiatric Association (APA) supports individual psychotherapy for major depressive disorder alone or in combination with psychiatric medication management. Researchers found that individual psychotherapy is an evidence-based treatment for patients with major depressive disorder. The authors stated that the current medical literature includes adequate evidence for weekly individual psychotherapy in this clinical setting. This patients records document the presence of depression and gender dysphoria. All told, the requested weekly individual behavioral health therapy sessions 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 with expertise in psychosomatic 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

The enrollees parent is requesting authorization and coverage for residential treatment center (RTC) services. The enrollee entered the Center for Discovery mood and anxiety program for the treatment of mood disorder. The enrollee struggled with depression, isolation, and suicidal thoughts since the age of 13; with symptoms increasing over the past two years. She has a history of two suicide attempts.  The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollees composite CALOCUS score is 18, which correlates with a Level 3; however, having a score of 4 on Dimension I requires Level V care.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for facial feminization surgeries. The World Professional Association for Transgender Health (WPATH) 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. In addition, WPATH further noted that, Other surgeries for assisting in body feminization includerhinoplastyfacial bone reduction, face-lift, and blepharoplasty. Researchers demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life in patients with gender dysphoria. This patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based on clinical documentation of persistent gender dysphoria related to masculine facial features associated with distress. All told, 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: Overturned Decision of Health Plan

The parent of the enrollee is requesting reimbursement for anesthesia services. The patient had cavities, which required treatment, extraction and spacers. The patient required surgery to fix the cavities. Because of his age, this could not be done in a dental office setting. Instead, the treatment was provided with general anesthesia. For young patients, treatment under general anesthesia in a hospital setting is the best way to treat this condition.  The medical records show the patient was extremely shy, fearful and anxious. General anesthesia is often used with young patients to fix multiple cavities; especially if the child is anxious and unable to cooperate, like this patient was.           Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 enrollee is requesting authorization and coverage for requested transcranial magnetic stimulation (TMS). The enrollee has a history of chronic depression. He reports his depressive symptoms started at age 15-16. The enrollee reports his depression has ranged from moderate to extreme for over 25 years. His depression has a negative impact on every aspect of his life. For the past thirteen years, he has tried many different medications. They either did not work or were not tolerable. Per enrollee report, he has not responded to multiple medication trials during his current depressive episode. The enrollee does not want electroconvulsive therapy, but he does want to try transcranial magnetic stimulation treatment. The medical records did not supply enough information about the enrollees medication trials and dosages, and the records did not supply enough information about the enrollees past and present depressive episode. Medical records do not show pre-treatment evaluations recommended by a professional society. The records provide conflicting information about the enrollee; first describing the enrollee as not being able to work because of his depressive symptoms, but also saying that the enrollee could not use electroconvulsive treatment because he was the sole provider and could not miss work for three to six months. 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.