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

The patient has requested reimbursement and prospective authorization and coverage for inpatient behavioral health hospitalization including electroconvulsive therapy (ECT). The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guidelines, this patient does not meet the criteria for inpatient behavioral health hospitalization. The patient has been at significant risk of harm as the records indicate that the patient demonstrated paranoia and verbalized delusions that people were conspiring against her. The patient has not been an imminent danger to herself or others. The patient has demonstrated moderate functional impairment. On admission, the patient showed some decrease in her ability for self-care. The patient has shown improvement while in a structured setting. Although she has demonstrated some paranoia, it was documented that she had good insight and judgment and has been capable of making decisions regarding her health care, specifically, whether or not to accept ECT treatment. The patient did not have any significant comorbidities as there is no report of substance abuse or coexisting medical condition that interferes with treatment. The patients recovery environment has been highly stressful. The patients recovery environment has been supportive as the patients husband stated that he would hire a caregiver and a driver to ensure that the patient would attend outpatient ECT. The patient has demonstrated moderate response to treatment. Although the patient continues to have some psychotic symptoms and ambivalence toward treatment, the progress notes do not indicate that the patient has significant skilled nursing needs. The providers report that the patient has been eating and sleeping. The providers indicate that the patient has improved with this admission. The patients caretaker has been adversarial, which has not benefitted the patients progress. Per the LOCUS instrument, that gave the patient a composite score that is consistent with medically monitored residential or non-residential services. Therefore, the inpatient behavioral health hospitalization including ECT was not and is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for advanced lipoprotein testing. The provider believed the patients history of familial hypercholesterolemia, resulted in an increased cardiac risk for the patient. The advanced lipoprotein testing was ordered to monitor and treat her cardiac health. She had no clinical evidence of cardiovascular disease. The medical literature indicates LDL particle analysis testing, apolipoprotein B testing, and lipoprotein (a) testing does not represent the standard of care for cardiovascular risk reduction. The results do not predict or rule out the possibility of acute cardiovascular events, such as heart attacks and strokes. The results offer no proven clinical benefit over conventional lipid testing in the context of cardiovascular risk assessment. There is no established proven efficacy of these technologies, either in randomized clinical trials or meta-analyses, to support their benefit compared to conventional cardiovascular risk assessment methods, as their use has not been conclusively linked to improved cardiovascular outcomes. Despite these tests having approval, the enrollee does not stand to benefit from their use over conventional lipid testing and established risk assessment strategies The guidelines on the evaluation and treatment of hyperlipidemia put forth by a variety of different expert panels and organizations do not require advanced lipoprotein measurements. Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for voice therapy. 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. The WPATH further states that, voice and communication therapy may help to alleviate gender dysphoria and be a positive and motivating step towards achieving ones goals for gender role expression. The WPATH does not require a mental health evaluation for voice therapy. This patients records document a history of gender dysphoria with distress related to the masculine sound of her voice. For this patient with severe gender dysphoria, voice therapy is indicated to help her voice be more consistent with her female gender identity. Therefore, the requested voice therapy 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has reimbursement for residential treatment center (RTC) services. Applying CALOCUS, this patient presented with some risk of harm (score 2). The medical records indicate that the patient was not actively suicidal at any time, but did have a history of speaking of suicide without past attempts. There was no indication that the patient was aggressive at any time. The progress notes did not indicate any active self-harm behaviors or homicidal ideation. The patient demonstrated mild functional impairment (score 2) as he showed significant improvement in function following a period of deterioration. He did not exhibit any significant behavioral problems, mood symptoms, or anxiety symptoms. The patient did not have any documented comorbidities (score 1). The records did not report any active medical problems or substance use. The patient did not express any symptoms of psychosis. There was no indication the patient had any medical issues affecting treatment. The patients recovery environment was mildly stressful (score 2), as there was no indication of an unsafe home environment. The patients recovery environment was supportive (score 2). The patients family was described as actively involved in treatment on a regular basis. The patient demonstrated moderate response to treatment (score 3). The providers noted that the patient was engaged well at the RTC and his symptoms were under good control with minimal mood and anxiety issues. The patient was constructive (score 2) while at the RTC and was cooperative in therapy. The patient was engaged in individual therapy and family sessions. The patients parent was constructive in treatment (score 2). The patient and his family participated in family therapy, home passes and appeared to have a working relationship. The records state that the patients parent worked actively and constructively with the providers on a regular basis. This gives the patients presentation a composite score of 16, which correlates with intensive outpatient services. Given these findings, the RTC services 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 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 enrollee is requesting reimbursement for removal of deep infiltrating endometriosis, endometrioma, and bowel re-section using a wide excision method with near-contact laparoscopy (CO2 laser). The provider notes the enrollee had surgery, which showed significant stage four disease of the posterior cul-de-sac due to endometriosis and adhesions; left untreated. The provider recommended a surgical procedure to include laparoscopy, excision of endometriosis, lysis of adhesions, enterolysis, ureterolysis, cystoscopy, and ovarian cystectomy. The provider noted endometriosis is a common disease, but its effective surgical treatment poses significant challenges that require extensive knowledge and surgical expertise. The enrollee had invasive endometriosis that grew through her bowel, and a section required removal. She underwent a laparoscopic wide excision surgery for treatment of her endometriosis with a board-certified gynecologic surgeon specializing in complex endometriosis cases. The enrollee has exhausted her medical treatment options, including oral progestins, GNRH agonists, combination oral contraceptives, elimination diet, and high dose NSAID use. She did not achieve relief from any of the hormone modulating medications, and the side effects were difficult for her to tolerate. She did get relief from NSAIDs, but over time they did not work as well. Because the enrollee had already exhausted the treatment options provided by her gynecologists and due to the debilitating nature of her severe endometriosis, she proceeded with her planned surgery. Both her physician and her surgeon have written letters explaining the complexity of her invasive endometriosis, urgency of her case, and why laparoscopic wide excision is the best treatment option for her unbearable chronic pain and other symptoms. Providers available to the enrollee could only offer laparoscopic ablation of endometriotic implants. There were many aspects of the surgery for which a general gynecologic surgeon is not trained to perform; specifically, ureterolysis, rectosigmoid and sigmoid enterolysis, and meticulous dissection of the dense adhesions throughout her abdomen. This is why the surgeon who performed this procedure was the appropriate surgeon for this enrollees complicated case. Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for multi-level lumbar fusion surgery. In this case, the patient presents with persistent grade low back pain radiating into the right leg with weakness and recent episodes of urinary incontinence. The patients records reflect that she has functional limitations in standing, walking, and performing activities of daily living. Clinical exam findings have documented motor weakness. X-ray findings have documented haloing of the S1 screws consistent with loosening, plausible pseudoarthrosis and spondylolisthesis. Imaging findings showed significant foraminal and lateral recess stenosis. Evidence of long-term reasonable and/or comprehensive non-operative treatment and failure has been submitted. Current evidence based medical literature supports revision fusion to treat the patients reported hardware loosening and plausible pseudoarthrosis. Fusion for adjacent segment disease is supported by the patients current spondylolisthesis, surgery adjacent to fusion, and for anticipated temporary intraoperative instability due to the reasonable need for wide decompression. Under these circumstances, the requested multi-level lumbar fusion surgery is medically necessary to treat 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Percocet 10 mg #20 every two months. The use of opioid medication is not recommended for the treatment of migraines due to their addictive nature and tendency for causing rebound headaches. There are currently multiple medications available for the prophylactic and abortive treatment of migraines. As per the guidance of the American Headache Society and the American Academy of Neurology, opioids should only be used for the treatment of migraines as a last resort after the patient has failed non-opioid treatment measures. The use of opioids in patients with migraine carries a high risk of medication overuse headache. All told, Percocet 10 mg #20 every two months 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Researchers found that physical rehabilitation for long-term care residents may be effective, reducing disability with few adverse events, but effects appear quite small and may not be applicable to all residents. The documentation provided for review reports that this patient is currently in a SNF, but is receiving custodial care. There is no reported indication for continuation of rehabilitation level of care with SNF services. The provider noted that the patient is planned to receive PT and OT, but these services can be provided on an outpatient basis. For these reasons, the requested SNF level of care 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine and pelvis (procedure codes 72148 and 72195). The Health Plan denied the request and reported the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were medically necessary for the evaluation of the patients medical condition. The American College of Radiology appropriateness criteria indicates that MRI of the lumbar spine is usually not appropriate for acute, subacute, or chronic uncomplicated low back or radiculopathy without red flags or prior management. In this case, there was no documentation of any red flags, such as neurological compromise. There was no indication of how many physical therapy sessions the patient had or the results of those sessions. There was also no documentation of a repeat ultrasound of the left ovary indicating a need for an immediate pelvic MRI. The clinical presentation of left sciatica does not support the medical necessity of a pelvic MRI. Therefore, MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services 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 radiology 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 total left knee replacement surgery. The patient should provide documentation of failure of non-operative treatments such as physical therapy and medications, as well as exercise and weight loss, when indicated. This patient presents with chronic left knee pain that has been reported as moderate, intermittent, and recurrent. She has an antalgic gait and uses a knee brace. The records include detailed documentation of recent, reasonable and comprehensive non-operative treatment. Clinical examination findings are consistent with imaging evidence of chondromalacia patella and minimal medial femorotibial joint space narrowing. There are only minimal findings of osteoarthritis. A recent evaluation with an orthopedic surgeon did not recommend surgical intervention at that time. Given these findings, the requested total left knee replacement surgery is 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 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: The patients parent has requested authorization and coverage for removal of a benign nevus. Based on review of the medical records, this patient has a left hand dorsal 4 x 5 cm melanocytic nevus. The nevus was determined to be a benign non-cancerous lesion on biopsy. There are no reported functional issues associated with the lesion. Thus, the removal of the benign nevus is not supported as medically necessary. In addition, the condition is not an abnormal structure of the body. Benign nevi are a common finding on the skin. Based on the available documentation, the proposed surgery would not improve function or provide a more than minimal improvement in the appearance of the patient. All told, the requested removal of a benign nevus is not medically necessary or reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary or 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 condition.