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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement for partial hospitalization program services received. Findings:  The physician reviewer found that  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 2. The patient had chronic poor impulse control, reactivity, history of suicide attempts, and drug use. The patient is assessed as having some risk of harm given her history; however, she no longer endorsed suicidal ideation and there did not appear to be acute safety issues.In terms of functional status, the records support a score of 3. The patient has a history of compromised functioning including bullying parents, not attending school, substance abuse, depression, anxiety, suicidal ideation, past suicide attempts, and a history of food restriction. With regard to comorbidity, the records support a score of 3. The patient had attention deficit hyperactivity disorder (ADHD), depression, and substance use.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has had chronic severe and stressful relational challenges with her parents. The patient has a history of being explosive and reactive towards her family. With regard to level of support of the recovery environment, the records support a score of 3 due to continued limited support in the family. There are also chronic family dynamic concerns.In terms of resiliency and treatment history, the records support a score of 3. The patient has had outpatient follow-up, with limited results. The patient appears to have responded to some degree to RTC and partial hospitalization program treatment, but there are also concerns for minimizing symptoms so she can be discharged.With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to have some constructive engagement while in treatment, but tended to want to push family away. Thus, the patient has a total score of 21. Thus, the records support Level 4 Medically Monitored Community Based Services. The documentation supports the medical necessity of partial hospitalization program in this patients case. Therefore, partial hospitalization program services received were medically necessary for treatment of the patients medical condition.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) (10%/120 grams, every four weeks). Liu and colleagues note that small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions, while Morrison and Chaudhry note that a large number of medications and toxins may also produce neuropathy. Geerts and colleagues note that in the first double-blind, randomized, controlled trial evaluating the efficacy and safety of intravenous IVIG versus placebo in patients with idiopathic small fiber neuropathy, IVIG treatment had no significant effect on pain in patients with painful idiopathic small fiber neuropathy. In this clinical setting, given the limited evidence in current medical literature supporting the use of IVIG in the treatment of small fiber neuropathies, the requested service is not medically indicated. Therefore, Gammagard IVIG (10%/120 grams, every four weeks) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 with sub-specialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycontin tablet 20 mg CR once every eight hours. Tewes and colleagues state, The World Health Organization (WHO) recommends a 3-step ladder in which the use of opioids is recommended for moderate and severe cancer pain. If possible, medication should be administered orally and at a specified interval. The dose should be increased gradually until the patient is pain-free. The WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents note that for pain control, any opioid can be considered, with regular monitoring of the severity of the pain, alone or in combination with a nonsteroidal anti-inflammatory drug. In this case, the patient has severe bone pain due to metastatic cancer spread to the spine, ribs, and lymph nodes, and reports debilitating pain despite medication management with methadone, Soma, oxycontin, oxycodone, and a Lidoderm patch. There is no evidence of inconsistent urine screens or CURES report, or of irregular patient behavior. Given that cancer pain is widely accepted indication for the use of chronic and high dose opioid therapy, the requested medication is medically indicated. Therefore, oxycontin tablet 20 mg CR once every eight hours 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 anesthesiology with sub-specialty certification in pain 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 requested authorization and coverage for right and left foot orthotics (CPT L3020). Findings:  The physician reviewer found that orthotics, either custom or prefabricated, are appropriate for the treatment of patients with plantar fasciitis. However, prior to initiation of a new pair of orthotics, it is reasonable for the patients provider to perform an extensive physical examination describing the patients foot structure. The provider should document specific clinical biomechanical abnormalities to support an indication for custom orthotics. This patient presents with a history of foot pain, plantar fasciitis, hallux valgus, and pronation of feet. The provider reports that the patients current foot orthotics are 2.5 years old and no longer support the patients abnormal pronation. The patients records do not include an assessment of the patients current orthotics or description of the orthotic breakdown. Moreover, there is a lack of documentation of a physical examination of the patients feet in the records provided for review. All told, the requested right and left foot orthotics (CPT L3020) are not medically necessary for 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 licensed D.P.M., board certified in podiatry 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 intensity-modulated radiation therapy (IMRT) (CPT 77263, 77334, 77338, 77011, 77301, 77370, 77280, 77300, 77336, 77470, G6015, G6002, and 77427). Betarbet and Blalock describe keloids as abnormal scars that may cause patients significant emotional and physical distress if inadequately treated. The authors further note that common treatment methods include steroids and radiation therapy. Lin and colleagues note that electron beam radiotherapy is typically utilized in the treatment of keloids to allow for a high surface dose and sharp dose fall off to tissues beneath the scar. However, electrons are typically not used on curved surfaces due to the dose distribution and dependency on the distance from the gantry to the skin, resulting in large amounts of dose heterogeneity. In this case, the patients radiation plan notes a large area of treatment over a curved surface. In this clinical setting, given the size and anatomic location of the patients keloid, the requested service is medically indicated to achieve a uniform dose distribution throughout the lesion treated while still sparing the underlying structures. Therefore, IMRT (CPT 77263, 77334, 77338, 77011, 77301, 77370, 77280, 77300, 77336, 77470, G6015, G6002, and 77427) is medically necessary for the 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 radiation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for opioid pain medication and/or cesarean section to be performed sooner than already scheduled. The records provided for review document that this patient has been scheduled for a repeat cesarean delivery in the setting of two prior cesarean sections. The patient has requested earlier delivery due to her worsening pain. Per the available documentation, the patients pain appears to be musculoskeletal in origin in a setting of known osteoarthritis and groin discomfort that is impacting her ability to ambulate. She reports having experienced this pain in prior pregnancies with resolution after delivery. She has been evaluated in the labor and delivery suite for this pain and has been discharged home with over-the-counter medication and outpatient follow-up. There is no clinical documentation to support any other maternal or fetal indications for her pain. The timing of cesarean section delivery prior to her scheduled date requires documentation of a clinical indication when the benefit of earlier delivery outweighs potential risk. Based on this patients records, there is a lack of clinical documentation to support an earlier delivery than on the already scheduled date. In terms of the patients pain, there is inadequate clinical documentation to support an indication for treatment with opioid medication. The risk-to-benefit ratio of opioid use in pregnancy has been established in the peer-reviewed medical literature. The studies report that opioids should only be used after non-opioid treatment has been tried and failed. The available records do not support the use of opioids for treatment of this patients chronic pain during pregnancy or that non-opioid therapy has been exhausted. Therefore, the requested opioid treatment is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Excimer laser treatment to the chin. Shin and colleagues note that for the treatment of vitiligo, combined treatment of narrow band (NB) ultraviolet light B (UVB) and excimer laser may enhance the treatment response without remarkable side effects. In a randomized, single-blind comparison study including 36 vitiligo lesions, Poolsuwan and colleagues reported that localized 308-nm excimer light appeared more effective and also more rapidly induced repigmentation than targeted 311-nm NBUVB for treatment of vitiligo. In this case, the patient has localized vitiligo and has failed treatment with topical steroids and tacrolimus. Given the potential psychosocial impact of untreated vitiligo, the requested service is medially indicated. Therefore, Excimer laser treatment to the chin is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 patient has requested authorization and coverage for bilateral custom shoe inserts. Neville and Lemley note that while data are limited on the various orthotic devices available for patients with stage II posterior tibial tendon dysfunction, custom devices were associated with greater hindfoot inversion and forefoot plantarflexion compared to walking with only a shoe, and that the off-the-shelf device was associated with forefoot plantarflexion but no change in hindfoot motion. Richie notes that in the management of adult acquired flatfoot deformity resulting from posterior tibial tendon dysfunction, ankle-foot orthoses may arrest the progression of deformity and help the patient avoid debilitating surgery. In this case, the patient has right posterior tibial tendonitis and has tried and failed treatment with over-the-counter orthotics. Given that custom shoe inserts and orthotics may control the abnormal biomechanics of the foot and alleviate excessive pressure from the posterior tibial tendon insertion, the requested equipment is medically indicated. Therefore, bilateral custom shoe inserts are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry, 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 endoscopic surgical ablation and concomitant catheter ablation. Findings:  The physician reviewer found that In a study by DeLurgio and colleagues, patients with long-standing persistent atrial fibrillation (AF) were randomized to two groups. One group was treated with minimally invasive epicardial/endocardial approach (hybrid convergent), and the other group was treated with endocardial catheter ablation. The group treated with the hybrid convergent procedure showed a significantly greater efficacy at 12 and 18 months. In a study by Gersak and Jan, 81% of patients with persistent AF were free from AF at four years following the convergent procedure. In this case, the patient has tried conventional approaches, including antiarrhythmic drugs and endocardial catheter ablation approaches. There is sufficient support for the requested services in this clinical setting. Therefore, endoscopic surgical ablation and concomitant catheter ablation are likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings: Two out of three physician reviewers found that endoscopic surgical ablation and concomitant catheter ablation are likely to be more beneficial for you than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 and reviewer 2 are board certified in internal medicine with sub-specialty certification in clinical cardiac electrophysiology; and reviewer 3 is board certified in cardiovascular disease. All reviewers 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 authorization and coverage for laser hair removal. The records provided for review document that this patient presents with excessive hair about the buttocks and gluteal cleft. The patients age, gender, and hirsutism are all risk factors for the development and recurrence of pilonidal cysts. Pilonidal cysts are characterized by chronic and recurrent inflammation and infection surrounding hair on the buttocks and gluteal cleft. Surgical treatments have a high rate of recurrence and often require repeated surgical interventions and systemic antibiotics for the accompanying folliculitis and cellulitis (Kelati, et al.). There is evidence to suggest that laser hair removal decreases the risk of delayed healing and recurrence of pilonidal cysts following surgical treatment, and/or as an alternative to surgical treatment. Thus, the requested laser hair removal is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Based on the available documentation, this patients pilonidal cyst is an abnormal structure of the body caused by a secondary infection due to ingrown hairs. On review of this patients records, the requested laser hair removal is reconstructive in nature per the California reconstructive surgery statute. The patients pilonidal cyst is an abnormal structure of the body and the requested laser hair removal will improve the patients function and will create a more than minimal improvement in the patients appearance. Given these findings, the requested laser hair removal is reconstructive in nature for treatment of this patient. All told, the requested laser hair removal is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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 patient has requested authorization and coverage for (1) Robaxin 750 mg (three times/day; 30-day supply), (2) bupropion 150 mg (Wellbutrin-XL, three tablets/day, 30-day supply), (3) gabapentin 600 mg (three times/day, 30-day supply), (4) Norco 10/325 mg (30-day supply), (5) myelogram computed tomography (CT) scan, and (6) single-photon emission computed tomography (SPECT-CT) scan. McGhee and colleagues note that winged scapula is one potential underlying cause of shoulder pain and that history taking, physical examination, and imaging are needed for a correct diagnosis. Didesh and Tang note that the condition is painful and debilitating. Rustagi and colleagues note that in rare instances, winging and snapping of scapula may be caused by space-occupying lesion of the thoracic wall. The authors further note that while osteochondroma of scapula is rare, it is the most common neoplasm of scapula, and osteochondroma of ventral scapula may lead to pseudo-winging, snapping, and rib erosion on the same side. In this case, the requested CT scans would help identify a bony tumor.  In this clinical setting, given the patients worsening pain and declining function that inhibit participation in therapy, a multimodal pain treatment approach with a trial of multimodal analgesics is indicated to assess if the patient is able to obtain some functional relief. Therefore, (1) Robaxin 750 mg (three times/day; 30-day supply), (2) bupropion 150 mg (Wellbutrin-XL, three tablets/day, 30-day supply), (3) gabapentin 600 mg (three times/day, 30-day supply), (4) Norco 10/325 mg (30-day supply), (5) myelogram CT scan, and (6) SPECT-CT scan are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services and medications 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 anesthesiology with sub-specialty certification in pain 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.