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

A female with hidradenitis suppurativa. She has been treated by a primary care provider with conservative home management and antibiotics, without resolution of symptoms. She has recurrent boils in axillae, groin, and buttocks. The patient has requested coverage for a referral to a dermatologist. The Health Plan denied the request and reported the requested service was not medically necessary for the treatment of this patient. At issue in this case is whether a referral to a dermatologist is medically necessary for the treatment of the patients medical condition. Hidradenitis suppurativa is a chronic, painful, follicular occlusive disease that affects the axillary, groin, perianal, perineal, genital, and inframammary skin. The clinical course is highly variable, ranging from relatively mild cases to severe cases demonstrating deep abscesses, draining sinuses, and severe rope-like scars. The symptoms caused by hidradenitis suppurativa profoundly affects patients quality of life. Treatment of hidradenitis suppurativa includes home management, oral antibiotics, oral retinoids, biologics and surgical interventions. A specialty consultation may be required when the diagnosis is uncertain, complex. or when the course of care may benefit from additional expertise. In this case, the patient has failed to respond to initial conservative care and oral antibiotics. Additional treatment options include oral retinoids, biologics and surgery, which are outside of the scope of practice of a primary care physician and within the expertise of a dermatologist. Thus, a referral to a dermatologist is medically necessary for treatment of this patients medical condition.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 family practice 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

An enrollee has requested authorization and coverage for five dental implants. The patient has a history of myofascial pain and headaches. The records document missing premolar teeth. The submitted records do not demonstrate a causal relationship between the missing teeth and the pain described, as the literature describes multiple factors which may lead to temporomandibular joint pain and myofascial pain. Although the patients provider recommended dental implants to stabilize the patients occlusion, the orthodontic treatment the patient previously received would have been reasonably expected to stabilize the occlusion and did not result in relief of the symptoms. As stabilizing the patients occlusion orthodontically has failed to correct the reported myofascial pain, there is a lack of evidence that dental implants would more effectively address the chief complaint of myofascial pain. There is a lack of support for the requested services in this clinical setting. Therefore, the requested five dental implants are not medically necessary for the 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 dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has a long history of rosacea. In this note, the patient admitted to excessive sun exposure. She had used Metrogel (metronidazole) 0.75% topical gel in the past with good results. Rosacea is a chronic condition that is treated with patient education, skin care techniques, and pharmacologic interventions. Patient education regarding trigger avoidance and skin care techniques such as moisturizing and sun protection are important non-pharmacologic first steps in treating rosacea. Pharmacologic interventions range from topical to systemic medications depending on the symptoms and severity of each patient. In this case, the patients rosacea is described as mild in severity. There are no indications that she has followed patient education regarding trigger avoidance and skin care techniques. Further, she admits to excessive sun exposure. Therefore, the requested Metrogel 0.75% topical gel is not medically necessary to treat this patient's medical condition.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 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 orthotic inserts. Current medical literature indicates that posterior tibial tendinitis and bunion deformities are caused by significant eversion of the heel, with significant subtalar joint valgus. This abnormal mechanical positioning causes severe stress to both the posterior tibial tendon as well as the first metatarsophalangeal joint (MPJ). Standard of care for this patient includes custom functional orthotics to reduce calcaneal eversion and overpronation which will alleviate stress and strain from the posterior tibial tendon, first MPJ, and sinus tarsi. Therefore, the requested orthotic inserts are medically necessary for this patients pedal biomechanical abnormalities and foot pain.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 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 monthly psychiatric appointments, and weekly or twice per month psychotherapy sessions. Findings:  The physician reviewer found that according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, for behavior that reflects a dysfunction in the psychological, biological, for developmental process underlying mental functioning. Mental disorders are usually associated with significant distress work disability in social, occupational, for other important activities. The DSM-5 and the medical literature indicate that functional impairment must be present in order for a set of symptoms to classify as a mental illness. The progress notes provided for review do not detail any functional impairment.  In addition, the records lack a description of the patients exact symptoms. The patients most recent psychiatric clinical assessment indicated the patient was exhibiting some depression symptoms and mood swings. Further, the records do not describe any recommended frequency of outpatient therapy sessions and there is no description of treatment goals or rationale to support the requested frequency of therapy. Thus, the requested weekly or twice per month psychotherapy sessions are not supported as medically necessary. However, monthly psychiatrist services are medically necessary as the patient is receiving medications that have recently been increased and will require monitoring. Therefore, the requested monthly psychiatrist services are supported as medically necessary.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether Cardio IQ panel tests that were rendered were likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy. The records documented a diagnosis of dyslipidemia which was treated successfully with medication therapy when taken as ordered.Findings:  Three physician reviewers found that the tests at issue were not likely to have provided additional information that would have affected treatment decisions for this patient. She had known dyslipidemia. There are multiple prior evaluations of both standard and advanced lipid profiles. In this case, this had been determined previously, and the risk was high enough to start medical treatment. Repeated measurements of advanced lipid profile parameters are not currently recommended or indicated. There is no guideline directed goals of therapy for these advanced lipid measurements beyond the standard LDL cholesterol parameters in the published 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.  Final Result: The reviewers determined that the requested test was 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 internal medicine with subspecialty certification in cardiovascular disease 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: This is a patient with chronic right hip pain. She has been diagnosed with osteoarthritis. She was scheduled for right total hip arthroplasty with discharge to home following inpatient admission. Physical examination of the right hip revealed painful flexion and extension and the inability to do internal and external rotation. Recommendations regarding post-operative care included ice, heat, modified, walking and follow-up as needed. The patient requested a referral to a skilled nursing facility (SNF) for postoperative care. She reported that she lives on her own and does not have anyone to care for her following surgery.The records provided for review noted the patient had made a reasonable attempt to find at-home assistance. SNF admission following joint replacement surgery is generally supported by evidence-based medical literature. In this case, the patient is of advanced age, lives alone and had inadequate post-operative in-home support services, and presents as an increased fall risk. Therefore, the requested SNF services after hip replacement surgery are medically necessary for the treatment of this 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy services at a frequency of three times per week for six months and occupational therapy services at a frequency of three times per week for six months. Spinal cord compression (e.g., due to spinal stenosis) can result in functional impairments in various domains, such as self-care, mobility tasks, bladder function and bowel function. These impairments may persist despite surgical decompression. These impairments require individualized rehabilitative measures and supportive care to address and manage. In this case, the patient underwent surgical decompression of multilevel cervical stenosis and was transferred to a skilled nursing facility for further care. Postoperatively, he has had profound functional impairments. He has been undergoing rehabilitation since early January 2019, but has continued to remain essentially dependent for all care and mobility. Limb strength has remained at the poor to poor plus level. He has remained non-ambulatory. The requested skilled therapy services are not medically necessary at this time given that they are not expected to positively impact the patients clinical or functional course or outcomes beyond a basic maintenance/restorative program. Resuming formal therapies can be reconsidered if there is significant neurological recovery in the future, which would provide a substrate with which the therapists could work. Therefore, physical therapy services at a frequency of three times per week for six months and occupational therapy services at a frequency of three times per week for six months are not medically necessary for the 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 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

Nature of Statutory Criteria/Case Summary: An enrollee transgender female with a history of gender dysphoria. The records indicate that she has been living as female and had been on hormone therapy. She had laser therapy to decrease facial hair. Her anxiety and depression have improved since she started presenting as female. The patient has a documented history of gender dysphoria and has been on cross-gender hormone therapy. Facial feminization surgery (FFS) would enhance this patients psychological and social functioning and alleviate distress due to gender dysphoria. Moreover, the requested FFS is consistent with the World Professional Association for Transgender Health (WPATH), which states that in addition to hormonal balancing, medically necessary gender affirming or confirming surgical procedures may include certain facial plastic reconstruction as appropriate to the patient. According to WPATH, the medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. Based on the documented history of gender dysphoria, the requested FFS (forehead, brow, and nose) are medically necessary for 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether for IOP services that were provided were medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that the medical records indicate the patient had limited insight into his need for treatment and he expressed suicidal ideation. The patient showed some commitment to therapy but also exhibited counterproductive behaviors including lying and producing fake signatures.  He continued to have symptoms of depression and insomnia. The medical records indicated the patient had poor judgment and insight, and demonstrated impulsive behaviors. The patient was at risk for substance use and relapse. IOP level of care includes direct services for patients with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. IOPs are alternatives to more restrictive levels of care designed to establish psychosocial support, as well as facilitate relapse management and coping strategies. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is used to determine the necessary level of care for adults. The six dimensions include risk of harm, functional status, comorbidity, recovery environment and level of support, treatment and recovery history, and engagement and recovery status. The patients composite score is 17, which correlates with an IOP level of care. The medical evidence supports the services at issue in this clinical setting. Therefore, the IOP services that were provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 a 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the genetic test (Colaris AP with myRisk) that was performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Findings: Three physician reviewers found that she has a history of cancer in her family that is concerning for possible hereditary cancer predisposition syndromes. Due to this patients family history of cancer and the literature to support genetic testing, the genetic test that was performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test was likely to be more beneficial for evaluation 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 clinical genetics 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ARUP Skeletal Dysplasia Panel, Sequencing and Deletion/Duplication. Findings:  Two out of three physician reviewers found that determining the etiology of skeletal dysplasia is critical in establishing the risk to future pregnancies. Assessment of radiographic findings, molecular analysis and pathology specimens enables postnatal assignment to a specific group within the Nosology and Classification of Genetic Skeletal Disorders system. In this case, tissue should be referred for DNA extraction for microarray analysis, mutation analysis for a specific gene disorder when a specific diagnosis is suspected, as well as gene panel testing. Therefore, the ARUP Skeletal Dysplasia Panel, Sequencing and Deletion/Duplication is likely to be more beneficial for evaluation of the patients condition than any available standard therapy. One reviewer found the testing is not llikely to be more beneficial for evaluation of the patients condition than any available standard therapy because the NCBI Genetic Testing Registry notes that the clinical validity and clinical utility of the test has yet to be supported by adequate current medical literature.Final Result: Two reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in obstetrics and gynecology and reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in maternal-fetal medicine, and all 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.