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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of breast implants and removal of breast capsules. Grossman and colleagues state, What is most important in the evaluation of rupture is just to know if it is a saline or silicone implant. Saline rupture results in the extravasation of a simple saline solution that is harmless and reabsorbed by the body. Researchers note, The most important information in the evaluation of a potential implant rupture is the makeup of the implant present, that is, is it a saline implant or a silicone implant, and how long ago was it placed? Saline implant rupture results in the extravasation of a simple normotonic saline solution that is harmless and will be reabsorbed by the body over time. In this case, the patient has a ruptured saline breast implant from a prior cosmetic breast augmentation. Given that rupture of a saline breast implant presents no risk from the free released saline, and that no risk is presented by the inert breast capsule, the requested services are not medically necessary. Therefore, removal of breast implants and removal of breast capsules is 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuromuscular reeducation physical therapy. There is inadequate evidence in the published medical literature to support the use of neuromuscular reeducation physical therapy over other forms of physical therapy in the treatment of young patients with global developmental delay. Studies addressing physical therapy in young patients with severe global developmental delay are limited. Reporters reviewed 846 articles investigating motor skill programs for young patients with developmental coordination disorder. The authors concluded that, no large-scale multisite randomized control trial (with adequately blinded assessors) has been conducted in relation to any motor skills intervention intended to remediate the impact of developmental coordination disorder. Overall, there is a lack of data to support neuromuscular reeducation physical therapy for the treatment of this patients global developmental delay. For these reasons, the neuromuscular reeducation physical therapy was not medically necessary for 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 neurology with special qualification in child 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 transcatheter aortic valve replacement (TAVR) surgery (CPT 33361). The records provided for review document that this patient has increasingly progressive cardiac symptoms consistent with aortic stenosis without another medical explanation for his symptomatology. His aortic valve area is moderately to severely stenosed. Based on current guidelines, he meets current criteria for aortic valve replacement (Nishimura, et al.). He is considered an intermediate risk for surgery based on his history of hairy cell leukemia, which is not a contraindication to the procedure (Coylewright, et al.). The patient has undergone a thorough work-up by a team of providers who have recommended TAVR surgery. Based on the available documentation, this patient meets the criteria for TAVR surgery based on published randomized controlled clinical trials (Bavaria, et al.; Mack, et al.; Halim, et al.). The records support that the requested TAVR surgery is appropriate for this patient since has undergone the required guideline-directed evaluations to ascertain that he is an appropriate candidate for the TAVR procedure. All told, the requested TAVR surgery (CPT 33361) 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 internal medicine with subspecialty certification in cardiovascular disease 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 a consultation with an endocrinologist that provides tertiary level of care. Findings:  The physician reviewer found that Miguel and colleagues describe Graves ophthalmopathy (GO) as an autoimmune disorder and the most frequent extrathyroidal manifestation of Graves disease that, despite recent progress in the understanding of its pathogenesis, often remains a major diagnostic and therapeutic challenge. Patel and colleagues report that current thyroid eye disease (TED) treatment strategies target inflammation and symptoms, but do not modify the disease course. The authors further note that targeted molecular therapy using teprotumumab demonstrates disease-modifying benefits with the potential to shift the paradigm for TED treatment. Given that such medications may be effective but are not without potential side effects and should be administered by health care practitioners with specific expertise in this field, such as an endocrinologist and an ophthalmologist, the requested services are medically indicated. Therefore, a consultation with an endocrinologist that provides tertiary level of care is medically necessary for the evaluation 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 internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychotherapy. Swanson note that evidence demonstrates that bipolar disorder-specific psychotherapies, when added to medication for the treatment of bipolar disorder, consistently show advantages over medication alone on measures of symptom burden and risk of relapse. For a patient with acute symptoms of bipolar disorder, psychotherapy once weekly with additional group psychotherapy and case management, as needed, is appropriate. In this case, the patient has a diagnosis of bipolar disorder and is destabilizing rapidly at this time, to the point of needing crisis services.  In this clinical setting, the requested services are standard of care and medically indicated. Therefore, weekly psychotherapy 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services, daily for six to nine weeks. This patient presents with diagnoses of depression and unspecified bipolar disorder versus bipolar II disorder. The patients provider has recommended treatment with TMS. In the peer-reviewed medical literature, Fitzgerald and Daskalakis noted that repetitive TMS is currently emerging as a new treatment for patients with mood disorders. The authors reported that their findings support the safety and efficacy of TMS in the treatment of patients with depression. This patients comorbid diagnosis of bipolar disorder does not preclude treatment with TMS as many studies have included patients with depression and bipolar disorder with reported benefit. In addition, this patients treatment regimen includes lithium, which is likely due to treatment resistance for depression rather than bipolar spectrum psychopathology. Overall, this patient has a questionable diagnosis of bipolar disorder and more consistent presentation of treatment-refractory depression.  TMS is an appropriate treatment modality for the treatment for depressive episodes, especially patients with treatment-refractory major depressive disorder, as in this patients clinical setting. For these reasons, the requested TMS services, daily for six to nine weeks, 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chest reconstruction (CPT code 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk)) performed in conjunction with a bilateral mastectomy. Findings:  The physician reviewer found that a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). WPATH states that medically necessary gender affirming/confirming surgeries may include bilateral mastectomy and chest reconstruction, as appropriate to each patient. Mastectomy with male chest reconstruction in transgender males is now commonly done in young adults and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. A recent study of adolescents and young adults concluded that chest dysphoria was high among presurgical transmasculine youth, and that surgical intervention positively affected both minors and young adults.In this case, the patient has a long history of gender dysphoria, and he has been living as a male, on testosterone. The patient has substantial documentation from licensed mental health providers of gender dysphoria regarding his chest and documentation of clinically significant symptoms supporting the medical necessity of chest reconstruction (CPT code 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk)), performed in conjunction with a bilateral mastectomy. Additionally, the fasciocutaneous flap is considered a necessary part of the chest reconstruction by this surgeon due to more extensive dissection of the abdomen and lateral chest. Under these circumstances, the requested chest reconstruction (CPT code 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk)), performed in conjunction with a bilateral mastectomy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for twice weekly psychotherapy sessions. Geddes and Miklowitz note that long-term maintenance and stabilization of depression in patients with bipolar disorder can be enhanced by the combination of psychosocial treatments with drugs. Swartz and Swanson note that evidence demonstrates that bipolar disorder-specific psychotherapies, when added to medication for the treatment of bipolar disorder, consistently show advantages over medication alone on measures of symptom burden and risk of relapse. For a patient with acute symptoms of bipolar disorder, psychotherapy once weekly with additional group psychotherapy and case management, as needed, is appropriate. In this case, the patient has symptoms of anxiety, posttraumatic stress disorder, and bipolar disorder. The records show that the patient failed to utilize resources other than individual therapy and psychiatrist sessions. In this clinical setting, individual therapy once weekly is standard of care and medically indicated. Given the patients demonstrated inability to utilize services at a higher level of care effectively, and as the records do not reflect evidence of twice weekly psychotherapy previously, twice weekly psychotherapy is not medically indicated. Therefore, once weekly psychotherapy sessions are medically necessary for the treatment of this patient.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neurological evaluation services rendered. Researchers report that, Early identification of dyslexia is crucial to ensure that children are able to maximize their educational potential. Researchers note that, Comprehensive intervention services for students with comorbid ADHD and learning disabilities will require empirically supported treatment strategies that address both disorders and that are implemented across school and home settings. Researchers observed that, Children with dyslexia often have related writing difficulties, but found that writing and even reading skills could be improved with instructional strategies in spelling, transcription, executive function, and working memory. In this case, the patient had a previous diagnosis of autism spectrum disorder, and has a current diagnosis of ADHD, dyslexia and dysgraphia. Given that the patient is now under medication management for ADHD, and has received recommendations for interventions to treat his dyslexia and dysgraphia, the services at issue were medically indicated in this clinical setting. Therefore, the neurological evaluation services rendered were medically necessary for the evaluation 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 neurology with special qualification in child 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 breast reduction.Cabral and colleagues state, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction.According to the American Society of Plastic Surgeons (ASPS), reduction mammaplasty is recommended when documentation shows severe symptoms of macromastia with at least two of the following signs or symptoms impacting health-related quality of life: chronic breast pain due to weight of the breasts; intertrigo unresponsive to medical management; upper back, neck, and shoulder pain; backache; thoracic kyphosis; shoulder grooving from bra straps; upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area; headache; or congenital breast deformity. The decision to perform reduction mammaplasty should be based on patient symptoms and a surgeons assessment of the likelihood of benefit as opposed to the amount (weight) of breast tissue to be removed.In this case, the records reflect that the patient reported neck and back pain, with shoulder grooving documented on physical examination and in photographs. She had significant intertrigo, although the records did not reflect if it was unresponsive to medical management. Given that the documentation reflects at least two symptoms impacting quality of life, the requested breast reduction is medically necessary for the 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. In this case, bilateral breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The requested service will improve function. Accordingly, the requested breast reduction is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Estrace cream. Vulvovaginal atrophy, or atrophic vaginitis, results from estrogen loss and is often associated with vulvovaginal complaints including dryness, burning, and dyspareunia in menopausal patients. The preparations of vaginal estrogen that are available are conjugated estrogens in the form of creams and estradiol in the form of creams, tablets, capsules, and rings. The patients records document isolated vaginal atrophy that requires treatment with only local estrogen therapy. Estrace cream is U.S. Food and Drug Administration (FDA) approved for this patients vulvovaginal atrophy. Additionally, peer-reviewed medical literature supports local estrogen treatment for patients with isolated vaginal atrophy and no vasomotor symptoms. This is consistent with the standard of care to treat this patients symptoms. The provider charted that the patient has responded well to brand-name Estrace cream treatment in the past. However, the patient developed side effects on the generic formulation of Estrace including headache and nausea. Given this report, she meets clinical criteria for treatment of menopausal vaginal atrophy with brand name Estrace cream. Therefore, the requested brand name Estrace cream is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested brand name 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 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.