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

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee is requesting reimbursement for Residential Treatment Center (RTC) Services. The enrollee was admitted to a residential treatment center (RTC) for decompensation in her mental health. Psychiatric evaluation indicated the enrollee denied current suicidal ideations. She has had self-injurious behavior, a history of suicide attempts and multiple mental health hospitalizations. Diagnoses are major depressive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, tobacco use disorder, panic disorder, cannabis use disorder, and unspecified feeding and eating disorder. She had no active suicidal or homicidal ideations, but had extreme distress and history of suicidal/homicidal behaviors. The residential treatment center criteria were not met with a total score of 19, Level of Care 3 - High Intensity Community Based Services.  Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for the removal of excessive thigh skin (thighplasty). Findings:  The physician reviewer found that removal of excessive thigh skin (thighplasty) is not medically necessary for the treatment of this enrollee.The enrollee was diagnosed with excess skin status post bariatric surgery. The enrollees provider noted the enrollee did not have recurrent infections or functional limitations from the redundant soft tissue on the buttock and thighs, or pain that was directly caused from excess skin. The enrollees provider noted the patient previously underwent laparoscopic sleeve gastrectomy, with a preoperative weight of 114 kg. The enrollees weight was 81.7 kg, with a body mass index of 26.68. Physical examination findings included excess adiposity on the superior lateral thigh and inferior gluteal area, with excess skin noted over the medial thigh. The enrollee reported skin irritation issues. A photograph of the medial thigh area shows transverse creases with no hanging pannus. The enrollee has requested authorization and coverage for the removal of excessive thigh skin (thighplasty). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this enrollee. At issue in this enrollees case is whether removal of excessive thigh skin (thighplasty) is medically necessary for the treatment of the enrollees medical condition or is reconstructive in nature. Medial thighplasty has a high rate of minor wound healing problems. Full-length vertical thighplasty is associated with prolonged edema. Concomitant liposuction may also increase complications. This patient underwent laparoscopic sleeve gastrectomy with significant weight loss resulting in loose skin in her thigh area. No hanging panniculus of thigh skin is visible in the photographs received for review. The enrollee endorsed skin irritation, but there is no report of appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. The enrollee does not have a functional problem with a rash that has been demonstrated to be resistant to appropriate medical treatment. The medical evidence does not support the requested service in this clinical setting. Therefore, removal of excessive thigh skin (thighplasty) is not medically necessary for the treatment of this enrollee. Excess thigh skin and fat is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. Excess skin is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors, or disease. The requested removal of excessive thigh skin (thighplasty) is not likely to improve function or create a normal appearance to the extent possible. There is no indication that the enrollee has difficulty ambulating or diminished function due to her excess skin. Therefore, the requested removal of excessive thigh skin (thighplasty) is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Infed iron infusion therapy. Despite long-term oral iron therapy, this patient has been unable to replete her iron stores. This may possibly be due to gastritis. Regardless of the presence of symptoms, all patients with iron deficiency anemia and most patients with iron deficiency without anemia require treatment. Although oral iron is the initial treatment approach for iron deficiency anemia, some patients fail to respond to or cannot tolerate oral iron. For these patients, there is an indication for intravenous iron to replenish iron stores. This patient has been treated with oral iron, yet her iron stores remain depleted based on recent laboratory results. Therefore, the requested Infed iron infusion therapy is medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 7T magnetic resonance imaging (MRI) machine, which would be used both before and during an endonasal endoscopic transsphenoidal pituitary tumor surgery to remove microadenoma. Microadenomas in Cushings disease are difficult to visualize preoperatively and challenging to identify intraoperatively. Adrenocorticotropin-secreting pituitary tumor represents approximately 10% of pituitary adenomas, which at the time of diagnosis, were microadenomas. Transsphenoidal surgery is the first-line treatment of Cushings disease and accurate localization of the tumor within the gland is essential for selectively removing the lesion and preserving normal pituitary function. MRI is the best imaging modality for the detection of pituitary tumors. However, adrenocorticotropin-secreting pituitary microadenomas are not identified in up to 50% of patients because of their size, location, and enhancing characteristics. One recent study found that in this clinical setting, lesions were detected more accurately with 7.0 T MRI as compared to 1.5 T MRI. Given this support, the requested 7T MRI machine, which would be used both before and during an endonasal endoscopic transsphenoidal pituitary tumor surgery to remove microadenoma, 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 neurological 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 patient has requested authorization and coverage for brand name Ampyra. Ampyra is U.S. Food and Drug Administration (FDA) approved for the improvement of walking in patients with a diagnosis of multiple sclerosis. Studies in ambulatory patients with multiple sclerosis support the safety and effectiveness of Ampyra. Blight and colleagues reported that Ampyra improved walking ability in patients with multiple sclerosis. The authors found that patients needed to be ambulatory in order to fully benefit from the medication. Similarly, a study demonstrating the long-term safety and efficacy of Ampyra for walking impairment in patients with multiple sclerosis. The current medical literature and FDA do not support that there is a significant difference between brand name and generic formulations of Ampyra.Final Result: The reviewer determined that the requested brand name 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 with subspecialty certification in pain management 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 acupuncture. The use of acupuncture to treat impingement syndrome has been demonstrated to be a safe and reliable technique with associated good results. When compared to sham acupuncture, trigger point acupuncture revealed decreased pain intensity with improved shoulder function. The authors found a significant decrease in pain noted at five weeks in the trigger point treated group. This patient presents with chronic left shoulder pain associated with a superior labral tear and evidence of impingement and scapulothoracic pain. Given his symptoms, the patient should benefit from the requested acupuncture treatment as noted in the current medical literature. Therefore, the requested acupuncture is medically necessary for treatment of this patients left shoulder pain. 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: The patient has requested authorization and coverage for Hyalgan injections in the left knee. Guidelines from the American Academy of Orthopedic Surgeons indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment. Hyalgan is not U.S. Food and Drug Administration (FDA) approved for treatment of a torn meniscus. Overall, the medical literature and AAOS no longer support the routine use of Hyalgan due to findings of poor efficacy. Therefore, the requested Hyalgan injections in the left knee are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. It was noted that the patient had significant anxiety and depression due to the incongruence between her anatomy and her gender identity. The patient has requested authorization and coverage for any or all facial feminization surgeries.  At issue in this patients case is whether any or all facial feminization surgeries are medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that a nationally recognized health organization states that gender affirming/confirming surgery, plays an undisputed role in contributing toward favorable outcomes. Medically necessary gender affirming/confirming surgical procedures include facial plastic reconstruction. Facial feminization surgery is associated with improved mental health quality of life in transgender patients.  Medical evidence supports the requested services in this clinical setting. Therefore, any or all facial feminization surgeries are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for suction assisted lipectomy. The enrollee underwent mastectomy for gynecomastia.  At a post-operative follow up visit, the right side of his chest had a thicker layer of subcutaneous fat and the impression was asymmetry following gynecomastia excision. The surgeon states that there is a noticeable difference between the right and left chest. The enrollee states that the mastectomy was incomplete and this it is now difficult to go jogging. He is requesting coverage for suction assisted lipectomy. The medical records fail to demonstrate the medical necessity of the requested suction assisted lipectomy. The enrollee complains of irritation while jogging, but there is no documentation of symptoms, chronic rashes or failed treatment in the records.  Photographs do not demonstrate the alleged abnormality constitutes an abnormal structure of the body that is a major variation from normal. They show slight fullness of the right breast without ptosis. Findings: the physician reviewer found that the doctor describes the fullness as secondary to subcutaneous tissue; that is, fatty tissue, and not breast tissue. The requested suction assisted lipectomy is not likely to improve function or create a normal appearance to the extent possible. The variance in symmetry is minimal and would not provide more than a minimal improvement in the appearance of the enrollee.  Therefore, this procedure is not reconstructive in nature. Final Result: The reviewer determined the requested service is not medically necessary and is not reconstructive for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic and reconstructive surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for PET Scan and immunology assay for free light chain, kappa. The enrollee had IgG Kappa multiple myeloma diagnosed after a hip fracture. Findings:  the physician reviewer found that the biopsy showed kappa light chain with restricted plasma cell dyscrasia and a bone survey revealed a lesion in the right pubic bone. He was treated with chemotherapy. Subsequently, he underwent magnetic resonance imaging (MRI) and a positron emission tomography (PET) scan for treatment strategy planning and they were unchanged from a prior scan. Laboratory testing for immunoglobulin free light chains (kappa and lambda) was performed. According to the medical literature, the role of PET Scan in staging myeloma is not clear. Traditionally, myeloma was staged with IgG levels, bone survey and lab tests. While PET is very sensitive for metastases, it can be falsely positive and is not a good study for nodal staging. Only retrospective analyses are available. At the same time, another guideline indicates PET imaging is not for routine use in the management of myeloma patients. Although it may be useful in selected cases that warrant clarification of previous imaging findings, this approach should be made within a clinical trial. This enrollee had the PET Scan done for surveillance, not for relapsed or refractory multiple myeloma. However, regarding the immunology assay for free light chain, kappa, follow-up by immunoglobulin studies is well established and recommended by guidelines. Low levels of abnormal immunoglobins are often present and levels are typically determined through assays. Final Result: Three of the three reviewers determined the PET scan was not likely to bemore beneficial than any available standard therapy for treatment of the enrollees medical condition. Three of three reviewers determined the immunology assay for free light chain, kappa was likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.   Credentials/Qualifications: Three reviewers are board certified in medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for corrective orthotics. The enrollee is diagnosed with posterior tibial tendonitis in both legs, plantar fascial fibromatosis and pes plano valgus.  His condition causes pain, trouble walking or running, and is affecting his school and physical education. He reported intermittent pain with increased activity and his orthotics were modified with varus wedging. The podiatrists assessment was severe pes plano valgus deformity with complete collapse of the medial arch, significant forefoot abduction and calcaneal valgus on weight-bearing examination.  The podiatrist recommended continued use of the custom functional foot orthotics. Findings: The physician reviewer found that  according to the medical literature, in the population of patients with painful juvenile flexible flat feet, generic foot orthoses are sufficient; unless the enrollee presents with concomitant juvenile arthritis as well.  There is no evidence in the record this is the case with this enrollee or of prior use of over-the-counter orthotics that failed at providing symptom relief. Very few studies show that, in these cases of flatfoot deformity in the presence of chronic juvenile arthritis, the pain is reduced with the use of functional custom orthotics.  In these cases, studies have shown there is no benefit to custom orthotics over the generic orthotics.Final Result: The reviewer determined the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Esketamine (Spravato) nasal spray for the treatment of major depressive disorder, anxiety disorder, and attention deficit hyperactivity disorder. Findings:  The physician reviewer found that treatment resistant depression is defined as a lack of significant improvement after two adequate trials of two different antidepressants from two different pharmacologic classes. There is insufficient evidence in the record this was done.  Many of the symptoms the enrollee reports are related to his anxiety/panic attacks; Esketamine is not FDA approved for the treatment of anxiety.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.