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

The patient has requested reimbursement for fertility preservation services. Currently, fertility preservation is a basic medical need for all reproductive aged patients newly diagnosed with cancer undergoing chemotherapy. Chemotherapy is a gonadotoxic treatment that results in infertility. For reproductive aged patients with newly diagnosed cancer, it is within in the current standard of care to provide counseling about their options fertility preservation. As noted by the American Society for Reproductive Medicine (ASRM), fertility preservation requires individualization. Established techniques for fertility preservation such as cryopreservation of embryos and oocytes are associated with the greatest likelihood of successfully generating offspring. As this patient was diagnosed with Ewing sarcoma and was planned to undergo gonadotoxic therapy, the fertility preservation services were medically necessary for 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 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for inverted nipple surgery of the left breast. Researchers found that, inverted nipples are usually a congenital problem but may be related to scarring from breast-feeding or infection in the ducts or a previous breast surgery. Nipple inversion can cause functional problems such as irritation, rash, discomfort and may prevent the ability to breast-feed. There is no reported problem or documentation of a problem with irritation. The patient is of advanced maternal age and there is no reported inability to nurse or anticipated problems with nursing. Given these findings, the requested inverted nipple surgery of the breast is not medically necessary. 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; (2) to create a normal appearance, to the extent possible. In this patients case, an inverted nipple is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The patients inverted nipple is a normal variant present in 2% of women, which is of medical significance only when it causes a functional problem. The records do not document any functional problems related to the patients inverted nipple. Moreover, the requested surgery will not provide a more than minimal improvement in the patients appearance. All told, the requested inverted nipple surgery of the left breast is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left shoulder surgery (CPT codes 29826, 29824, and 29806). Researchers found subacromial decompression to be safe effective for patients with impingement syndrome. Studies concluded that limited distal clavicle excision of patients with acromioclavicular (AC) joint osteoarthritis resistant to conservative treatment reduced the pain and improved the shoulder function in this patient population. This patient presents with persistent left shoulder pain following an initial traumatic shoulder dislocation injury. She has reported two additional dislocation events while dressing as well as ongoing limited function and range of motion. Clinical examination findings are consistent with imaging evidence of an anterior inferior labral tear, small Hill-Sachs lesion, moderate AC joint osteoarthritis, and impingement morphology. She has failed to improve despite reasonable conservative treatment, including activity modification and medications. Current evidence-based medical literature supports surgical intervention for this patient given the recurrent dislocations, marked loss of range of motion, positive apprehension sign, imaging findings, and failure to improve over at least three months with conservative therapy. All told, the requested left shoulder surgery (CPT codes 29826, 29824, and 29806) 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral platelet rich plasma (PRP) injections (CPT 0232T). This patient has a history of chronic bilateral knee pain due to osteoarthritis. She has undergone two arthroscopies on the right knee and one arthroscopy on the left knee. She has been treated with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and hyaluronic acid injections. The provider recommended PRP injections. Current evidence indicates that compared with viscosupplementation and prolotherapy with saline, intra-articular PRP injections may have more benefit in pain relief and functional improvement in patients with symptomatic knee osteoarthritis at one-year post-injection. The authors found that at six months post-injection, PRP and hyaluronic acid had similar effects with respect to pain relief and functional improvement. However, at 12 months post-injection, there was better pain relief with PRP as compared to hyaluronic acid. Given this support, the requested bilateral PRP injections (CPT 0232T) are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested bilateral PRP injections (CPT 0232T) are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment 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 orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic arterial embolization (CPT 37243) surgery. The American Urological Association (AUA) guidelines state that, prostatic arterial embolization is not recommended for the treatment of lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH) outside the context of a clinical trial. First-line therapies for management of BPH includes alpha-blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medications. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of prostate (TURP). Holmium laser enucleation of the prostate (HoLEP) and simple prostatectomy are options for patients with large glands measuring 100 cc or greater, as this patient. Current data on prostatic arterial embolization is limited to case series and retrospective comparisons. There is a lack of randomized trials demonstrated improved symptomatic relief or survival rates with prostatic arterial embolization over TURP, HoLEP, or simple prostatectomy. Accordingly, the requested prostatic arterial embolization (CPT 37243) surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested prostatic arterial embolization (CPT 37243) surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment 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 urology 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

An enrollee has requested authorization and coverage for laparoscopic reversal Roux-en-Y gastric bypass and proceeding with laparoscopic loop duodenal switch.Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. Researchers have found that the evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Obesity is understood to be a chronic condition and patients may need more than one operative intervention. In this case, the patient is morbidly obese with a BMI that is greater than 40 kg/m2. The present request is for the reversal of the patients gastric bypass and conversion to a malabsorptive operation which has greater weight loss outcomes. The patient meets American Society for Metabolic & Bariatric Surgery reoperative guidelines with the completion of an updated multidisciplinary evaluation that did not reveal any obvious behavioral, dietary, medical or cardiac barriers to surgery. The patient has also failed ongoing dietary efforts with six months of supervised weight loss and net weight gain despite intervention. Under these circumstances, the requested laparoscopic reversal Roux-en-Y gastric bypass and proceeding with laparoscopic loop duodenal switch is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 additional facial feminization performed at the same time as the approved facial feminization surgeries. Researchers noted that, facial feminization surgery can include forehead remodeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. Forehead remodeling reduces male brow bossing, rhinoplasty reduces a prominent, masculine nose, and mentoplasty shapes the mandible. Patient satisfaction after facial feminization surgery is high. The authors noted that the reduction of gender dysphoria has psychological and social benefits and significantly affects patient outcome. This patients medical records support a diagnosis of gender dysphoria. However, the documentation does not demonstrate that the requested additional facial feminization surgeries are medically necessary for this patient. With regard to upper/lower lip augmentation/filling, the photographs provided for review reveal that the lower and upper lips are pouted. Based on the photographs, lip fullness is not a gender-defining feature in this patient. Therefore, the requested upper/lower lip augmentation/filling is not medically necessary. The submental/neck liposuction is not medically necessary, as the photographs do not show a collection of fat that is outside the wide range of normal for a female appearance. Fatty tissue fullness of the submental/neck region is not a gender-defining feature in this patient. Thus, a submental/neck liposuction is not medically necessary. The requested cheek/midface augmentation with fat grafting is not supported as the photographs show jowl formation with ptosis of the malar fat into the jowl area. This is a facial change characteristic of aging and is not a gender-defining feature in this patient. Accordingly, the cheek/midface augmentation with fat grafting is not medically necessary. A lower lid blepharoplasty is not indicated as the photographs show excess lower lid skin and fatty tissue, which is a lower lid change characteristic of aging and is not a gender-defining feature in this patient. A lower lid blepharoplasty is not medically necessary for this patient. Given these findings, the requested additional facial feminization performed at the same time as the approved facial feminization surgeries 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 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: An enrollee has requested reimbursement for right knee osteochondral allograft transplantation (CPT Code 27415-22).Medical literature supports that the services at issue were medically necessary. Articular cartilage lesions are difficult to treat in the knees and osteochondral allograft transplantation is a good option for the relatively large lesions described in the operative report. Wise and colleagues considered the use of this allograft in all four regions described in the operative report. They found that research has shown that patients undergoing this procedure have favorable outcomes and are satisfied with the procedure. A researcher studied osteochondral allograft transplantation and found that 88% of patients undergoing this procedure return to competitive sports, a fact which was not possible with other procedures in the past. In this case, the patient had injury related full thickness chondral lesions of the patella, trochlea, medial femoral condyle, and lateral femoral condyle as well as recurrent anterior cruciate ligament deficiency with instability. In this setting of full thickness chondral lesions, osteochondral allograft transplantation is supported by medical literature showing favorable outcomes and patient satisfaction. Accordingly, the right knee osteochondral allograft transplantation (CPT 27415-22) at issue was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for rhinoplasty, as part of facial feminization surgery. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Facial feminization surgery provides reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would enhance this patients psychological and social functioning. This patient has a documented history of gender dysphoria and has had genital and other facial feminization gender confirming surgeries. Based on the current medical literature, the requested rhinoplasty, as part of facial feminization surgery, 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 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

The enrollee is requesting authorization and coverage for mental health residential treatment center (RTC) level of care services. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. Though the enrollee had a history of substance use, she had managed this issues during her admission. She has supportive resources, but still demonstrates a lack of understanding about her illness. She has not gained complete control over her symptoms. The enrollees composite LOCUS score correlates with Level IV, medically monitored, non-residential services.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for abdominoplasty surgery. The enrollee has a history of diabetes, hypertension, high body mass index, and lumbar radiculopathy. He was evaluated by a plastic surgeon for an abdominal panniculectomy. Medical records show a physical examination revealed a large, hanging abdominal pannus covering the entire mons pubis. The surgeon determined the risks of surgery outweighed the benefits. The records do not support the enrollee has a significant functional impairment secondary to the excessive abdominal pannus. The records do not support recurrent infections that are not manageable with optimal medical therapy. The abdominoplasty surgery was deemed not medically necessary in various encounter notes. Literature describes abdominoplasty as a procedure to reduce excess skin and fat around the abdomen and strengthen the muscles of the abdominal wall, resulting in a visually pleasing abdomen. 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 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: An enrollees parent has requested authorization and coverage for Nutropin AQ Nuspin Pen Injector. This patient is being treated with a combination of growth hormone and Supprelin to optimize her height potential while suppressing puberty. However, her height has levelled off and she has not grown in stature for over one year. Her bone age of 15 years is consistent with fused epiphyses. She has no known diagnosis of hypopituitarism and no known morphological abnormalities of her pituitary gland. Continuation of growth hormone therapy is not indicated as it will not improve the patients growth once epiphyses are fused. There is no information to support that there is a morphological abnormality of the pituitary gland or evidence of hypopituitarism. Thus, the requested Nutropin AQ Nuspin pen injector is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Nutropin AQ Nuspin pen injector is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment 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 pediatrics with subspecialty certification in pediatric endocrinology 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.