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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (CPT 97153).The submitted documentation supports that the requested services are medically necessary. The Behavior Analyst Certification Board (BACB) has established guidelines that are specific to the treatment of individuals with autism. The guidelines highlight that treatment intensity will vary with each patient and should reflect the goals of treatment, specific client needs, and response to treatment. In this case, the patient is accessing applied behavior analysis, which is required to meet their essential health needs. The treatment is consistent with the patients autism spectrum disorder diagnosis, and the requested frequency and duration are appropriate, given the rate of problem behavior and the number of goals being actively addressed (21 goals). The progress report outlines a level of need that coincides with the number of hours requested. The services are also not being provided as a convenience to the patient or the provider and are being delivered in the least restrictive environment. Under these circumstances, the requested 40 hours per week of direct applied behavioral analysis (CPT 97153) 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 a licensed psychologist who is a board certified behavior analyst 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 been diagnosed with chronic recurrent multifocal osteomyelitis (CRMO) and psoriasis. The provider noted that the patient was initially treated with methotrexate, Humira, and leflunomide. It was noted that the patients psoriasis had flared recently on the knees and elbows. Physical examination findings included erythema and scaling on the ears, and erythematous and scaling plaques in the left axilla, elbows, and knees. Erythematous scaling and peeling were noted on the right palm. The patient was being treated with Simponi for CRMO and Stelara for psoriasis. The patient has also been treated with halobetasol, tacrolimus, and triamcinolone. The patients parent has requested authorization and coverage for Stelara 45 mg/0.5 ml. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 45 mg/0.5 ml is medically necessary for the treatment of the patients medical condition. Authors reported, Ustekinumab is recommended as an effective therapy for adolescents 12 years and older with moderate to severe plaque psoriasis. The authors also reported, A retrospective case series of 51 patients with pediatric psoriasis ages seven through 18 years by patients treated with etanercept, adalimumab, or ustekinumab from initiation to one-year of follow-up. Patients had a successful response (defined as a statistically significant improvement in Physician Global Assessment score at five months) to all three medications, with low adverse risk effect. In this case, the patient has previously tried and failed methotrexate and multiple topical medications. The medical evidence supports the requested medication in this clinical setting. Therefore, Stelara 45 mg/0.5 ml is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Combigan 0.2%-0.5% eye drops. This patient has progressive peripheral vision loss with a diagnosis of primary open angle glaucoma of both eyes. The records provided for review do not document that the patient has tried and failed, or has a contraindication to, treatment with the standard available eye drops on the Health Plans formulary to support an indication for Combigan. The medical literature has provided data demonstrating the safety and efficacy of several medical therapies for the treatment of open angle glaucoma. All told, the requested Combigan 0.2%-0.5% eye drops are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested 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 ophthalmology 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 been diagnosed with atopic dermatitis. The patient was noted to have been treated in the emergency department due to an eyelid infection. Physical examination findings included a few excoriations over the right frontotemporal scalp, erythematous papules on the face, a reticulated vascular pattern throughout the extremities, and hyperpigmented macules on the left posterior leg. The patient has been treated with triamcinolone and tacrolimus for the body, and hydrocortisone for the face. The patients parent has requested authorization and coverage for tacrolimus 0.03% ointment. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus 0.03% ointment is medically necessary for the treatment of the patients medical condition. Researchers reported, Topical calcineurin inhibitors are an effective therapeutic option for pediatric patients with periorificial dermatitis and were well tolerated in this cohort. Authors reported, For patients with atopic dermatitis (AD) less than two years of age with mild to severe disease, off-label use of 0.03% tacrolimus or 1% pimecrolimus ointment can be recommended. The authors also noted, Tacrolimus is approved for moderate to severe disease, whereas pimecrolimus is indicated for mild to moderate AD, and six-week comparative studies support a greater effect for tacrolimus over this time period for all AD severities. In this case, the patient has been diagnosed with atopic dermatitis and has had an eyelid infection. Tacrolimus ointment is indicated for the treatment of periorificial dermatitis. The medical evidence supports the requested medication in this clinical setting. Therefore, tacrolimus 0.03% ointment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested reimbursement for ThyGenNEXT (CPT 81445) and ThyraMIR (CPT 81479) genetic testing.There is sufficient support for the services at issue in this clinical setting. When a fine needle aspiration of a suspicious thyroid nodule does not reveal definitive pathology, one option is to continue to follow the lesion and re-biopsy it in the future. The other option, depending on the level of suspicion, is to send the tissue for mutational analysis. Sending the tissue for molecular analysis is an accepted and reasonable step. Labourier and colleagues noted a negative predictive value over 90% with a positive predictive value for malignancy of 82%. Thus, the test is useful in deciding whether surgery is needed. Therefore, ThyGenNEXT (CPT 81445) and ThyraMIR (CPT 81479) genetic testing were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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 medical oncology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the spine.The submitted documentation supports the medical necessity of the requested services in this clinical setting. Many studies have reported a high incidence of osteoporosis in patients with Ehlers-Danlos syndrome. Studies reported the prevalence of vertebral fractures in Ehlers-Danlos syndrome patients with chronic back pain. Vertebral fractures were significantly more prevalent in Ehlers-Danlos syndrome patients as compared to normal controls. Severe back pain was more frequent in these patients for that reason. In light of this study, the patients request for an MRI scan of the spine in order to accurately diagnose the cause of her low back pain is medically appropriate. Therefore, the requested MRI of the spine 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 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 suction assisted lipectomy (trunk). The World Professional Association for Transgender Health (WPATH) 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. The WPATH further noted that body contouring, including liposuction, is a surgical treatment for gender dysphoria. However, this patients records do not provide sufficient evidence that the requested body contouring procedures will address the patients gender dysphoria. The providers letters provide documentation supporting feminizing mammoplasty, but do not demonstrate the medical necessity of body contouring. Therefore, the requested suction assisted lipectomy (trunk) is 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implant removal surgery. Based on the records provided for review, this patient has postural orthostatic tachycardia syndrome (POTS), saline breast implants, and symptomatic breast hypertrophy. Causation of systemic illness, including POTS, has not been associated with saline breast implants. Based on the American Society of Plastic Surgeons (ASPS) criteria, the patient does not meet the requirement for reduction mammaplasty. Specifically, there is no report of chronic breast pain due to the weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, or congenital breast deformity. There is no documentation of shoulder grooving. All told, the requested breast implant removal surgery is 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a Quantum Q6 Edge 3.0 wheelchair with requested accessories. The submitted documentation does not support that the requested power mobility device is medically necessary. The medical literature identifies that the disease is progressive and that adaptive equipment must be modified with time. In this case, the submitted medical records do not reflect that the requested wheelchair will enable the patient to perform activities of daily living in the home. Records indicate that the patient requires maximum assistance, or total care, to complete activities of daily living and that the patient has caregiver assistance. The submitted records include a DME consultants evaluation of the mobility needs of the patient which states that their needs can be met with an alternative device such as a manual wheelchair with tilt in space and appropriate positioning components, and that the requested power mobility device will not change the patient's ability to participate in the completion of his activities of daily living. Under these circumstances, the requested Quantum Q6 Edge 3.0 wheelchair with requested accessories is not medically necessary to treat their medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in neuromuscular medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for speech therapy services once per week. The documentation provided for review supports that this patients diagnoses include autism spectrum disorder as well as speech and language delays. Despite oppositional or maladaptive behaviors present, this does not present an insurmountable obstacle to achieving benefits for the development of speech and language with services once per week. The provider noted that the patient has demonstrated some negative behaviors, which interfere with interactions and intervention. However, the patient has made progress since starting speech and language therapy services and he responded well to positive reinforcements to keep him engaged. Given these findings, the requested speech therapy services once per week 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 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for upper eyelid blepharoplasty. Upper eyelid blepharoplasty and brow lift requires documentation of functional vision complaints and supporting visual field testing. This patients records do not include documentation that the patient has functional visual complaints related to the eyelids blocking her vision. In addition, physical examination did not reveal a margin reflex distance of 2 mm or less. The patients margin reflex distance measured 4 mm in the right eye and 3.5 mm in the left eye. Moreover, the records do not include visual field tests that demonstrate loss of superior visual field and improvement with taping of the patients eyelids. For these reasons, the requested upper eyelid blepharoplasty is 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 ophthalmology 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 reimbursement for bilateral breast explant with full capsulectomy and bilateral superior pedicle breast lift.  Researchers noted that although silicone implants are now routinely used in breast surgery they have previously been the subject of controversy. The authors also concluded that there is a paucity of research to establish long-term outcomes. Medical literature notes that the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. This patient has been experiencing seizures and she has expressed concern that her condition is related to her silicone gel breast implants. The current data does not support a causal relationship between the presence of silicone gel implants and this patients symptoms. Thus, removal of silicone gel breast implants and capsulectomies were not medically necessary. In addition, the bilateral superior pedicle breast lift was performed to tighten the breast skin and compensate for removal of the breast implants. All told, the bilateral breast explant with full capsulectomy and bilateral superior pedicle breast lift was not medically necessary for treatment of 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) with placement of the EsophyX device. This patient has GERD and reports some symptoms despite adequate trials of treatment with PPI therapy. His provider recommended a TIF procedure with placement of the EsophyX device. TIF is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference. TIF can be performed in patients with typical GERD symptoms, no or only low-grade erosive esophagitis, and a small hiatal hernia measuring no more than 2 cm. Although TIF is associated with fewer postoperative adverse effects such as gas bloating and dysphagia compared with surgery fundoplication, the durability of TIF is inferior to surgery. Therefore, the requested TIF with placement of the EsophyX device 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 internal medicine with subspecialty certification in gastroenterology 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.