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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The enrollee was evaluated for lower back pain and reported it began 12 years ago. The enrollee participated in physical therapy but his pain persisted. Neurology ordered a magnetic resonance imaging scan, which revealed a disc herniation. He has been using conservative treatment for his pain, but has had occasional flare-ups. The enrollee participates in home exercise, which has improved his pain. However, the enrollee reports worsening pain over the last four to five months described as sharp in nature, with occasional radiation to the posterior right hip. The pain is exacerbated by sitting, transitioning from sit to stand, and exercising. It is worse in the morning. The physician indicated the enrollees symptoms are consistent with lumbosacral radiculitis, secondary to disc herniation at L3-L4; degenerative disc disease and disc desiccation; facet arthropathy, and myofascial pain. The provider recommended outpatient physical therapy and ordered a magnetic resonance imaging scan. Medical records indicate the enrollee reported subjective weakness in his legs and pain on Valsalva maneuver, but denied any numbness or tingling, change in bowel or bladder control, unintentional weight loss, or night sweats. The physical exam shows tenderness to palpation of the paraspinal muscles on the right at L3-4, positive flexion, adduction, and internal rotation, and positive flexion, abduction, and external rotation on the right; and a negative slump test and supine straight-leg raise. The magnetic resonance imaging scan shows paracentral disc herniation, left greater than right, at L3-4, and degenerative disc disease with disc desiccation and facet arthropathy. The diagnoses were lumbosacral radiculitis, secondary to disc herniation at L3-4, degenerative disc disease, facet arthropathy and myofascial pain. The enrollees physical exam and history appear consistent with degenerative disc disease and facet arthropathy. The enrollee does not have any red-flag signs suggestive of an acute process, such as worsening pain, cauda equina syndrome, or symptoms worrisome for an underlying tumor. The enrollees exam is more consistent with a myofascial syndrome, such as piriformis syndrome; sacroiliac joint dysfunction, and facet arthropathy. 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 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 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 magnetic resonance imaging (MRI) of the left lower extremity and joint. The American College of Radiology (ACR) state that MRI of the knee for evaluation of pain after a total knee arthroplasty is not supported as the initial imaging evaluation. MRI may be appropriate as additional imaging following radiographs for pain after total knee arthroplasty when joint aspiration cultures are negative or inconclusive, or if there is a suspected infection. This patient presents with chronic left hip, knee and foot pain with reported frequent lower extremity cellulitis. She is status post left total knee replacement, which she indicates is possibly infected. She states that her provider recommended a sit-down MRI, as she was unable to lay down for a traditional MRI due to pain. The records suggest the provider recommended a sit-down MRI to assess the left knee for hyperbaric chamber treatment. However, there is no discussion of an infection work-up to support the current role of MRI in this patients clinical scenario. Additionally, there are no indications for the medical necessity of a sitting MRI for evaluation of the left lower extremity over a standing MRI. All told, the requested MRI of the left lower extremity and joint is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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

The enrollee is requesting authorization and coverage for Buttock Augmentation with a one-day hospital stay. The enrollee has gender dysphoria and has been on hormone therapy, consisting of estradiol, progesterone, and spironolactone. Her plastic surgeon indicates the enrollee has severe dysphoria and requires surgical intervention to treat it. The operation will drastically improve her quality of life. She has a significantly masculine body that prevents her from being fully accepted as a woman. The masculine qualities include a square torso, a lack of hips, and a lack of buttock projections. The enrollees estrogen treatment has not resulted in appropriate feminine fat distribution; therefore, surgical correction of the soft tissue is needed to address these body deformities. Her psychiatrist indicates she meets the full DSM V diagnostic criteria for gender identity disorder. There is no indication that her gender dysphoria is a symptom of any other mental disorder. Standards of care indicate that although surgery for assisting in body feminization, such as Buttock Augmentation, are generally labeled as purely aesthetic, the surgical procedures for an individual with severe gender dysphoria can be considered medically necessary, depending upon the unique clinical situation of the patients condition and life situation. Review of the record indicates the patient has been on long-term estrogen (hormone) therapy for the past eight years but has not achieved the appropriate feminine fat distribution. She has severe gender dysphoria and reports numerous situations where she has faced the threat of stigmatization and physical harm. This is impacting her psychological well-being. The medical literature indicates for certain patients, an intervention, such as, a reduction rhinoplasty, for example, can have a radical and permanent effect on a patients quality of life and is therefore, much more medically necessary than for a patient without gender dysphoria. In this case, Buttock Augmentation is requested for feminization. Considering the failure of long-term estrogen therapy in achieving this, as well as the patients severe gender dysphoria impacting the patients mental health, the Buttock Augmentation has the potential to radically and permanently positively impact this patients quality of life.Final Result: The reviewer determined that the requested service is 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: Overturned Decision of Health Plan

The enrollees parent is requesting reimbursement for the intensive outpatient program level of care. The enrollee has diagnoses of unspecified trauma and stressor-related disorder, severe cannabis use disorder, and oppositional defiant disorder. The enrollee participated in the day program and the intensive outpatient program. His participation was mostly disruptive and surface-level, though at times he showed an effort to support his peers and develop an interest in his own behaviors. He had difficulty trusting others; especially authority figures. He relapsed twice during this treatment episode and did not begin work with a sponsor. The day before discharge, he left the facility without permission. The enrollees provider notes the enrollees history of depression and suicidality, anxiety, substance abuse, and unhealthy family dynamics warranted the containment and support of the intensive outpatient program prior to his discharge. Due to limited support outside of treatment, the enrollee continued to engage in high-risk behaviors. The enrollee was unable to modulate anxiety and depressive symptoms. His group participation showed the enrollee struggled with interpersonal connections. He required close monitoring to prevent regression, and to reduce the risk of substance-use relapse. The Child and Adolescent Level of Care Utilization System (CALOCUS), is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The enrollees composite CALOCUS score correlates with high intensity-based community services.Final Result: The reviewer determined that the requested services were 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: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. Applying LOCUS, the patient was at some risk for harm as evidenced by passive suicidal ideation over the past month prior to admission. The records also document that prior to admission, the patient was placing herself in risky sexual situations. The patient demonstrated serious functional impairment with significant withdrawal and avoidance of social interactions, disrupted sleep and fatigue due to her intrusive thoughts. The patient had major comorbidities including syncope, which was worsened by her anxiety and obsessive-compulsive disorder (OCD) symptoms. The patients recovery environment was moderately stressful as her OCD symptoms, anxiety and depression caused significant discord in family and other relationships. The patients recovery environment was highly supportive and her parents were involved in her treatment. The patient showed limited response to treatment as previous treatment exposures have been marked least partial recovery for moderate lengths of time with the help of strong professional supports. The patient demonstrated limited engagement as she related to her provider that she established few, if any trusting relationships. This gives the patient a composite score which is consistent with Level 4, medically monitored community based services, such as PHP level of care. Further, PHP services were appropriate for this patient given her frequent panic attacks, disabling OCD symptoms and depression. Given these findings, the PHP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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

The enrollee is requesting reimbursement for residential treatment center level of care. The enrollee has alcohol use disorder, type 2 diabetes mellitus, hypertension, sleep apnea and acute encephalopathy. The patient indicated he started to drink alcohol in his twenties and had been drinking about three cups of hard liquor per day for years. The enrollee attended Alcoholics Anonymous meetings for about one year.  He is employed and worries that his drinking is affecting his ability to conduct business. He last drank two days before admission. He went through a detoxification process; after which he transferred to a residential treatment center level of care. Review of the records indicates the enrollee was not willing to move into sober living and he was unsure how long he would continue treatment. The records indicate it was imperative he utilize healthy coping skills, maintain relationships with his peers in the community, check in with his sponsor, and attend Alcoholics Anonymous meetings. The Level of Care Utilization System (LOCUS), is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. This tool was used in this review. The enrollees composite LOCUS score correlates with high intensity community based services. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service was 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: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Hyaluronan Injections (Synvisc) in both knees. The enrollee has bilateral knee osteoarthritis. Previous cortisone injections provided one week of benefit. An x-ray showed mild medial and patellofemoral compartment joint space narrowing and spurring. Her provider recommended hyaluronic acid injections (Synvisc) injections to her bilateral knees due to the enrollees mild degree of osteoarthritis and her decreased benefit from the cortisone injections. The enrollee notes she has finally found a treatment that worked and it has changed her quality of life. She is now able to squat with less pain to her knees, and going up and down the stairs is tolerable after the hyaluronic acid (Synvisc) injections. This enrollee is too young for total knee replacement surgery. The enrollee has tried and failed steroid injection therapy. This enrollees condition, two-compartment osteoarthritis, is an indication for management with hyaluronic acid (Synvisc) injections. The enrollee has experienced positive results with previous hyaluronic acid injections. Literature describes osteoarthritis as a common condition that results in pain, reduced mobility, and decreased function. Recent studies have shown hyaluronic acid injections (Synvisc) can provide longer-term improvement in both pain and function. Literature notes a single injection of hyaluronic acid (Synvisc) is safe and effective for six months in individuals with knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested reimbursement for Optune treatment for glioblastoma, World Health Organization grade IV. Medical records indicate the enrollee was initially seen in the emergency department after a seizure.  A magnetic resonance imaging scan revealed a mass, and the tumor was resected. However, follow-up imaging indicated tumor progression.  The enrollee participated in an Avastin study and completed an additional course of radiation.  The enrollee continued to have tumor progression and his condition worsened. During a follow up visit, the enrollee reported his left hand incoordination was worsening and the left corner of his mouth was drooping. After discussing treatment options, the provider recommended Optune treatment.  The enrollee began treatment.  He has increased his Optune usage to nearly 24 hours per day. Medical records indicate the enrollee tolerated the treatment well. The enrollees neuro-oncologist indicates due to the aggressive nature of the enrollees disease and extremely limited treatment options, Optune is the best approved option for treating the enrollees recurrent glioblastoma. This enrollee has been treated maximally with surgery, radiation in conjunction with concurrent chemotherapy, and additional chemotherapy. The tumor treating fields-device (Optune) may likely be this enrollee's only remaining effective therapeutic option. His disease is likely to progress within the next year without treatment with the tumor treating fields-device (Optune).  This enrollee is a good candidate for the tumor treating fields-device (Optune). Literature describes glioblastoma as a devastating brain tumor with poor prognosis; despite advances in surgery, radiation, and chemotherapy. This enrollee has failed all conventional frontline treatments for glioblastoma. There are no other approved therapies for recurrent glioblastoma.Final Result: Three of the three reviewers determined that the requested services are 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 radiation 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

The enrollee is requesting authorization and coverage for an injection of Monovisc for the right knee. The enrollee has a history of three prior arthroscopic knee surgeries due to meniscal injuries. He had been doing well until he fractured his left ankle. He was provided a brace for the left ankle. His right knee developed pain with prolonged sitting on the bus and with walking. His knee has started to improve.  He is favoring his left ankle less because he is now in an ankle sleeve. The pain is primarily around the knee cap. Previous treatments include ibuprofen, ice, and activity modification. The enrollee was referred to physical therapy. The physician diagnosed the enrollee with moderate osteoarthritis of the knee. His physician is requesting Monovisc. A recently published scientific statement presents high-level care recommendations for the general use of hyaluronic acid injections, but the statement does not provide guidance for specific clinical scenarios. A multidisciplinary panel of health care providers, with substantive knowledge of intra-articular hyaluronic acid injection therapy, formed a workgroup to investigate the appropriate use of hyaluronic acid injections in patients with knee osteoarthritis. This workgroup developed appropriate use criteria for hyaluronic acid injections. The benefit of these injections in individuals with mechanical meniscus pathology, with underlying osteoarthritis of the knee was considered uncertain by the workgroup. This enrollee has moderate arthritis. The medical literature describes exercise-based therapy as the foundation for treating knee osteoarthritis. This enrollee has not completed a recent course of physical therapy. Physical therapy was prescribed at the same time as viscosupplementation. The authors indicate weight loss should be encouraged for all patients with osteoarthritis and a body mass index greater than 25 kilograms per square meter. The enrollee has a body mass index of 34. Medical records indicate weight loss was recommended by the provider. Corticosteroid injections are effective for short-term pain relief in patients with osteoarthritis. A trial of conservative care is typically recommended prior to treatment with hyaluronic acid (Monovisc) and medical records do not support a trial and failure of conservative care in this case. 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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for Humatrope 24 mg. Based on the available documentation, this patient has a normal growth velocity at 4.81 cm per year based on height measurements. The provider noted that the patient has been following the 10th percentile on the growth chart. An absence of poor height velocity suggests normal growth. In addition, the patient is still pre-pubertal and her growth rate is expected to improve when she enters puberty. This patient does not meet the current U.S. Food and Drug Administration (FDA) approved indications for growth hormone (GH), because her height is not -2.25 standard deviations below the mean for age and sex. Moreover, the patients predicted adult height is within normal range for an adult female. All told, the requested Humatrope 24 mg is 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 pediatrics with subspecialty certification in pediatric endocrinology 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.