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

The patient has requested authorization and coverage for power wheelchair with tilt recline, elevated leg rest, and power seat elevation. This patient has a history of limb girdle muscular dystrophy, which causes muscle fiber loss, primarily affecting skeletal muscles. She has functionally deteriorated from independent with a walker for short distance ambulation with occasional falls, to a functional non-ambulatory status. The records provided for review do not document that this patient requires the assistance of a power wheelchair with power seat elevation in order to be independent with slide board transfers. The patient has greater than antigravity strength at her shoulders. However, additional specifics on the patients upper limb strength and function are limited. There is no documentation of persistent leg swelling in the injured leg and a long-term need for an elevated leg rest. There is no documentation on physical and functional evaluation confirming the need for tilt recline. The records do not suggest that the patient cannot perform effective pressure relief using her own body power, including body lifts, side shifts, or forward leaning. Overall, the records do not establish that the patients current power wheelchair is inadequate or that the requested components are medically necessary. All told, a power wheelchair with tilt, elevated leg rest, and power seat elevation is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 facial feminization surgeries. The patient is a male-to-female transgender woman. The patient socially transitioned and has been consistently on hormone therapy for two years. She is interested in pursuing facial feminization surgery. The patients provider reports the patient has been in psychotherapy treatment with the provider. She meets the criteria for gender dysphoria. The patient currently lives as a female full-time, is confident in her gender identity, and has a social support system that is supportive of her gender, presentation, and plans for surgery. Facial feminization surgery would likely remedy her persistent gender dysphoria. Professional society guidelines support surgeries for assisting in body feminization, and can be considered medically necessary in an individual with severe gender dysphoria, depending on the unique clinical situation of a given patients condition and life situation. The medical records do not document any unique situations. The requested procedures are aesthetic procedures to make the patient more attractive in her new gender. Additionally, studies show women who had both facial feminization surgery and gender reassignment surgery did not have improved mental health outcomes compared to those who had gender reassignment surgery alone.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a whole body Positron Emission Tomography (PET) scan.The submitted documentation does not support that the requested service is medically necessary. National Comprehensive Cancer Network (NCCN) Cutaneous Melanoma Guidelines establish that it is standard practice for melanoma in-situ and early invasive melanoma (stage 1A) to be treated with a wide local excision with periodic longitudinal surveillance via clinical examination alone (skin exam, lymph node exam, and review of systems). Under NCCN guidelines, there is no role for a PET-CT scan for surveillance purposes alone. A PET-CT scan might be indicated in the event that a new suspicious mass or unrelenting or unexplainable clinical symptom developed where metastatic disease might be in question. In this case, the submitted records reflect that a PET scan has been requested for surveillance purposes, and there is no indication that a new suspicious mass or unrelenting or unexplainable clinical symptom has developed where metastatic disease might be in question. Under these circumstances, whole body Positron Emission Tomography scanning is not medically necessary to treat the patients medical condition.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 dermatology, with subspecialty certification in dermatopathology, 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 an organ biopsy to completely rule out systemic amyloidosis. Evaluation of amyloid light-chain (AL) amyloidosis should involve a comprehensive assessment, as the condition can involve multiple organs. This patient notes multiple complaints that could be early symptoms of organ compromise by amyloid involvement. In addition to comprehensive organ directed evaluations, patients with a diagnosis of AL amyloidosis should undergo evaluation for systemic involvement by additional tissue biopsy. Additional tissue biopsies can include an abdominal fat pad aspirate, bone marrow, kidney, liver, and/or skin biopsies. A comprehensive work-up to determine whether she has systemic amyloidosis is essential to limit or reverse organ damage. Given these findings, the requested organ biopsy to completely rule out systemic amyloidosis is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

The patient has requested reimbursement for residential treatment center (RTC) 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. Applying the LOCUS criteria, this patient met the requirements for RTC services. The patient was at serious risk of harm given his excessive substance use with loss of self-control and self-harming behaviors. The patient demonstrated the inability to care for himself or remain safe as evidenced by instances of wandering naked in a public park. The patient exhibited serious functional impairment with ongoing impulsivity due to severe cannabis use and a psychotic disorder even while he was in the hospital environment. He had been unable to function in his home or college environments due to his psychosis and cannabis addiction. The patient was noted to have significant comorbidities with ongoing cannabis usage despite multiple detrimental effects, including the development of a psychosis that led to his inability to complete college or to live with his parents. The patients recovery environment was highly stressful, as he was unable to live with his parents and at the time of admission, was living in a tent surrounded by people who were using substances. The patients recovery environment provided limited support. The patients parents were his main supports, but they were unable to fully participate in treatment and make the necessary changes. The patient had previously shown moderate response to treatment but was unable to maintain recovery. At the time of discharge, he was not at baseline and continued to express ambivalence about taking psychotropic medications. The patient was minimally engaged in treatment, as he expressed little desire to change his previous behaviors or lifestyle. He had difficulty accepting the reality of his underlying psychiatric illness and the role that cannabis played in exacerbating his condition. The patients composite score is 25, which is consistent with medically monitored residence-based services. Given this support, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollees parent has requested authorization and coverage for a standing frame device. Researchers described the numerous benefits of standers in patients with cerebral palsy. The noted advantages include improved range of motion and reduced risk of contractures, promotion of vital organ capacity and bone health, and reduction of abnormal muscle tone and spasticity. Researchers also studied the effect of a daily standing program with hip abduction on hip acetabular development in ambulatory children with cerebral palsy. The authors found that a daily standing program with hip abduction in the first five years enhances acetabular development in ambulatory children with spastic diplegia cerebral palsy. Kim and colleagues conducted a meta-analysis to assess the effects of weight-bearing exercise on increasing bone mineral density in children who have cerebral palsy with low bone mineral density. The authors concluded that weight-bearing exercise has a significant effect on improving bone mineral density of the femurs in children with cerebral palsy. Given this patients level of function and risk for secondary complications due to his neurological condition, he is likely to benefit from the requested standing device. Therefore, the requested standing frame device is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested standing frame device is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is 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 reviewer 1 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is 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

The patient is diagnosed with bilateral knee osteoarthritis. The patient received a series of bilateral knee Orthovisc injections, the patient reported knee pain a few months after. The provider noted the patient had been treated with Orthovisc injections seven months prior, with excellent pain relief. Physical examination findings included bilateral knee medial condyle tenderness. The provider noted the patient had failed to respond to nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid injections. The patient has requested authorization and coverage for Orthovisc injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of good response to viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in both knees 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 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 enrollee is requesting authorization and coverage for the medication, Orilissa, 150mg tablet. The enrollee has endometriosis, uterine fibroids, and complaints of pelvic pain. She has used acetaminophen 300mg-Codeine 20mg, ibuprofen 600mg, and hydrocodone 5mg/325mg, but they did not help with pain. She reported a 60 percent improvement with vaginal valium. The enrollees physician is requesting renewal of Orilissa, as the enrollee has reported it is the only medication that helps with the pain from her endometriosis. The source of this enrollees pain is not clear from the medical records. The progress notes suggest the pain is due to vaginismus. The enrollee has a very small myoma that should not be causing pain. If the enrollees pain is caused by endometriosis, then the treatment is based on the severity of symptoms. This enrollee did not fail treatment with oral contraceptives or the progestins Danazol or Lupron; nor does she have a contraindication to these products. There are no studies comparing the efficacy, side effects, or long term outcomes between Lupron and Orilissa.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 obstetrics and gynecology and reproductive 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a psychoeducational assessment. The records provided for review document that this patient sustained a head injury at six years of age due to a fall. The patient required inpatient psychiatric treatment for severe mood disorder with suicidal ideation with intent and plan. She has been evaluated and treated by two psychiatrists, and has completed at least three different medication trials without substantial improvement in her symptoms. She has also participated in occupational and speech therapy services for conditions consistent with neurological issues. She underwent a psychoeducational assessment for her persistent symptoms. In the medical literature, Pritchard and colleagues noted that untreated children with ADHD [attention-deficit/hyperactivity disorder], and those who have untreated comorbidities, are at greater risk for poor outcomes in social, academic, vocational, and practical settings. The authors reported that the current data supports the utility of neuropsychological assessments in this clinical setting to provide information that can potentially reduce risks for poor outcomes and improve quality of life among children with ADHD. Given this support, the psychoeducational assessment was medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for lumbar spine disc replacement surgery and in-patient hospital services. The enrollee has a long-standing history of low back pain. He has a history of a L4-L5 left micro discectomy. He underwent micro-discectomy for a herniation of the nucleus pulposus. The enrollee had a reduction of low back pain after the procedure, but it returned and it was worse. He has had physical therapy, nerve blocks, epidural injections, acupuncture, and radiofrequency facet denervation. These treatments were ineffective. The enrollee underwent an anterior lumbar approach discectomy at L3-L4-L5; followed by placement of the M6 lumbar artificial discs at both levels. There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and fewer adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Total disc arthroplasty has been associated with substantial morbidity and even mortality. Literature shows that, while there is a large amount of data to support the short-term outcomes of total disc replacement surgery, it is important to note that most of the data concern single-level studies. Data on multilevel disc replacement are more limited.  The alternate approaches described in studies involve hybrid approaches with one level disc replacement and one level fusion. This highlights the uncertainty surrounding multilevel disc replacement. Lumbar total disc replacement was developed with the goal of preserving motion and avoiding fusion-related complications, but the relative merits of single versus multiple level procedures remain unclear. 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 neurosurgery 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 35 sessions of proton beam radiation therapy. This patient has unresectable Ewings sarcoma involving the left sacrum. The treating provider has supplied a proton versus photon comparison plan, which demonstrated better target volume coverage with the proton plan and less exposure to surrounding radiosensitive normal tissues, including her reproductive organs and adjacent small bowel. The reduction in dose to her reproductive organs will maximize the chance that she will remain fertile and be able to bear children in the future. The reduction in dose to the bowel will lessen the risk for gastrointestinal toxicity. In addition, the reduction in low dose exposure to her pelvic organs will lessen the risk for radiation induced second malignancy, which can occur decades after delivery of photon-based radiotherapy. Moreover, the American Society for Radiation Oncology (ASTRO) and current peer-reviewed medical literature support the use of proton beam radiation therapy in the management of unresectable Ewings sarcoma. Proton radiation therapy is the most appropriate radiation modality in the patients clinical setting. Therefore, the 35 sessions of proton beam radiation therapy were and are 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 radiation 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.