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

The enrollee is requesting authorization and coverage for free T3, reverse T3, progesterone-ester and testosterone testing, as outlined in the Bredesen Protocol. The enrollee has severe dementia. She has experienced a steady decline over the past 10 years. The tests recommended under the Bredesen Protocol are necessary to determine the drivers of the enrollees Alzheimers. A search of the clinical trials in progress revealed that there is currently an ongoing study, though observational and with no control group, to determine the efficacy of the Bredesen protocol in 30 persons with either Alzheimers dementia or mild cognitive decline. Since this treatment would be considered complementary or alternative medicine, a separate search of a relevant site found nothing under Bredesen protocol. A separate search revealed only anecdotal studies, or, in the most recent Bredesen publication, a report on ten individuals with no controls. Thus, at this time there are no data in the scientific literature that supports the use of this protocol outside of a research study. This protocol has not been rigorously tested and is not considered medically necessary for the treatment of dementia.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of left knee pain due to patellofemoral osteoarthritis of three years duration. Treatment has included arthroscopic debridement, physical therapy, and non-steroidal anti-inflammatory drugs (NSAIDs). As the remaining treatment options are limited, the requested Monovisc injection  in the left knee 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Fioricet.The medical literature and submitted documentation do not support that the requested medication is medically necessary. Fioricet, the requested medication, contains a combination of acetaminophen, butalbital, and codeine. Butalbital-containing medications are associated with serious and undesirable side effects, and have been linked to the chronification of migraine and development of medication-overuse headaches. Additionally, there are multiple randomized controlled studies showing that relative to standard treatment with triptan and naproxen combination medications, butalbital-containing combination medications are less effective and often lead to transformation of migraines into chronic migraines. Use of sumatriptan and naproxen, in contrast to Fioricet, has been shown to be associated with less rescue medication use and a longer time before use of rescue medication compared with Fioricet. Thus, there is no strong medical data supporting Fioricet use over triptan and NSAID class of abortive medications and no evidence exists to vouch for Fioricet's strong effectiveness as an abortive migraine medication. In addition, the submitted documentation does not reflect that the patient has had recent treatment failure or intolerance to alternative abortive medications for migraines including other types of triptans besides sumatriptan, ibuprofen, dihydroergotamine (DHE), or other triptan/DHE class medications, which can be administered subcutaneously or intranasally. Under these circumstances, the requested medication Fioricet is not medically necessary for treatment of the patients medical condition.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 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: Overturned Decision of Health Plan

The patient had requested authorization and coverage for Supartz injections for the left knee. The patient has been diagnosed with osteoarthritis of the left knee. 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 found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, 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 request services in this clinical setting. 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: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for Saxenda. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the medications are discontinued. Saxenda has demonstrated a statistically significant and clinically meaningful weight loss as an adjunct to a reduced-calorie diet and increased physical activity. Studies have demonstrated that patients using Saxenda can successfully achieve weight-loss benchmarks. This patient has Hashimotos thyroiditis, obesity, and elevated morning serum cortisol. She has failed to lose weight with diet changes and exercise. The addition of Saxenda to her regimen is appropriate given the support in the medical literature.  Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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 Goodnites brand diapers. The current management of this patients incontinence includes diapering in addition to intermittent catheterization. The medical records do not document skin care issues requiring specific treatment in the perineum or genital area. However, individual patients have varying degrees of success with specific products and often have a period of trial and error until they achieve their best personal regimen. The fact that two different diaper brands are part of this patients successful regimen suggests that the unique benefits are likely due to design similarities found in multiple brandings. All told, the requested Goodnites brand diapers are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medical supplies 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 urology with subspecialty certification in pediatric urology 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 a transthoracic echocardiogram. Based on the records provided for review, this patient has a dilated non-ischemic cardiomyopathy with an initial recent left ventricle ejection fraction (LVEF). The patient did not subsequently demonstrate any symptoms or physical examination findings of heart failure while on low dose medication at follow-up visits with his provider. In this specific circumstance, additional therapies such as primary prevention defibrillator or biventricular pacing have not been shown to improve outcome and maximizing medication dosage is indicated regardless of findings on a follow-up echocardiogram. The records report clinical stability and use of low dose medication without documentation of maximization of medication prior to reevaluation. Therefore, the transthoracic echocardiogram was not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty certification in cardiovascular disease 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 excision, excessive skin and subcutaneous tissue (includes lipectomy), and abdomen, infraumbilical panniculectomy. The enrollee had gastric bypass surgery for weight loss. The enrollee reports she now has excess abdominal skin that causes irritation, itchiness, redness, and prevents her from participating in certain activities. A progress note showed the enrollee had a large pannus with candidiasis. Her surgeon states that they have tried conservative treatment, including over the counter medications, but she has not had any positive results. The enrollees surgeon indicates the skin removal surgery is medically necessary for the enrollees medical condition, health, quality of life, and to increase her level of activity. Literature shows panniculectomy procedures have been shown to improve quality of life, increase mobility, and improve hygiene in those with a significant pannus formation. Researchers note panniculectomy individuals have usually experienced a dramatic weight loss, and, as a result, the excess abdominal skin overhangs the groin and pubic regions and may strike against the thighs as the person walks, causing significant discomfort and irritation. Because the risks of surgery are relatively high, researchers report surgical management for unresponsive intertrigo, rashes, cellulitis, skin necrosis, ulcerations, or significant excess skin which interferes with function is reserved for those who have failed all conservative medical management options. This enrollee has excess skin that is causing infections, which have not improved with conservative measures. Therefore, this enrollee is a good candidate for the requested procedures.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lung transplant. This patient has end-stage interstitial lung disease. He is being treated with 6 liters of supplemental oxygen and chronic steroids. The medical records document that the patients recent body mass index (BMI) was 35. However, the records also document that the patient has lost weight over the past year. The patient reports a current BMI of 34. Morbid obesity, as defined as a BMI over 35, is a contraindication to lung transplantation. Providers may consider proceeding with placing a patient on the transplant list when the patient has demonstrated weight loss with changes in diet and exercise changes. Given the advanced nature of this patients lung disease and his documented weight loss, the requested lung transplant is medically necessary.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 internal medicine with subspecialty certification in pulmonary disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for systemic hyperbaric oxygen therapy (HBOT). The U.S. Food and Drug Administration (FDA) has not approved HBOT for the treatment of patients with SSNHL. Systematic reviews have reached discordant conclusions about the effectiveness of HBOT. In this case, the available clinical documentation did not demonstrate initial steroid therapeutic failure. In addition, no follow-up audiogram was documented to determine the hearing thresholds following treatment with steroid therapy and prior to starting HBOT. Given these findings, the requested systemic HBOT 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 that the requested systemic HBOT 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 reviewer 1 is board certified in family practice with subspecialty certification in undersea and hyperbaric medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the SpaceOAR system (insertion of a perirectal hydrogel spacer). The enrollee has prostate cancer. His treatment plan includes radiation therapy. His radiation oncologist has recommended the SpaceOAR System, which involves the insertion of a perirectal hydrogel spacer prior to initiation of the radiation therapy to help reduce damage to the rectum during treatment. His physician indicates the SpaceOAR allows an increased dosage to the prostate gland while decreasing the dosage to the organs at risk. The physician reports the SpaceOAR System will enhance radiation treatment while preserving healthy tissue to help ensure that rectal, urinary, and sexual quality of life may be maintained. Literature shows the spacer materials have an excellent safety profile and can be implanted in a well-tolerated procedure. The separation reduces the volume of rectal tissue receiving high doses of radiation, and can reduce the maximum dose delivered to the rectum. This enrollee would be an ideal candidate for this procedure, because he has low-risk prostate cancer and his cancer is located in the apex, which is relatively closer to the anterior rectal wall.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: Overturned Decision of Health Plan

The patient has requested reimbursement for Inpatient mental health treatment. 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. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with medically monitored residence-based services. However, the patients score for risk of harm supports treatment at the medically managed residence-based services, such as inpatient level of care. Given the severity of the patients illness, the inpatient mental health treatment was 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a ReWalk personal system. The published evidence indicates that powered exoskeletal devices aimed at enabling upright ambulation in patients with paraplegia are not an efficient, reliable or practical means of mobility for this patient population. Further, there are multiple risks associated with the use of these devices as mobility devices outside of controlled environments including falls. There is a paucity of proven health benefits with the use of an externally powered exoskeleton to passively move a patients lower limbs. The current standard of care for achieving appropriate levels of cardiovascular and musculoskeletal exercise in the setting of this patients condition include regular physical activity using volitionally active musculature such as propulsion of a manual wheelchair, wheelchair sports, and other adaptive sports and exercise activities. For these reasons, the requested ReWalk personal system 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 equipment 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in sports medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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.