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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical artificial discectomy. Based on the available documentation, this patient has no symptoms or signs consistent with cervical radiculopathy or myelopathy. He has numbness of his hands and feet. However, despite these symptoms, the records do not include a physical examination of the hands or feet. Except for a supple neck examination, he has not had a complete neck examination. In addition, the records do not demonstrate that other sources of pain have been ruled out in the absence of documentation of Tinels examination, vascular examination, or electromyography with nerve conduction velocity (EMG/NCV) testing. He has not had any symptoms or signs to implicate the C5-6 or the C6-7 level, thus his pain generator has not been established. There is no report that he has functional limitations due to his cervical symptoms. Further, there is no report of at least six weeks of non-steroidal anti-inflammatory drug (NSAID) usage in therapeutic amounts, physical therapy, or a home exercise program. He has abnormal magnetic resonance imaging (MRI) and computed tomography (CT) findings at both levels, but there is no correlation with his history and physical examination. His neurological examinations have been grossly normal. Considering these findings, the patient does not meet the criteria for the requested surgical intervention. The criteria for cervical artificial discectomy requires documentation of intractable radiculopathy, cervical myelopathy, and persistent pain with functional limitations. Imaging must show nerve root compression at each level which corresponds to the patients history and physical examination, which is not present in this case. Furthermore, the patient has not failed at least six consecutive weeks of conservative management including NSAIDs, physical therapy, and a home exercise program. Thus, he fails to fulfill the criteria for artificial disc replacement. Accordingly, the requested cervical artificial discectomy is not medically necessary for treatment of this patients neck pain. Final Result: The reviewer determined that the requested surgery 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for prednisolone sodium phosphate oral dissolving tablets (Orapred-ODT). It is critical for this for this patients family and caregivers to have immediate access to emergency medications, such as epinephrine autoinjectors in case of allergic reactions that occur outside the presence of medical supervision. In addition, adjunctive medications such as systemic steroids and antihistamines, can also be helpful to alleviate the patients symptoms. Although systemic steroids should not be used for initial therapy, there is support for their use as an adjunctive therapy per the American Academy of Allergy, Asthma and Immunology (AAAAI) and American College of Allergy, Asthma and Immunology (ACAAI) practice parameters. Based on the current medical literature and guidelines, there is a lack of data that the Orapred-ODT formulation is more effective than the Health Plans formulary alternative. However, in this case, the patient is school-aged and requires a formulation that will be tolerated and readily available. The Orapred-ODT oral dissolving tablets allow the medication to be separated out into discrete doses to provide access to the medication at multiple locations where the patient could potentially experience an allergic reaction. The availability of medication is important as anaphylaxis requires timely administration of medication. Given these specific circumstances, the requested Orapred-ODT is medically necessary for treatment of this patients medical condition. 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 allergy and immunology with subspecialty certification in pediatrics 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 reimbursement for the cell-free fetal DNA prenatal testing (CPT code 81422) that was performed. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees fetus.Findings:  Two out of three physician reviewers found that a cohort study of 8,141 pregnancies evaluated with noninvasive prenatal screening (NIPS) found that the accuracy of trisomy 21 detection was higher than that of other chromosome aneuploidies. Additionally, the positive predictive value for chromosomal deletions was low. It is therefore important to improve the specificity, accuracy and sensitivity of NIPS technology on the detection of subchromosomal microdeletions and microduplications. The patient is at high risk for a fetal aneuploidy based on her age. However, NIPS without microdeletion testing has been demonstrated to have a high degree of sensitivity and accuracy. The addition of cell-free fetal DNA prenatal testing at issue in this case was to evaluate for fetal chromosomal microdeletions, which is not supported by current medical literature. As such, the cell-free fetal DNA prenatal testing (CPT code 81422) that was performed on was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1and 3 are board certified in medical genetics and genomics and are actively practicing. Physician reviewer 2 is board certified in clinical biochemical genetics 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

Nature of Statutory Criteria/Case Summary:  The enrollee has requested authorization and coverage for Bydureon BCise. Findings:  The physician reviewer found that the medication requested is medically necessary. The patient has a diagnosis of type 2 diabetes. The patient was prescribed Bydureon BCise for controlling his postprandial blood sugars. Glucagon-like peptide-1 (GLP-1) agonists like Bydureon are U.S. Food and Drug Administration (FDA) approved for use in type 2 diabetes. Per the American Diabetes Association (ADA), glucagon-like peptide-1 receptor agonists may help patients meet their blood glucose levels as an adjunctive medication. The patient was prescribed basal insulin therapy, metformin therapy, and as an adjunctive medication, Bydureon to aid in controlling his postprandial blood sugars. Based on current literature, Bydureon therapy as an adjunctive therapy is medically necessary to treat type 2 diabetes patients in helping them meet their glucose goals. Therefore, the request for Bydureon BCise for the management of the patients type 2 diabetes is medically necessary. 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 internal medicine with sub-specialty certification in endocrinology, diabetes 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dialysis after 5:00 pm. Findings:  The physician reviewer found that there are potential complications that can occur during and immediately following dialysis including low blood pressure, fatigue, and prolonged bleeding, which can interfere with a patients ability to perform activities of daily living. In addition, many patients experience other symptoms following dialysis. As noted in the medical literature, noncompliance with dialysis has been associated with a poorer clinical outcome. A medical study dependably demonstrates substantially inferior health-related outcomes associated with missing treatments in hemodialysis patients. Moreover, mechanical difficulties with the dialysis machine itself are not infrequent, and can delay the time for dialysis to be completed. For a patient who continues to work while receiving dialysis, continued compliance requires a practical schedule using fourth shift dialysis (after 5:00 pm). This patients current dialysis schedule at 3:45 am interferes with his ability to perform activities of daily living and encourages noncompliance, which is associated with a poorer health outcome. Therefore, the requested dialysis after 5:00 pm is supported as medically necessary for treatment of this patients end stage renal disease (ESRD). 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 nephrology 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 transfer to an acute care hospital for treatment until he is stable to resume chemotherapy (preferred); or transfer to an acute care rehabilitation hospital until he is stable to resume chemotherapy; or to remain in a long-term acute care hospital (LTACH) for treatment until he is stable to resume chemotherapy are not medically necessary. At the time of initial presentation, this patient was independent with his activities of daily living (ADLs). Since diagnosis, he has been in the hospital with evidence of significant physical and cognitive decline. Currently, he is being cared for in a LTACH with the goal of improving his functional status. He has not been receiving optimal occupational and physical therapies primarily due to refusal and ongoing medical issues. A physical therapy evaluation reports that he requires assistance to sit and stand, and is dependent for all ADLs, including dressing, toileting, and feeding. Although the patient indicates that his primary goal is to improve his condition to be stable enough to resume treatment with chemotherapy, returning to that level of function would require improvement in occupational and/or physical therapy. The patient does not require acute inpatient treatment as his medical issues can be managed in a LTACH. However, treatment in a LTACH is not appropriate as he has been described as a poor acute rehabilitation candidate as he has refused participation in occupational and physical therapies. Moreover, he does not meet the criteria for acute rehabilitation as his medical needs are too complex and he is unable to participate in the minimal requirement for acute rehabilitation. The records indicate the patient is at the level of supportive or palliative rehabilitation with the goal of improving his quality of life and ability to perform self-care. He would benefit from psychological support and a formal palliative care evaluation to reassess his goals of care. Based on the documentation provided for review, his current medical issues preclude transfer to a higher level of care or resumption of chemotherapy. Thus, the requested transfer to an acute care hospital for treatment until he is stable to resume chemotherapy (preferred); or transfer to an acute care rehabilitation hospital until he is stable to resume chemotherapy; or to remain in a LTACH for treatment until he is stable to resume chemotherapy are not medically necessary.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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the implantation of a hypoglossal nerve stimulator is likely to be more beneficial for the treatment of the patients condition than any available standard therapy. The patient had a diagnosis of sleep apnea. She is status post uvulopalatopharyngoplas. She reported that she discontinues continuous positive airway pressure (CPAP) ty (UPPP) and turbinate reduction.Findings:  Two out of three physician reviewers found that the medical literature demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This procedure is recognized by the American Academy of Otolaryngology Head and Neck Surgery to be an effective second-line treatment of moderate to severe obstructive sleep apnea. In this case, the patient has a body mass index and apnea-hypopnea index within appropriate parameters, and a nonconcentric airway collapse, thereby meeting the criteria. She has failed CPAP. She has failed previous sleep surgery. Therefore, implantation with a hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One out of three physician reviewers found that there is a lack of support for the requested services in this patients case. Her compliance data confirmed that the patient does well on the CPAP and benefits from treatment.  She has had several surgical procedures on her upper airway and nose.  She has not used an oral appliance, which is a good alternative to patients that are CPAP intolerant.  Therefore, implantation with a hypoglossal nerve stimulator 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 procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a male with a history of osteoarthritis of the right knee. According to the progress note, the patient reported that over the last few years he has greatly benefitted from viscosupplementation, including pain relief lasting six months or more. The Synvisc One injection resulted in significant pain relief. The patient was able to reduce his need for non-steroidal anti-inflammatory drugs. The pain has since recurred, and the patient has requested authorization and coverage for Synvisc injection to the right knee. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue is whether Synvisc one injection to the right knee is medically necessary to treat the patients medical condition.researchers found that viscosupplementation reveals mixed results.  Based on current medical evidence, viscosupplementation may be appropriate for patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Therefore, its well-documented that viscosupplementation works for this patient. As such, the request for Synvisc One injection into the right knee is medically necessary to treat the patients medical condition.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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). The Health Plan has denied the bilateral breast MRI as not medically necessary.According to the American College of Radiology (ACR), the initial recommended imaging studies for evaluation of a palpable breast mass include diagnostic mammography and sonography. The specific indications for breast MRI include high-risk screening, new diagnosis of breast cancer to evaluate for additional sites of disease, patients with positive margins after lumpectomy, evaluation of response to chemotherapy prior to surgery, evaluation for breast cancer recurrence, evaluation of metastatic cancer of an unknown primary source and when mammographic or sonographic findings are inconclusive. In this case, the patient does not meet the criteria for high-risk MRI. The appropriate imaging examinations include diagnostic mammography and sonography. A diagnostic ultrasound did not identify any suspicious abnormality and the patient deferred the recommended mammogram. Therefore, bilateral breast MRI is not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested test 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the FoundationOne testing panel that was performed was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient had a diagnosis of stage three low grade papillary serous ovarian cancer. She presented secondary to a rising CA 125 with suspicion of malignancy.Findings:  One out of three physician reviewers found that there is a lack of evidence that the FoundationOne assay adds to our decision-making ability and yields a result that is clinically beneficial. Finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. Therefore, the FoundationOne testing panel that was performed was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Two out of three physician reviewers found at the time of request for FoundationOne testing, the patient was undergoing combination therapy for platin-sensitive recurrence but clinically demonstrating lack of significant response, with persistently elevated CA-125 and new complications of extensive peritoneal carcinomatosis.  As a patient with platin-resistant ovarian cancer, the choice of the available standard of care chemotherapies is uncertain. Therefore, the FoundationOne testing panel that was performed was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the evaluation at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology, 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.