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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology (ACR) appropriateness criteria for the evaluation of inflammatory back pain with known or suspected axial spondyloarthritis notes that MRI of the sacroiliac joints and areas of interest in the spine may be appropriate following radiographs. MRI findings may demonstrate inflammatory changes such as spondylitis, spondylodiscitis, inflammation of the facet joints, or enthesitis, and may aid in diagnosis and affect treatment planning. In this case, given this patients ulcerative colitis and spondylarthritis, and as prior MRIs demonstrated significant disease at L4-L5, the requested service is medically indicated for further evaluation of this patient. Therefore, MRI of the lumbar spine is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a custom cranial remolding orthotic. Positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes may include the resting of the fetal head against a hard surface, such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period, while postnatal causes are more common and may include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep positions. Presentation ranges from mild or moderate cases, that may respond to mechanical adjustments and exercises, to severe cases that are refractory to repositioning and may require surgery for correction. Jung and Yun note that conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Current treatment of mild head shape abnormality includes repositioning, physical therapy, and increased time in the prone position. Cranial orthoses are recommended for infant patients with moderate-to-severe skull deformity due data in current medical literature showing the long-term distinct benefits from helmeting when compared to repositioning. In a longitudinal cohort study design comparing helmeting with repositioning by following 100 infants with deformational plagiocephaly and/or brachycephaly for ten years, Naidoo and colleagues concluded, Infants will have more improvement in head shape with a helmet than with repositioning. The Congress of Neurological Surgeons guideline on the role of cranial molding orthosis, or helmet, therapy for patients with positional plagiocephaly states, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). In this case, the patient has a combination of moderate to severe plagiocephaly and moderate-to-severe brachycephaly, exacerbated by torticollis. Given the severity of this patients head shape abnormality and his failure to show improvement with repositioning, exercises, and stretching, treatment with a cranial remolding orthosis was medically indicated. Therefore, a custom cranial remolding orthotic was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. The records document that this patient has a history of obesity. The provider reports that the patient has undergone diet and exercise changes without substantial weight loss. The patients provider has recommended treatment with Wegovy. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Wegovy is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Wegovy in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). For these reasons, the requested Wegovy is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for testosterone cypionate injections Findings: One study noted that, The aim of testosterone replacement therapy (TRT) is to improve symptoms and signs of testosterone deficiency including decreased libido, erectile dysfunction, depressed mood, anaemia, loss of muscle and bone mass, by increasing serum testosterone levels to physiologic range. Testosterone replacement therapy for hypogonadotropic hypogonadism is based upon laboratory documentation of below normal values on two serum testosterone levels drawn in the morning at least 24 hours apart. In patients receiving ongoing therapy, a pre-injection morning value in the low to low-to-normal range is also a clinical indication for continuation of therapy. However, this patients records do not include report of two testosterone levels in the morning at least 24 hours apart. The current medical literature supports holding therapy to obtain supportive laboratory values to establish whether the patient meets the requirements for treatment. Based on the documentation provided for review, the requested testosterone cypionate injections are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a positron emission tomography (PET) scan with computed tomography (CT) for attenuation. In this case, based on the available medical information, the patient has a diagnosis of intermediate risk prostate cancer. A metastatic work-up, including a CT scan, bone scan, and magnetic resonance imaging (MRI) was negative. Given that this patient is in the initial stages of prostate cancer, and as the records document a prior metastatic workup that was negative, the service at issue was not medically indicated. Therefore, PET scan with CT for attenuation was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was 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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Nutropin AQ Nuspin.The submitted records do not support the medical necessity of the requested medication. Essential diagnostic criterion for idiopathic short stature is a standing height below 2.25 standard deviations for age and gender. In this case, the patient has not met this essential diagnostic criterion for idiopathic short stature. They have not met the generally accepted diagnostic criteria for any United States Food and Drug Administration (FDA) approved indication for growth hormone therapy, including growth hormone deficiency. Their heights, bone ages, growth velocities, and growth patterns have been within normal variations and consistent with their twin birth status and their familial pattern of growth and development. Therefore, the requested Nutropin AQ Nuspin is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. The submitted records do not support the medical necessity of the requested medication. Essential diagnostic criterion for idiopathic short stature approved by the United States Food and Drug Administration (FDA) is standing height below 2.25 standard deviations for age and gender. In this case, the patient has not met this essential diagnostic criterion for idiopathic short stature. They have not met generally accepted diagnostic criteria for any FDA approved indication for growth hormone therapy, including growth hormone deficiency. Their heights, bone ages, endocrine test results, growth velocities, and growth patterns have been within normal variations and consistent with their twin birth status and their familial pattern of growth and development. Their recent growth spurt was most likely due to their pubertal hormone milieu rather than to exogenous growth hormone. Based on their recent heights and bone age, they are likely to attain a final adult height within the normal range for North American women (above 58.5 inches). Under these circumstances, the requested Nutropin AQ Nuspin is not medically necessary to treat 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 pediatrics with sub-specialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an ExoDx Prostate (IntelliScore) test. The National Cancer Comprehensive Network (NCCN) guidelines for the early detection of prostate cancer do not include testing for biomarkers as part of first-line screening. Routine testing for biomarkers is generally not recommended as there is often insufficient data for the results to be clinically actionable, especially in the setting of a PSA level under two. In cases of a PSA level under two, further prostate cancer work-up would depend on other PSA values, such as the PSA velocity or PSA doubling, and prostate examination findings. In this case, laboratory results reported a low PSA level of 0.5 ng/mL. ExoDX testing is typically reserved for patients with a PSA of at least two. Based on the current medical literature and this patient's history and PSA levels, the service at issue was not likely have been more beneficial than standard therapies. Therefore, the ExoDx Prostate (IntelliScore) test was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapyFindings:  Three of the three physician reviewers found the ExoDx Prostate (IntelliScore) test at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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: 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 lymph node. The American College of Radiology (ACR) states that in the case of a suspicious axillary lymph node, an ultrasound with needle biopsy is considered the most appropriate modality for investigation. MRI of the breast and axilla may be utilized to detect occult malignancy in the breast when an ultrasound guided biopsy of an axillary node detects malignancy. MRI does not have a role in surveillance of inflamed lymph nodes. Axillary lymphadenopathy after COVID vaccination is a well-documented phenomenon at this point. When the vaccines were initially deployed, the presentation of axillary adenopathy created diagnostic dilemmas and confusion, particularly in women and people with known cancers. In a study of adenopathy following Covid vaccination, Wolfson and colleagues noted that adenopathy may remain for several months, with one case demonstrating persistent axillary lymphadenopathy up to 43 weeks following a second dose of vaccination. In a review of recommendations from multiple societies regarding adenopathy following Covid vaccination, Brown and colleagues report that a common recommendation is a wait and see approach unless there is evidence for or suspicion of malignancy. In this case, the patient underwent biopsy which revealed non-malignant pathology.  In this clinical setting, given that a biopsy has eliminated the suspicion of malignancy, the requested service is not medically indicated. Therefore, MRI of the lymph node is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for peripheral nerve/branch injection. Peripheral nerve stimulation is a minimally invasive interventional option for treatment of chronic pain. In this case, given that the patient has neuropathic pain after a stroke that is not well controlled despite a multidisciplinary treatment approach, the requested service is likely to be more beneficial than other available treatment options that the patient has already tried including medication therapy, acupuncture, chiropractic care, and physical therapy. Therefore, a peripheral nerve/branch injection is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested peripheral nerve/branch injection is 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 service 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.
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).Findings:  The physician reviewer found that American College of Radiology (ACR) notes that indications for breast MRI may include screening for high-risk patients with a lifetime risk of breast cancer equal to or greater than 20%, such as patients with a genetic predisposition to breast cancer as determined by either gene testing or family pedigree. The ACR appropriateness criteria for breast pain note that MRI is generally not appropriate for the evaluation of breast pain, recommending mammography with ultrasound instead. Given the lack of support in current medical literature for the use of breast MRI in the evaluation of breast pain and as the records do not indicate that this patient meets the criteria for high-risk screening, the requested service is not medically indicated. Therefore, MRI of breast with contrast is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for use of an electric mobility scooter (Group 1 power operated vehicle). The records document that this patient has a history of multiple chronic health conditions including diabetes mellitus, obesity, and arthropathy. On physical examination, the patient has normal range of motion, coordination, and strength in all limbs. The provider noted that the patient is able to stand for up to 15 minutes and walk more than 40 feet. Overall, the patient does not have any documented impairments that preclude use of a mobility device such as a walker with a seat to accomplish mobility related activities of daily living in the home, and a manual wheelchair to perform community based instrumental activities of daily living. Patients with chronic health conditions such as hypertension, heart disease, obesity, and diabetes mellitus generally benefit from exercise such as regular walking or self-propelling a manual wheelchair (Forhan and Gill; Heymsfield and Wadden; Kahan; Kushner). Reliance on motorized mobility when ambulation or manual wheelchair use are feasible can have detrimental effects on cardiovascular health and expected longevity. Therefore, the requested use of an electric mobility scooter (Group 1 power operated vehicle) 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 36 sessions of transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that Per the American Psychiatric Association (APA), repetitive TMS is considered an option for patients with severe episodes of treatment resistant, unipolar major depression. Severe major depression is indicated by a score 20 or greater on the self-reported Patient Health Questionnaire - Nine Item (PHQ-9). This patients most recent PHQ-9 score was 10, which indicates a moderate severity of depression. In addition, the patient does not meet the criteria for having treatment resistant depression. The most common treatment resistant depression definition for major depressive disorder requires a minimum of two prior treatment failures and confirmation of prior adequate dose and duration. The records document that this patient has only undergone two trials of antidepressants including the first in 2005. The trial of fluoxetine at 40 mg daily in 2005 was for three months. The patient has reportedly experienced a partial response to his current antidepressant, Wellbutrin. Standard augmentation strategies for the treatment of patients with treatment resistant depression include pharmacotherapy options such as antidepressants, second generation antipsychotics. The provider noted that the patient has declined treatment with alternative medications due to the potential for side effects. For patients with unipolar major depression who receive an antidepressant as initial treatment and do not improve sufficiently, augmentation with psychotherapy is often beneficial. Moreover, the patients records do not document previous or current treatment with evidence-based psychotherapy. For these reasons, the requested 36 sessions of TMS are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.