Persius/hicric huggingface dataset:
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 FlexiTouch compression device with two garments. In this case, the unique features of the patients condition, including her severe pain, intractable restless leg syndrome, chronic lymphedema, and hemodialysis needs, require an advanced pump with individual segment calibration. As the patients PD catheter has been removed, the requirement to maintain both regular dialysis appointments and lymphedema clinic appointments would be unreasonable. The provider has stated that a basic pump is insufficient for this patients needs and recommended the Flexi-Touch device as the most appropriate device for the patient. The submitted documentation supports the medical necessity of the requested device. Therefore, FlexiTouch compression device with two garments is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 vascular 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 patient has requested reimbursement for esophagogastroduodenoscopy (EGD) procedure. Clinical guidelines recommend endoscopy for investigation of upper gastrointestinal symptoms such as GERD disease and dyspepsia when these symptoms are refractory to proton pump inhibitor taken properly for one to two months without response. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that EGD is warranted if an appropriate trial of therapy for a suspected benign digestive disorder has been unsuccessful. The American College of Gastroenterology (ACG) guidelines support EGD if symptoms have been refractory to proton pump inhibitor for at least one month. The ACG do not recommend endoscopy in patients below age 60, even when alarm symptoms are present. These recommendations are concordant with current medical literature. In this case, the records provided for review do not document an attempt of proton pump inhibitor for at least one month prior to EGD. Moreover, there is a lack of evidence of an accepted indication for the use of EGD. For these reasons, the EGD procedure 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 gastroenterology 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: This is a patient with diabetes, hyperlipidemia, hypertension and a fatty liver, that was being followed by an internist, his primary care physician (PCP). The PCP prescribed orlistat 120 mg capsules to be taken three times a day (TID). The orlistat prescription was refilled monthly in 2007 through May of 2019. The patient requested to resume orlistat due to hard stools after stopping Orlistat. The PCP recommended that he should take over the counter stool softeners for the hard stools, as orlistat 120mg taken three times a day, can cause liver toxicity. At issue is whether the requested medication Orlistat (Xenical) 120 mg capsules, is medically necessary to treat the patients medical condition. According to medical records, the patient was started on orlistat in 2007 since, diet and exercise for weight loss, had not worked. Despite taking orlistat (Xenical) for over 10 years duration, the patients body weight has not significantly changed. The physician recommended an over the counter stool softener (Colace). Currently, orlistat (Xenical) is approved by the Federal Drug Administration (FDA) for the following indications: obesity with a body mass index (BMI) of over 30 kilograms per meter squared (kg/m2), body mass index great than 27 kg/m2 and presence of risk factors including hypertension, diabetes mellitus, and dyslipidemias. It is only effective as an adjunct to caloric restriction, increased physical activity, and behavioral modification. According to the medical records including correspondence from the patient, the main purpose for taking orlistat in this case was for constipation. Orlistat is not FDA approved for constipation. Based on the FDA recommendations, and documentation in the medical records provided, the requested medication is not indicated for this patient. 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 internal medicine         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 spouse of an enrollee has requested authorization and coverage for immediate cataract surgery.The American Academy of Ophthalmology (AAO) has issued interim guidelines on resuming elective ophthalmic care during the COVID-19 pandemic. The AAO states that cataract surgery is considered semi-urgent, not elective, when the affected person cannot drive, work or see to take their medications properly, or has an increased risk of falling, phacomorphic glaucoma or intolerable anisometropia. The AAO states that such cases warrant surgery within days to weeks. In this case, because the patient has a history of dementia and decreased mobility, the typical considerations of encumbered working or risk of falling are not applicable. However, the patients bilateral visual acuity measurements of 20/400 demonstrate a visual decline that would correlate with marked decrease in functioning in most cases. The potential harm resulting in delayed treatment of 20/400 vision related to cataracts would likely be related to increased difficulty with mobility, eating, or taking medications. Under these circumstances, immediate cataract surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 magnetic resonance imaging (MRI) of the bilateral feet with contrast. The American College of Radiology (ACR) recommends an MRI of the foot without contrast for evaluation of chronic metatarsalgia with clinical concern for sesamoiditis, Mortons neuroma, intermetatarsal bursitis, chronic plantar plate injury, or Freibergs infraction when radiographs are negative or equivocal. Santiago and colleagues reported, In the appropriate clinical setting, administration of gadolinium contrast medium is not required for a reliable diagnosis of Mortons neuroma. In this case, the patient reported bilateral foot pain, reportedly refractory to prior treatment. Clinical examination findings reported a normal gait. She underwent bilateral foot MRIs with findings of bilateral peroneus longus tenosynovitis along the plantar surface of the midfoot, mild left degenerative changes about the right first metatarsophangeal joint, and mild to moderate first metatarsophangeal joint osteoarthritis with chondromalacia and small joint effusion. An MRI without contrast or ultrasound is generally sufficient to diagnosis a neuroma condition, and the patients clinical examination findings are not suggestive of a neuroma. The medical evidence does not support the requested service in this clinical setting. Therefore, an MRI of the bilateral feet 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 treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for skilled nursing facility services. The enrollee has also requested authorization and coverage for physical therapy, cognitive therapy, vocational therapy, and speech therapy for three to six months.Functional impairments due to traumatically acquired brain insults can improve with time through a natural recovery processes. These impairments are also generally amenable to rehabilitation interventions. Nevertheless, deficits can remain severe, particularly in the setting of severe injuries, resulting in protracted and profound functional deficits. There may be a limit to the benefits of rehabilitation interventions when impairments are severe. The efficacy of rehabilitation specifically aimed at improving cognitive deficits due to severe traumatic brain injury, moreover, is not established.In this case, the patient sustained a severe traumatic brain injury due to an assault, with additional cerebral insults that followed. The patient is noted to have undergone rehabilitation but has had persistent, profound functional deficits. Records show that the patient had limited active participation with therapies four months ago, and no significant progress. The patient continued to have significant cognitive, physical and functional deficits three months ago, and her capacity to actively participate in therapies and potential for progress were limited. There were no nursing, medical, physical therapy, occupational therapy, speech therapy or vocational therapy needs requiring ongoing inpatient level care from that time forwards. The patient was discharged from therapies one month ago without having made significant progress. There is no indication in the submitted records of any ongoing formal therapy needs for the next three to six months based on the patients documented status. Accordingly, the skilled nursing facility services at issue and the requested skilled nursing facility services were not, and are not, medically necessary for the patients medical condition. In addition, the requested physical therapy, cognitive therapy, vocational therapy, and speech therapy for three to six months are not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the brand name medication, Copaxone. Researchers conducted a 15-month study to evaluate the efficacy, safety, and tolerability of switching from branded Copaxone to generic glatiramer acetate (GTR). They concluded that the efficacy and safety of GTR was maintained over two years, and that switching from branded Copaxone to GTR was safe and well tolerated. Cohen and colleagues also found that as treatment for relapsing-remitting multiple sclerosis, glatiramer acetate generic drug and brand drug had equivalent efficacy, safety, and tolerability. In this case, the patient has been diagnosed with multiple sclerosis and had been taking Copaxone for two months. The documentation submitted does not indicate the patient is allergic to or intolerant of the generic form of the medication. Given that current medical literature supports the efficacy, safety, and tolerability of the generic medication, and that there is no evidence suggesting that the generic medication would be less effective or cause an allergic reaction for this patient, the requested branded form of the medication is not medically indicated. Therefore, the brand name medication, Copaxone is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services for rehabilitation services including physical therapy, occupational therapy, and speech therapy. Dementia is progressive and results in various adverse outcomes such as impaired social participation, compromised self-care abilities, and increased hospitalizations. Management options include redirection, structured care and support, involvement in stimulating activities, cholinesterase inhibitors, and reducing unnecessary polypharmacy. In this case, the patient has a history of multiple, chronic brain insults with dementia, manifested by severe cognitive deficits affecting domains such as memory, sensorium, and safety awareness. She also has severe physical impairments. She has undergone an extensive trial of post-acute inpatient rehabilitation to optimize function and care. She remains primarily dependent for care and mobility. She has plateaued with respect to the benefits expected from formal rehabilitation interventions and she requires custodial level of care. This level of care can be met in the community in an appropriate environment with caregiver support, or in a long-term care institutional setting if a community setting is not feasible. The patient does not require ongoing SNF level services with ongoing physical therapy, occupational therapy, or speech therapy. Therefore, the requested SNF services for rehabilitation services including physical therapy, occupational therapy, and speech therapy 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 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

Nature of Statutory Criteria/ Case Summary: This is a female that was seen by podiatry and diagnosed with posterior tibial tendonitis and pes planus (fallen arches) to both feet. The examination reports moderate loss of foot arch with a medical shift bilaterally and tenderness to the posterior tibial tendons bilaterally. She reports that her foot pain is relieved with rest and orthotics, and that her orthotics are broken down. Podiatry recommends new functional orthotics to control the potential collapse secondary to her pes valgus deformity. At issue is whether the custom molded orthopedic shoe inserts are medically necessary to treat the patients medical condition. The use of functional custom molded orthotics (shoe inserts) for the treatment of a patients pes planus and posterior tibial tendinitis is widely accepted across literature and is an effective conservative solution for these diagnoses. Custom molded orthotics will take the pressure off the first toe joint to help reduce pain. The rational for custom orthotics versus prefabricated (over the counter or OTC) arch supports is that OTC arch supports do not control the biomechanical forces (movement) on the foot and do not contour to the patient's feet. The patient has posterior tibial tendinitis and a calcaneovalgus deformity, which needs to be controlled with a semi-rigid material, a deep heel and possibly a medial flange to prevent foot collapse. These specifications cannot be found in a prefabricated arch support. As noted in the literature, almost all of them used some form of orthosis with or without physiotherapy. They note that studies used various custom orthoses including the University of California biomechanic lab orthoses. The record provided for review notes that the patient has orthotics that are no longer effective in supporting the arches and taking pressure off the posterior tibial tendon. The patient and physician report that she has benefited from custom orthotics with reduced pain, and increased function. Literature reports that custom orthotics may help to avoid any further, more serious issues, such as the need for surgery, in the future. Therefore, based on literature and the medical record provided for review, custom molded shoe inserts (orthotics) are indicated for the patient in the treatment of pes planus and posterior tibial tendinitis. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant Health gene test (CPT 81479). Langerhans cell histiocytosis is characterized by single or multiple osteolytic bone lesions or skin rashes demonstrating infiltration with histiocytes with bean-shaped nuclei on biopsy, with or without histiocytic infiltration of extraskeletal tissues. As part of the work-up, BRAF testing is indicated and can be performed without an entire molecular panel. This patients records document a diagnosis of Langerhans cell histiocytosis, but there is no report of BRAF testing prior to the Guardant360 assay. Although BRAF mutation is recommended, there is a lack of support for additional molecular testing to help guide treatment decisions making. Thus, the Guardant Health gene test (CPT 81479) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Guardant Health gene test (CPT 81479) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 1, 2, and 3 are board certified in internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax 0.25 mg every 12 hours. Xanax is a class of medications known as the benzodiazepines, which are effective in the treatment of anxiety. However, benzodiazepines are associated with dependence, and in elderly patients can increase risk of sedation and falls. In addition, Xanax has been associated with worsening symptoms of OSA. One recent study from Researchers concluded that benzodiazepines use in patients with OSA increased the risk of acute respiratory failure. Based on current data, Xanax is supported for the short-term treatment of acute anxiety. Anxiety and depression should be treated with a selective serotonin reuptake inhibitor (SSRI), while benzodiazepines can be used for temporary relief of acute anxiety symptoms. Appropriate use of Xanax is based on the risks and benefits determined by the provider. The records provided for review do not document an adequate trial of a medication to address her sleep issues, such as Ambien or melatonin. Moreover, the patient has several medical comorbidities including OSA as well as advanced age, which place her at risk for adverse effects with use of Xanax. All told, the requested Xanax 0.25 mg every 12 hours is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in geriatric 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.