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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for low back surgery. In this case, while the patient was documented to have low back pain, a lumbar magnetic resonance imaging (MRI) showed a widely patent canal, a small disc bulge at L1-L2 that did not affect the central canal, lateral recess, or nerve roots, and a central disc herniation at L5-S1 that did not cause any canal stenosis, lateral recess stenosis, or nerve root compression. The records did not support nerve root compression at either level. Given that the records did not indicate conditions other than a minimal disc bulge at L1-L2 without central canal or neural foraminal stenosis, and that the absence of nerve root compression was a contraindication to surgery, the requested service was not medically indicated. Therefore, low back surgery was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage all or any of the Food Tolerance Induction Program services (CPT 99215 and 95076). Current medical evidence has not established the efficacy of tolerance induction for the management of food allergies. Sicherer and Sampson note that the diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges. The authors further note that management remains largely based on allergen avoidance. While it is standard of care to measure immunoglobulin E (IgE) levels to specific foods in question that the patient may have an allergic reaction to, there is a lack of support for an extensive array of blood tests examining foods to which the patient has not had a reaction. Additionally, there is a lack of support for oral desensitization to a multitude of foods to which the patient does not have a history of anaphylaxis. There is a lack of evidence in current medical literature supporting tolerance or sustained unresponsiveness with oral food desensitization. Therefore, Food Tolerance Induction Program services (CPT 99215 and  95076) were not and are not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Food Tolerance Induction Program services (CPT 99215 and  95076) were not and are 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 services at issue were not and 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 allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and pediatrics and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard Liquid 30 gm IV every four weeks. Researchers note that measurement of IgG subclass concentrations is a standard laboratory test run as part of a panel to investigate the suspicion of antibody deficiency that may also help determine a revaccination strategy for patients and support patient management. Researchers indicated that IgG subclass 2 deficiency is a condition in which the patient is unable to mount an adequate antibody response to polysaccharide antigens. These antigens are commonly found on gram-positive organisms, such as pneumococcus, staphylococcus and streptococcus bacteria. This failure to respond to polysaccharide antigens also results in minimal or no response to vaccines that use polysaccharide components, such as the pneumococcal vaccine. Thus, the diagnostic presentation is one where the patient has laboratory confirmation of low IgG levels, clinical history of recurrent infections with polysaccharide containing bacteria, such as sinusitis, otitis, and pneumonia, and a failure to respond to a vaccine challenge, such as pneumococcal vaccine. In this case, the provider has documented that the patient had low IgG2 levels and that she had allergic reactions to vaccines in the past. It is also noted that the patient has had upper respiratory infections in the past. However, there is no documentation of a vaccine challenge. Therefore, on this basis, the patient does not meet the guideline recommended evaluation for IgG subclass 2 deficiency. In this clinical setting, the requested medication is not medically indicated. Therefore, Gammagard Liquid 30 gm IV every four weeks 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 allergy and immunology 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 factor 9 gene testing. This patients provider noted clinical suspicion of a hereditary coagulopathy. There was no family history but the bleeding in the brain was significant enough to require a hematology consultation. The patients activity levels of factor 9 were analyzed after the transfusion of multiple blood products including cryoprecipitate. Thus, the factor 9 activity levels could be falsely elevated. The 44% activity noted in the hospital was at the low end of normal and did not rule out factor 9 deficiency. Moderate or mild symptomatic factor 9 deficiency is characterized by activity levels under 40%. Hence, factor 9 deficiency was not ruled out. The provider thoroughly evaluated the patient and recommended genetic testing as the appropriate next step. The presence of trauma or injury to the brain as the initiating event for the bleed does not obviate the need for genetic testing for factor 9. Given these findings, the requested factor 9 gene testing is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for rituximab infusions. This patients records support a diagnosis of severe length dependent motor sensory axonal polyneuropathy. Prior treatment has included IVIG without substantial improvement and glucocorticoid, which was not tolerated. The provider reports that treatment with rituximab has resulted in symptomatic improvement for this patient. The use of monoclonal antibodies, such as rituximab, has been demonstrated to provide significant improvement in patients with neuropathic pain. Rituximab, a chimeric anti-CD20 monoclonal antibody, has shown benefit in the treatment of patients with peripheral neuropathy associated with immunoglobulin M (IgM) gammopathy. Moreover, current studies have reported a favorable side-effect profile. Therefore, the requested rituximab infusions are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested rituximab infusions are 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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 patients parent has requested authorization and coverage for applied behavior analysis (ABA) services. Per the ABA Coding Coalition treatment plan guidelines, ABA services are medically necessary when supported by adequate documentation including proposed treatment targets, goals, and objectives. This patients records do not include a thorough treatment plan and this information was not reported in the patients medical records. The patients diagnostic report did not recommend ABA, rather, the provider endorsed parent training, individual therapy, family therapy, and assistance in the school setting. The Centers for Disease Control and Prevention (CDC) guidelines support the use of parent training in behavior management, behavioral classroom management, and medication for young patients with attention-deficit/hyperactivity disorder (ADHD). In addition, the recommended treatment for oppositional defiant disorder (ODD) includes include individual therapy, family therapy, social skills training, and medication. The current medical literature and guidelines do not recommend ABA as an effective treatment modality for patients with ODD. Moreover, the requested ABA services fail to meet the medical necessity criteria. Researchers noted, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these criteria, the patient fails to meet criteria (b) and (c). There is lack of evidence that ABA is an appropriate treatment for this patients ADHD or ODD, and the type, frequency and duration of treatment cannot be assessed without a current treatment plan. For these reasons, the requested ABA services are not medically necessary for 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 a licensed B.C.B.A, board certified in psychology, 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 a surgical implant of a leadless pacemaker (CPT 33274). In this case, there is no reported contraindication to placement of a standard leaded pacemaker system such as lack of venous access, young age with anticipated multiple subsequent procedures, or need for venous catheters. In addition, leadless pacemakers lack adequate long-term follow-up data to support a clinical role for patients in this clinical setting (Reddt, et al.; Miller, et al.; Kusamoto, et al.). This patient has an intermittent Mobitz II atrioventricular (AV) block that cannot be effectively treated with a leadless ventricular pacemaker and requires a standard leaded dual chamber system to maintain AV synchrony. For these reasons, the requested surgical implant of a leadless pacemaker (CPT 33274) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested surgical implant of a leadless pacemaker (CPT 33274) 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 internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 patient has requested authorization and coverage for endovenous ablation therapy. Researchers noted that in a study of 1,406 patients with varicose veins, endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation at 55.2%, and endovenous laser ablation at 33.9%. In this case, the patient has reflux of the vein to be treated and arterial perfusion to the lower extremities. Given that the records note that the patient is a candidate for vein ablation, and that her symptoms are of a severity to limit daily activities despite efforts at conservative treatment, the requested service is medically indicated. Therefore, endovenous ablation therapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda pen 3 mg/0.5 mL. Findings:  The physician reviewer found that clinical practice guidelines recommend diet, exercise, and behavioral modification in all obesity management approaches. The authors further note that patients with a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. The guidelines recommend continued use of weight loss medication if the patients response is deemed effective, with 5% or more body weight loss at three months, and safe. In this case, the patient has a history of obesity and has been unable to lose and maintain weight with diet and exercise alone. He has responded well to Saxenda, with 9% weight loss over the past three months. Given the current medical literature and the providers recommendation that the patient continue on weight loss medication, the requested medication is medically indicated. Therefore, Saxenda pen 3 mg/0.5 mL is medically necessary for the treatment of this patient.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 reimbursement for facial feminization surgery. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, given that the patient had a diagnosis of gender dysphoria and the provider recommended facial feminization surgery, the service at issue was medically indicated.  Therefore, facial feminization surgery provided August of 2019 was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service 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 psychiatry with expertise in transgender health 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 Otezla starter pack (day 1 to day 5) followed by Otezla 30 mg twice daily starting on day 6. Otezla is a small molecule drug that inhibits phosphodiesterase-4 (PDE-4). This action decreases the levels of proinflammatory cytokines like tumor necrosis factor alpha (TNF-a) and interleukin (IL)-23 and increase anti-inflammatory mediators. This decreases anti-inflammatory action in many inflammatory diseases like psoriasis and dermatitis. As this patient has already failed many traditional therapies for psoriasis, Otezla is the next logical treatment step. Otezla is a safe and efficacious treatment that is U.S. Food and Drug Administration (FDA) approved for psoriasis and shows great efficacy in the treatment of dermatitis (Mobasher, et al.; Papp, et al.). Given this support, Otezla starter pack (day 1 to day 5) followed by Otezla 30 mg twice daily starting on day 6 is medically necessary for treatment of this patient.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 dermatology 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 a Diagnostic Audiologic & (Central) Auditory Processing Evaluation. Findings:  The physician reviewer found that Auditory processing disorder (APD) is a well-recognized condition. The condition is associated with reading, language, and reading disorders. It is also associated with other conditions such as attention deficit hyperactivity disorder (ADHD), developmental language disorders, and reading disorders (Bailey, T.). Abnormal auditory testing results seen in children diagnosed with central auditory processing disorder (CAPD) are most commonly due to attentional problems (Moore, D., et al.). Children with attention deficit hyperactivity disorder (ADHD) can be diagnosed with CAPD because of their difficulties with attention and focus, which are due to the underlying disorder and not to a separate auditory processing problem. In this case, the patient is suffering from some spelling difficulty and inattention at home and school. The patients mother has expressed concern about the patients auditory processing disorder and wanted CAPD testing. The patient was seen and was thought to have ADHD, and a referral to an ADHD clinic was made. If the patient is evaluated for ADHD and is not found to have ADHD, then CAPD testing and treatment is warranted. At this point, however, CAPD testing is premature and not medically necessary. Accordingly, the requested Diagnostic Audiologic & (Central) Auditory Processing Evaluation is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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.