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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. Findings:  The physician reviewer found that Spinal cord compression, which often presents with a combination of symptoms that can include motor weakness and sensory changes, is generally considered a neurosurgical emergency and delays in the diagnosis and treatment can result in progression of neurological dysfunction.  O'Phelan notes that as interventions are critically time-sensitive, the recognition and treatment of spinal cord compression is part of emergency neurologic life support protocol. Cram and colleagues report that there is variation in the utilization of cervical spine surgery. In this case, the patient was admitted for hospitalization on the recommendation of the treating provider upon presenting to the emergency department. The records documented the providers recommendation for  decompressive surgery upon the patients admission for treatment of severe cord compression causing documented neurological symptoms. The patients condition eventually improved with intravenous steroids, a treatment that could only have been administered in the hospital setting and based on the improvement in her clinical condition, the patient was discharged home with plans for further conservative therapy and consideration for outpatient surgery down the road. In this case, given that the records document that the assessment of the providers upon the patients admission that the severity of her condition required urgent surgery, the services at issue were medically indicated. Therefore, inpatient hospitalization services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for fertility preservation services (stimulation and removal of her oocytes, inseminating the oocytes, and the cryopreservation of the embryo). Researchers found that fertility preservation in both female and male oncological patients is now possible and should be integrated as part of the oncological healthcare. In this case, the patient had negative margins from the initial excisional procedure. According to medical literature, the rates of residual AIS, recurrent AIS, and concomitant or subsequent invasive adenocarcinoma in this clinical setting are approximately 2.6%, 20%, and less than one percent, respectively. For this patient, a hysterectomy after completion of childbearing is recommended, although continued surveillance is a reasonable option if the patient has consistently normal testing, particularly for five or more years, following their cone biopsy. The records do not note that the patient is undergoing any cancer therapy or gonadotoxic treatment such as radiation therapy or chemotherapy. While the patient has a low risk of losing her uterus, they are not at risk of having their ovaries removed. Given the absence of gonadotoxic treatment or possible damage to the ovaries, the requested services are not medically indicated. Therefore, fertility preservation services (stimulation and removal of her oocytes, inseminating the oocytes, and the cryopreservation of the embryo) are not medically necessary for the 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 custom orthotic for the left foot. It is well established in the medical documentation that this patient presents with a history of excessive pronation to the left foot, leading to a functional leg length discrepancy with a raised right side. The patient reports ongoing back pain due to an altered gait secondary to overpronation and functional leg length discrepancy. The provider has recommended for the patient be fitted with a  custom orthotic. On review of the medical literature, there is adequate support for use of a custom orthotic in this patients clinical setting. Researchers evaluated the effectiveness of orthotic insoles in patients with mild leg length discrepancy. The authors concluded that, Orthotic insoles significantly improved gait symmetry in the pelvis in the frontal plane and the ankle in the sagittal plane, as well as pain. Thus, an orthotic insert is indicated for this patient to help compensate for a functional leg length discrepancy as recommended by his provider. A customizable orthotic will allow for exacting compensation of a leg length discrepancy. Given these findings, the requested custom orthotic for the left foot 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 a licensed D.P.M., board certified in podiatric 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 reimbursement for inpatient hospitalization services. Findings:  The physician reviewer found that Based on the available documentation, the inpatient hospitalization services provided to this patient were medically necessary for the treatment of left ovarian torsion. As noted in the medical literature, ovarian torsion is considered a gynecological emergency that requires prompt surgical attention in order to preserve the function of the ovary and prevent future complications of pain, adhesions, and infertility. This patient presented to the emergency department for an emergent medical condition. The patients care was delayed due to the attempt to transfer her to another hospital. Once the patient underwent laparotomy, her post-operative course was uneventful. Remaining in the hospital for one day post-operatively is consistent with current recommendations and medical literature to assure that the patient has met all of her goals of diet, pain, and ambulation prior to discharge. For these reasons, the inpatient hospitalization services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 30 treatments (two hours per treatment) of hyperbaric oxygen therapy in a multi chamber provided by Ronald Gordon Medical Corporation. Kleban and Baynosa state, Hyperbaric oxygen (HBO2) therapy can serve as a useful adjunct in the salvage of compromised flaps and grafts. The literature demonstrates the benefit of adjunctive HBO2 therapy for multiple types of grafts and flaps with various etiologies of compromise. HBO2 therapy can enhance graft and flap survival by several methods, including decreasing the hypoxic insult, enhancing fibroblast function and collagen synthesis, stimulating angiogenesis and inhibiting ischemia-reperfusion injury. The expedient initiation of hyperbaric oxygen therapy as soon as flap or graft compromise is identified maximizes tissue viability and ultimately graft/flap salvage. Bassetto and colleagues note that hyperbaric oxygen therapy may be indicated for compromised flaps and grafts. While current medical literature documents the utility of hyperbaric oxygen therapy in compromised flaps/grafts, in this case, the patient began hyperbaric oxygen therapy two months after his fat grafting. The patient reported concerns over irregularities in contour and in breast shape, both of which are functions of surgical technique, rather than a consequence or symptom of a compromised fat graft at two months post procedure. While the patient reported chest tenderness, such tenderness in the area of extensive fat grafting is within the range of normally expected postoperative healing and is not a consequence or symptom of a compromised fat graft at two months post procedure. In this case, given that the records do not demonstrate clinical evidence of a compromised graft, the services at issue were not medically indicated. Therefore, 30 treatments (two hours per treatment) of hyperbaric oxygen therapy in a multi chamber provided by Ronald Gordon Medical Corporation were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 plastic 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 authorization and coverage for ketamine therapy. Findings: Ketamine is reserved as an option for management of patients with treatment refractory depression, which is defined by failure of adequate improvement in depressive symptoms after two antidepressants trialed for appropriate durations and at appropriate dosages. Based on the documentation provided for review, this patient has not undergone the requisite two medication trials. Additionally, with reduction of his substance use, adjustment of lithium, and initiation of regular individual psychotherapy, the patient has shown positive response to treatment over the course of the last couple of months. The patient has reported subjective symptomatic improvement and his Personal Health Questionnaire scores have decreased to half of his score from October 2021. Given these findings, the patient does not meet the criteria for a diagnosis of treatment refractory, severe depression with an indication for ketamine therapy. Therefore, the requested ketamine therapy 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for full inpatient hospital admission at Swedish Medical Center. Kim and colleagues report that in patients who visited the emergency department with abdominal pain and were diagnosed with a ruptured ovarian cyst with hemoperitoneum, while most cases could be managed conservatively, a low diastolic blood pressure and a large amount of hemoperitoneum suggested the need for surgical intervention. Hecht and colleagues note that ruptured ovarian cysts are among the most common gynecological causes for acute pelvic pain and their diagnosis can be challenging. In this case, the patient presented with severe pain with a large, 8 cm, left ovarian cyst and hemoperitoneum. Given that patients with this condition who are otherwise healthy may appear well, with normal vital signs and laboratory results until they acutely decompensate from hemorrhage, hospitalization for observation for worsening symptoms from bleeding and the possible need for surgery was medically indicated. In this case, the patient ultimately underwent surgical management, and her postoperative course was medically indicated due to her age and to assure that the patient was stable for discharge home. Therefore, full inpatient hospital admission at Swedish Medical Center from was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 Daavlin Series 7 home phototherapy unit. As noted in the records provided for review, this patient presents with a history of psoriasis and Down syndrome. The provider described the patients psoriasis as moderate-to-severe. Although the patient has responded well to treatment with in-office phototherapy, the provider has recommended a home unit for long-term care. Per the American Academy of Dermatology (AAD) guidelines, phototherapy (NB-UVB) is a recommended treatment for patients with moderate-to-severe psoriasis. This patient meets the AAD criteria, given the severity of disease involvement. Moreover, the option of home treatment is also supported for use in this patients clinical setting. Per the AAD guidelines, For patients for whom travel to a phototherapy center is a limiting factor, home NB-UVB units should be considered. In addition, the AAD noted that, The burden of treatment was significantly lower, and patients were happier with their treatments when the UV light was delivered in the home phototherapy setting. Moreover, the requested Daavlin Series 7 home phototherapy unit is medically necessary to promote physical health and efficiency and ameliorate a physical condition. For these reasons, the requested Daavlin Series 7 home phototherapy unit is medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal and/or biopsy of skin lesions. For approaching melanocytic lesions, criteria such as the algorithm presented by the American Academy of Dermatology (AAD), and evaluation of gross features such as bleeding, pain, and growth, are critical (Tsao, et al.). The AAD algorithm for the evaluation of nevi assesses asymmetry, border, color, diameter, and evolution (ABCDE) suggest that biopsy is indicated for this patient as a bleeding and painful nevus is a sign of potential evolution. This patients clinic notes from 1/5/22 do not document the patient complaints of a bloody and painful scalp lesion. The patients physical examination noted scattered tan and brown macules on the scalp, trunk, and extremities. No sizes or specific descriptions corresponding to particular nevi were included in the records. Given the patients history of sun damage-induced lesions on his face including actinic keratoses, recent history of basal cell carcinoma on his trunk, family history of melanoma, and the self-described concern about pain and bleeding, it is prudent to perform a biopsy of the concerning skin lesions. In this clinical setting with concerning symptoms such as bleeding, pathological examination is recommended for diagnosis. Given these findings, the requested removal and biopsy of skin lesions are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL pen injectors. Findings:  The physician reviewer found that records provided for review document that this patient has a long history of atopic dermatitis that has failed to substantially respond to treatment with Vaseline, mometasone or tacrolimus. The patients provider has recommended treatment with Dupixent. Simpson and colleagues noted that, Although most patients with atopic dermatitis (AD) are effectively managed with topical medication, a significant minority require systemic therapy. Once all non-systemic factors have been addressed such as routine skin care and elimination of allergens or infections, and a patient still experiences symptoms with itching, it is reasonable to start systemic treatment for control of atopic dermatitis. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with atopic dermatitis. Bosma and colleagues found that Dupixent can be considered a long-term effective treatment for atopic dermatitis in combination with topical and initial concomitant systemic treatment, showing a sustained improvement of signs, symptoms, and quality of life. As a chronic disease, moderate to severe atopic dermatitis typically requires long-term treatment. However, continuous, long-term use of many treatments, particularly higher-potency oral and topical corticosteroids, ultraviolet therapy, and systemic immunosuppressants are not recommended because of safety risks or lack of efficacy data. Given this support, the requested Dupixent 300 mg/2 mL pen injectors are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections x 3 in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited.  In this case, the patient has a history of relief from prior injections of Euflexxa in both knees. The patient has tried and failed other conservative treatments, including naproxen and physical therapy without relief. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections x 3 in both knees are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.