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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the intensive care burn unit services at Bothin Burn Center provided. Findings:  The physician reviewer found that  Frugoni and colleagues state that the mortality rate in burn patients has declined significantly because of reflective of changes in the care of burn patients, particularly the introduction of early excision and grafting and the use of autograft, cadaveric allograft, and synthetic matrices. For calculation of average length of stay, Taylor and colleagues suggest estimating length of stay by calculating the patients age divided by ten, then subtracted by two, and finally adding TBSA for patients 40 years of age or older. Taylor and colleagues do not report standard deviation for length of stay, limiting its practicality for application to any individual hospitalization. Average length of stay is certainly not a determinant of any individual hospital stay, since all patients differ, and all burns differ in severity, even if they are similar in extent. In this case, the patient is 44-years-old and sustained a deep 10% TBSA burn from falling into a fire pit. The patients estimated length of stay would be 12.4 days as an average length of stay after her initial admission for stabilization. The patient had a 10% TBSA burn that was completely third degree and involved her hand and one digit. The patient was transferred for care after initial resuscitation and stabilization after two days on 9/14/20. She underwent surgical debridement and xenografting the following day on 9/15/20. On 9/21/20, five days later, she underwent debridement and split-thickness skin grafting. She was discharged 9/29/20, eight days later. The Health Plan notes that the patient was stable for discharge and hospital transfer on 9/26/20, which was the fifth postoperative day. The mesh over the skin graft was not removed until 9/25/20, by which time she was ambulating to the bathroom with supervision and using a cane. She was still on pain medication with daily dressing changes. By 9/28/20, she was stable with all staples out. There is no indication in the medical records that burn unit care was medically necessary for an additional day and that she could not be discharged or transferred on 9/28/20. Therefore, intensive care burn unit services at Bothin Burn Center provided on 9/26/20 and 9/27/20 were medically necessary for the treatment of the patients medical condition. However, intensive care burn unit services at Bothin Burn Center provided on 9/28/20 were not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
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 Norditropin Flexpro 15 mg/1.5 mL. Findings:  The physician reviewer found that manifestations of Down syndrome include short stature. However, short stature in the context of Down syndrome is not likely due to growth hormone (GH) deficiency. Common contributors to poor growth in patients with Down syndrome include cyanotic heart disease and trisomy 21. This patient is GH sufficient based on his normal growth pattern compared to his peers with Down syndrome, his circulating insulin like growth factor 1 (IGF-1) and insulin like growth factor binding protein 3 (IGFBP-3) levels, as well as his normal bone age, and normal responses to standard GH provocative tests. Magnetic resonance imaging (MRI) of the brain with and without gadolinium contrast to exclude intracranial pathology is important prior to administration of GH therapy. The report for this patients MRI of the brain was not provided for review. In addition, the patients afternoon cortisol level was slightly elevated in 2018, but there is no report that a 24-hour urinary free cortisol assessment to exclude hypercortisolism has been performed. Based on the available documentation, this patient does not meet the accepted and U.S. Food and Drug Administration (FDA) approved indication for Norditropin. Therefore, the requested Norditropin Flexpro 15 mg/1.5 mL 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 pediatrics with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested  authorization and coverage for a 28-day residential treatment center (RTC) program with the following CPT codes: 97112 x 96, 97116 x 96, 97530 x 96, 97535 x 96, 90837 x 15, 90846 x 4, 90847 x 4, 96151 x 12, 96154 x 12, 97810 x 8, and 97811 x 8. Findings:  The physician reviewer found that a review of pediatric complex regional pain syndrome (CRPS), Weissmann and Uziel report, Exercise and physical therapy (PT) are the main treatment cornerstones of all pediatric CRPS patients. The authors further note regarding studies of pediatric patients with CRPS, Brooke and Janselewitz reported complete resolution of pain in 25 of 32 children with CRPS after intensive inpatient rehabilitation, which consisted of physical, occupational, and psychological therapy, with no other medical intervention, followed by a home program. A study of a day hospital pediatric pain rehabilitation program performed by Logan et al. included 56 pediatric CRPS patients who failed to improve with outpatient treatment. Treatment included daily physical, occupational and psychological therapy, for a median duration of three weeks. They found statistically significant improvements from admission to discharge in pain intensity, functional disability, subjective reports of limb function and occupational performance, these functional gains were maintained or further improved at follow-up. Hoffart and Wallace report that the standard treatment for pediatric patients with amplified pain syndromes is multidisciplinary, emphasizing exercise therapy, cognitive-behavioral treatment, and self-regulation. In this case, the patient has a diagnosis of localized amplified musculoskeletal pain syndrome. She has tried and failed medication management with multiple different classes of drugs, outpatient physical therapy, and behavioral pain management. The patients provider has recommended admission to a pediatric amplified pain rehabilitation (PAPR) program. In this clinical setting, given the patients severity of disease and failure to respond to treatment, the requested services are medically indicated. Therefore, a 28-day RTC program with the following CPT codes: 97112 x 96, 97116 x 96, 97530 x 96, 97535 x 96, 90837 x 15, 90846 x 4, 90847 x 4, 96151 x 12, 96154 x 12, 97810 x 8, and 97811 x 8, is 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 anesthesiology with sub-specialty certification in pain 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 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 and prospective authorization and coverage for continued inpatient hospitalization. The records provided for review document that this patient underwent a lung biopsy and removal of a brain metastasis. The provider noted that the patient was stable for discharge to home or a SNF. The documentation from the provider indicates that the patient has recovered well from the lung biopsy and resection of the brain metastasis. Specifically, the patient has been physically stable, without evidence of any ongoing issues that require continued inpatient hospital admission. Further evaluation and therapy for her metastatic cancer could have been safely and effectively provided on an outpatient basis. All told, continued inpatient hospitalization was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in medical oncology 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 the Inspire upper airway stimulation system (hypoglossal nerve stimulation). Current medical literature supports the safety, efficacy, and long-term outcomes in the treatment of OSA with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea/hypopnea index (AHI), oxygen desaturation index (ODI), and Epsworth Sleepiness Scale (ESS), combined with improvements in quality-of-life scales. Researchers report that the Stimulation Treatment for Apnea Reduction (STAR) trial showed that upper airway stimulation systems provide significant improvement in sleep-related quality of life outcome measures across 48 months. Researchers note that the ADHERE registry following the outcomes of upper airway stimulation in patients who have failed CPAP therapy of OSA continued to show significant improvement in subjective and objective OSA outcomes with the use of upper airway stimulation therapy. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA as a safe and effective second-line treatment of moderate-to-severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP therapy. In this case, the requested service is likely to be more beneficial, given that the patient has already failed CPAP therapy, and the alternative, no treatment, would lead to potential harms such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. Therefore, the Inspire upper airway stimulation system (hypoglossal nerve stimulation) 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 Inspire upper airway stimulation system (hypoglossal nerve stimulation) 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. Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for vedolizumab (Entyvio), 1 mg injection  Findings:  The physician reviewer found that Lichtenstein and colleagues, for patients with moderately to severely active Crohns disease and objective evidence of active disease, anti-integrin therapy (with vedolizumab) with or without an immunomodulator is more effective than placebo and should be considered to be used for induction of symptomatic remission in patients with Crohns disease. Moreover, vedolizumab should be used for maintenance of remission of vedolizumab-induced remission of Crohns disease. Additionally, several studies have assessed the use of Stelara with Entyvio, including both used at dosing every four weeks. In aggregate, no significant safety issues were attributed to dual biologic therapy, and the therapy was broadly successful in improving response in patients who had failed biologic therapy. In this case, the patient had improvement on Stelara with Entyvio, although a colonoscopy showed ongoing inflammation (ulceration in the ileum and rectum). Therefore, a discontinuation or decrease in dose of either Entyvio or Stelara could result in additional complications of uncontrolled disease, flare, hospitalization, need for surgery, fistula, and stricture. The patients alternative options are limited. Therefore, vedolizumab (Entyvio), 1 mg injection is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: The patient has requested authorization and coverage for massage therapy for (1) one-hour sessions twice a week, (2) a one-hour session once a week, (3) 30-minute sessions twice a week, or (4) a 30-minute session once a week. Findings:  The physician reviewer found that Chronic benign musculoskeletal pains affecting the neck and back attributed to strain injuries may be managed using pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. Urits and colleagues note that the aim of rehabilitation in chronic back pain patients is to reduce pain, reduce impairment and/or disability, and improve the quality of life. Chou and colleagues report nonpharmacologic therapies for low back pain include exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture. Current medical literature does not establish the benefit of formal passive modalities, such as massage therapy, for non-specific low back pain. Farber and Wieland report very little confidence that massage is an effective treatment for low back pain, noting that massage resulted only in short-term improvements in acute, sub-acute, and chronic low back pain. Cohen and Hooten note that among complementary and alternative treatments, the strongest evidence in the management of chronic neck pain is for exercise, with weaker evidence supporting massage, acupuncture, yoga, and spinal manipulation in different contexts. In this case, the patient has chronic neck and back pain. The records do not document any impairments that would preclude the patient from performing an appropriate independent exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, such as self-massage using foam rollers or massage balls, and topical treatments such as ice or heat. Given that there is no expectation of a marginally significant difference in clinical course or outcomes with the requested massage therapy over an appropriate independent program, the requested services are not medically indicated. Therefore, massage therapy for (1) one-hour sessions twice a week, (2) a one-hour session once a week, (3) 30-minute sessions twice a week, or (4) a 30-minute session once a week is 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 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: The patient has requested authorization and coverage for rhinoplasty. This patient has a long history of nasal obstruction and nosebleeds despite maximal conservative medical therapy. Nasal endoscopy demonstrated a significantly deviated nasal septum. The provider noted that the patient also has significant nasal stenosis. Correction of nasal valvular stenosis requires cartilage grafting with a rhinoplasty approach. Addressing the nasal septal deviation will not correct the patients symptomatic nasal valvular stenosis. Friedman and colleagues noted that, Planning for functional rhinoplasty involves the identification of the sites of nasal airway obstruction or old trauma and addressing those regions during the operation with a number of different techniques that have been described. Wo and colleagues state that, With the advent of new techniques and overlapping functional rhinoplasties, some patients may even have a clinical improvement in nasal function following rhinoplasties. For instance, the use of spreader and alar grafts is effective in patients with nasal valve insufficiency. Thus, these can be utilized in both septoplasties as well as septorhinoplasties. Given these findings, the requested rhinoplasty is 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 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:  An enrollee has requested authorization and coverage for all or any of the requested twelve physical therapy office visits.Clemens and colleagues state that the pathophysiology of chronic male pelvic pain syndrome is generally poorly understood. While pharmacotherapy, physical therapy, injection therapy and mental health interventions are often employed for treatment of this condition, there is a dearth of evidence supporting the efficacy of any treatment, according to Franco and colleagues. In this case, the patient has had chronic, persistent symptomatology without sustained benefit from any intervention to date. The patient is otherwise able to exercise regularly. No significant improvement in the patients clinical course or outcomes is expected with the proposed intervention. Therefore, all of the requested twelve physical therapy office visits are not medically necessary for the treatment of the patients medical condition.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for testing for assay of apolipoprotein. The records document that this patient has established CAD. Per the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines, treatment in this clinical setting includes achievement of LDL cholesterol goals with intensive lifestyle and pharmacologic lipid lowering therapy, which is currently being done (Arnett, et al.). Although there is some emerging observational, population based data that apolipoprotein measurements may have utility in determining residual risk in patients with goal or near goal LDL cholesterol levels, the data is mixed at present and current guidelines do not recommend the use of repeated measurements to guide lipid lowering therapy (Stone and Lloyd-Jones; Welsh, et al.). Similarly, repeated advanced lipoprotein measurements to guide lipid lowering therapy are not considered consistent with current AHA/ACC guidelines. For these reasons, the testing for assay of apolipoprotein 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 testing for assay of apolipoprotein 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 reviewer 1 is board certified in certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology 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.