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 Vyvanse tablets.Findings: Lisdexamfetamine dimesylate (LDX), or brand name Vyvanse, is a medication within a newer class of long-acting agents for the treatment of attention deficit hyperactivity disorder (ADHD). These drugs are known as prodrugs and do not rely on mechanical release of active drug that may be affected by gastrointestinal (GI) factors such as transit time and pH. Unlike other stimulant medications that use a pH-dependent mechanical formulation (beads) to deliver active medication, LDX absorption and conversion are not affected by variations in gastric pH. Therefore, LDX is not prone to pH-mediated food or drug interactions. LDX was FDA approved for the treatment of adult ADHD in 2009. Its effects last for 14 hours in adults, and its safety and tolerability profile is similar to that of other stimulant medications. Several trials have demonstrated LDXs efficacy in treating ADHD in adults. Compared with other long-acting drugs indicated for ADHD, LDX is associated with lower daily average consumption, less need for augmentation, and greater persistence with therapy. The medication also has lower potential for abuse. In this case, the patient has ADHD, they are taking Vyvanse for an FDA approved diagnosis, and they have been stable for over a year. The patient also functions as an educator, and they pose a risk of decompensation and functional decline without this medication. Accordingly, the requested medication, Vyvanse tablets, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.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 authorization and coverage for insulin pump supplies including syringe (HCPCS A4232), disposable sensor (HCPCS A9276), and insulin infusion set (HCPCS A4230). This patients records document a diagnosis of type 1 diabetes complicated by autonomic dysfunction, depression, and asthma. The provider reports that the patient is on an insulin pump. In addition to improving glycemic control, insulin pump therapy can significantly improve the quality of life of diabetic patients (Ghazanfar, et al.). To maintain adequate glycemic control, this patient would benefit from closely tracking her blood glucose levels. To facilitate self-monitoring of blood glucose levels, a glucometer has been shown promising results (Al Hayek, et al.). It is important for this patient be able to use test strips which are compatible with her insulin pump. For these reasons, the requested insulin pump supplies including syringe (HCPCS A4232), disposable sensor (HCPCS A9276), and insulin infusion set (HCPCS A4230) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for group 3 power wheelchair with manual recline and multi-power options. Findings:  The physician reviewer found that medical literature supports the use of exercise therapy. Hagen and colleagues note that there is empirical evidence that exercise therapy has beneficial clinical effects for most musculoskeletal conditions. Hastings and colleagues found that manual wheelchair users demonstrated better physical function and mobility than power wheelchair users. In this case, the patient has a history of multiple spinal surgeries. A review of systems did not note difficulty with walking or dizziness, did not document upper body impairments on examination, and documented 4/5 leg strength with intact leg sensation. A durable medical equipment evaluation demonstrated 4/5 upper limb strength and functional range of motion in the upper limbs. The records do not document impairments that would preclude the use of an optimally fitted manual wheelchair to accomplish mobility-related activities of daily living. Therefore, a group 3 power wheelchair with manual recline and multipower options is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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 CT of abdomen and pelvis, with contrast. Researchers note that insight into the molecular biology of renal cell carcinoma (RCC) may provide an improved understanding of potential risk factors, oncologic behavior, and imaging features. Researchers conclude that optimal screening modality for RCC remains to be elucidated, and that it is unlikely that CT imaging would be recommended for population screening due to radiation dose and increased potential for other incidental findings. In this case, the documentation does not reflect that the patient is experiencing symptoms indicating possible malignancy. Given that the patient is asymptomatic, and that genetic counseling may be more appropriate in investigating a hereditary risk for malignancy, the requested service is not medically indicated. Therefore, CT of abdomen and pelvis, with contrast is not medically necessary for the evaluation 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance angiography (MRA). Moyamoya disease is a cerebrovascular occlusive disease that manifests as headache, seizure, and recurrent transient ischemic attacks. The disorder is characterized by severe stenosis or occlusion of the internal carotid artery bifurcation. The treatment goal in moyamoya disease is to improve blood flow to hypoperfused cerebral regions. Superficial temporal artery to middle cerebral artery (STA-MCA) bypass is a direct revascularization procedure that mainly addresses the MCA territory. Traditionally, conventional angiography is the gold standard for diagnosis of moyamoya disease. Current data supports that noninvasive MRA is comparable with conventional angiography in diagnosing and managing patients with moyamoya disease. After bypass surgery, the development of collateral vessels from the external carotid artery into the territory of the middle cerebral artery (MCA) and the enlargement of the superficial temporal artery are expected to be seen on conventional angiography. MRA can help assess the anastomotic vessels after bypass surgery. Li and colleagues reviewed the current status of imaging of moyamoya disease and noted that MRA is recommended as a completely noninvasive examination with no requirement of contrast medium and radiation exposure. In this case, the patient has moyamoya syndrome. She underwent a revascularization procedure with STA-MCA bypass. Based on the current medical literature, MRA is indicated for post-surgical evaluation in this clinical setting. In addition, MRA is indicated for this patient with kidney disease as it is noninvasive, and no contrast medium is required. For these reasons, the magnetic resonance angiography (CPT 70544) was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological testing. Findings:  The physician reviewer found that he American Psychological Association (APA), neuropsychological testing is recommended when initial assessment or assessment over time is needed to measure cognitive or functional deficits in patients based on an inability to develop expected knowledge, skills or abilities as required to adapt to cognitive, social, emotional, or physical demands, or evaluate primary symptoms of impaired attention and concentration that occur in neurological and psychiatric conditions. Per the APA, neuropsychological testing evaluation services typically include integration of patient data with other sources of clinical data, data interpretation, clinical decision making, and treatment planning and report. In this case, the patient continued to struggle despite years of accommodations and interventions, as well as previous psychological testing. She showed an inability to develop expected knowledge, skills or abilities as required to adapt to cognitive, social, emotional, or physical demands. She demonstrated difficulties with academic, social, behavioral and emotional realms with conflict at home, poor grades, social difficulties, and symptoms of depression and anxiety. She also has a long history of ADHD and low achievement in mathematics relative to her intellectual ability, as evidenced by her poor grades despite average range intelligence. Per the APA and American Academy of Child and Adolescent Psychiatry (AACAP) recommendations, neuropsychological testing was the next reasonable next step in this patients treatment. For these reasons, the neuropsychological testing provided was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for hereditary hearing loss deficiency deafness panel. Autosomal recessive hearing loss and other defects of the inner ear have been associated with specific genes. Researchers noted that in syndromic hearing loss, it is important to determine the syndrome and gene mutation, which can impact treatment and vital structures such as the kidneys, heart, and thyroid. This patient presents with bilateral hearing loss. His providers have recommended genetic testing. Certain syndromes are actionable, and a diagnosis would affect the patients health if revealed through the requested hereditary hearing loss panel. Accordingly, the requested hereditary hearing loss deficiency deafness panel is 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 requested hereditary hearing loss deficiency deafness panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa 1 gm capsules. The U.S. Food and Drug Administration (FDA) approves the use of Vascepa for the management of elevated triglyceride levels and established cardiovascular disease, elevated triglyceride levels with diabetes and two or more additional risk factors for cardiovascular disease, or severe hypertriglyceridemia. In this case, the documentation does not reflect a history of symptomatic coronary artery disease or diabetes, and she has only moderate elevation of triglycerides. In this clinical setting, statin therapy is recommended. Therefore, Vascepa 1 gm capsules are 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 internal medicine with sub-specialty certification in cardiovascular disease 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 Vistara Natera genetic testing. Findings:  The physician reviewer found that records provided for review indicate that this patient has undergone Panorama screening, which reported low risk results and Horizon Natera carrier screening, which was negative for 274 out of 274 diseases. A transabdominal ultrasound showed no anomalies and ultrasound consistent with dates. The patients provider has recommended cell-free DNA testing. According to the American College of Obstetricians and Gynecologists (ACOG), cell-free technology may be beneficial to predict the risk for fetal genetic disorders during pregnancy including various skeletal dysplasias, sickle cell disease, and cystic fibrosis. However, there are insufficient data to provide information regarding accuracy and positive and negative predictive value in the general population. Thus, ACOG does not recommend routine use of cell-free DNA screening. Overall, there is a paucity of peer-reviewed medical literature and guidelines supporting cell-free DNA testing as superior to standard testing and evaluation of single gene disorders. Therefore, the requested Vistara Natera genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Vistara Natera genetic testing is 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 requested services are 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 genetics and is actively practicing. Physician reviewer 2 is  board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is  board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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: An enrollee has requested authorization and coverage for radiofrequency ablation.American Society of Interventional Pain Physicians evidence-based guidelines for interventional techniques state that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. A systemic review by Manchikanti and colleagues found that in the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy. Researchers found that there was a reduction in pain 12 months post-procedure for patients with facet joint disease of the lumbar spine. Researchers found that radiofrequency ablation of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6-12 months and possibly up to 2 years. This study investigated function, pain, and medication use outcomes of radiofrequency ablation for lumbar facet syndrome in a cohort with long-term follow-up.In this case, the patient has a diagnosis of lumbar facet arthropathy with a presentation of chronic low back pain. The patient underwent a previous lumbar radiofrequency ablation procedure of the L3 through S1 medial branches, and notes from a follow-up visit confirm that the patient received significant pain relief which lasted approximately 6 to 8 months before the pain gradually returned. The patient has therefore had a previous positive response to the radiofrequency ablation procedure that is now requested. The requested radiofrequency ablation is also consistent with current standards of care as well as recommendations from current pain management guidelines and evidence based literature. Accordingly, the requested radiofrequency ablation is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) in both knees. Findings:  The physician reviewer found that Functional limitations are noted in his ability to perform activities of daily living. He is status post bilateral knee arthroscopy with medial meniscus repair and chondroplasty of the medial femoral condyle. Physical examination findings have been consistent with radiographic evidence of bilateral knee medial joint space narrowing, small marginal osteophytes over the medial aspect of the medial tibial plateau, and bilateral flabella. The provider noted that the patient has failed to improve with conservative treatment including activity modification, physical therapy, exercise, and bracing. Bennett and colleagues recommend radiography as the initial imaging examination for nontraumatic knee pain. Per the American College of Radiology (ACR), an MRI examination for nontraumatic knee pain is indicated when the pain is persistent and conventional radiographs are nondiagnostic or when additional information is necessary before instituting treatment. MRI of the knee is an appropriate next step in the work-up of patients with chronic knee pain and initial knee radiographs demonstrating prior cartilage or meniscal repair. Evidence-based medical guidelines support MRI imaging in this patients medical condition to direct further treatment. For these reasons, the requested MRI in both knees is medically necessary for evaluation of 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 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.