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

The patient has requested authorization and coverage for Adderall 35 mg and alprazolam 1 mg. Researchers noted that stimulant medications, such as Adderall must be used with great care if there is a history of drug abuse. They are contraindicated in patients with a history of illicit use or abuse of stimulants, unless the patient is being treated in a controlled setting or can be supervised closely. In this case, the patient has a history of multiple chronic mental illnesses and longstanding amphetamine misuse. While his providers have attempted to arrange intensive behavioral treatment and medication management, the patient has wavered between a desire to stop using stimulants and a wish to receive Adderall for treatment of possible ADHD symptoms. This patients providers recommended behavioral approaches to address both his stimulant use disorder and his other mental health issues, including intensive outpatient treatment. The patient did not attend these programs consistently. Given the patients recent history of stimulant use disorder, Adderall 35 mg is contraindicated. Likewise, given the chronicity of the patients anxiety symptoms and history of substance misuse, alprazolam 1 mg is contraindicated. Therefore, Adderall 35 mg and alprazolam 1 mg are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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

The patient has requested authorization and coverage for custom molded orthotic shoe inserts. Conservative treatments for hallux rigidus have historically included activity modification, non-steroid anti-inflammatory medication, shoe modifications and orthotics. Custom orthotics support the medial arch and foot, reducing excessive pressure to the first metatarsophalangeal joint (MPJ). The Mortons extension is a device that further reduces first MPJ range of motion, allowing for a reduction in pain. Custom orthotics with a Mortons extension are a standard of care treatment for painful first MPJ, degenerative joint disease (DJD) of the first MPJ, and hallux rigidus. In this case, the patient was noted to have pain to the right first MPJ. A physical examination as well as an X-ray evaluation demonstrated DJD, osteophyte formation first MPJ, and hallux rigidus. Therefore, custom molded orthotic shoe inserts are medically necessary for the 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 Nerve repair with nerve allograft, each nerve, first strand (cable) (CPT 64912); with approved breast reconstruction (reconstruction breast with free flap (CPT 19364), biopsy or excision of lymph node(s), open, internal mammary node (CPT 38530), intravenous injection of agent to test vascular flow in flap or graft (CPT 15860), open periprosthetic capsulotomy, breast (CPT 19370), and removal of tissue expander(s) without insertion of prosthesis (CPT 11971). Studies reported on a series of 48 innervated DIEP flaps in 36 patients and 61 non-innervated DIEP flaps in 45 patients. The authors concluded that, nerve coaption in DIEP flap breast reconstruction resulted in a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. Researchers reported that, this article shows that it is technically possible to routinely carry out innervated DIEP breast reconstructions and that this may improve sensory recovery of slowly adapting nerve fibers of the reconstructed breast. However, the authors concluded that, there remains insufficient evidence to show that this is of clinically relevant benefit. In response, Studies discussed the recent peer-reviewed contributions and reported that, the results and clinical relevance should be confirmed in a double-blind, randomized, controlled trial that includes patient-reported outcome measures and quantitative sensory testing. In addition, the study did not report on the return of sensation following cadaveric nerve grafting. The medical information received for review demonstrates that the patient has been approved to undergo breast reconstruction. Overall, there are limited peer-reviewed medical literature supporting the safety and efficacy of nerve repair with allograft. For these reasons, the requested nerve repair with nerve allograft, each nerve, first strand (cable) (CPT 64912); with approved breast reconstruction (reconstruction breast with free flap (CPT 19364), biopsy or excision of lymph node(s), open, internal mammary node (CPT 38530), intravenous injection of agent to test vascular flow in flap or graft (CPT 15860), open periprosthetic capsulotomy, breast (CPT 19370), and removal of tissue expander(s) without insertion of prosthesis (CPT 11971) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature 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

The patient has requested reimbursement for air and associated ground ambulance transportation services. Status migrainosus is a headache that persists despite treatment for more than 72 hours. Treatment of status migrainosus and intractable migraine focuses on adequate fluid hydration and combination intravenous therapy with non-opioid medications from multiple drug classes. Stroke, myocardial infarction, trauma injury, and intractable seizures are considered life-threatening conditions that require rapid medical intervention. In this case, the patient was diagnosed with status migrainosus, which is not a life-threatening condition that would require air ambulance transfer with ground transport at each end. The medical evidence does not support the services at issue in this clinical setting. Therefore, air and associated ground ambulance transportation services 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a power wheelchair to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. The records show the patient underwent bilateral knee replacements and has conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power wheelchair would encourage. There are no documented impairments that would preclude the use of a manual wheelchair for longer distance community mobility. Therefore, the requested power wheelchair is not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Synvisc injections in the right knee. 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 lasting benefit from prior injections. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, for Synvisc injections in the right knee 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient requested authorization and coverage for a fully body CT scan. According to the American College of Preventative Medicine, No medical societies recommend whole-body scans. Thats because there is no evidence that the scans are a good screening tool. The authors also noted, These scans use large amounts of radiation. This can increase your risk of cancer. Regarding chronic extremity joint pain, The American College of Radiology reports, CT can be used to show cortical erosions, bone proliferation, and enthesitis but is not routinely used for this indication in the extremities. Soft-tissue abnormalities and synovitis are not well demonstrated. In this case, the patients symptoms are consistent with subacute to chronic pain. Full body CT scans may be utilized in the setting of acute major trauma; however, they have limited utility in the setting of subacute to chronic pain. There is no indication to warrant a full body CT scan for the patient without signs or symptoms of trauma, infection, or acute neurological/cardiopulmonary/hemodynamic compromise. The medical evidence does not support the requested service in this clinical setting. Therefore, a full body CT scan is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

The enrollee requested coverage for water physical therapy. The patient is diagnosed with Guillain-Barre syndrome, quadriplegia, and multi-joint osteoarthritis. Analgesic medication and aquatic therapy has helped in the past. Guillain-Barre syndrome affects one to two people per 100,000 people in our population each year. Disability caused by Guillain-Barre syndrome generally progresses over the course of a day to weeks. Various physical therapy regiments, including water physical therapy, can help the active movement of muscle groups that are not yet able to move independently against gravity. These activities may facilitate stretching, strengthening and pain relief. Water physical therapy has been shown in literature to improve conditions such as joint osteoarthritis similar to, if not more than, land physical therapy. In this particular case, the patients underlying diagnoses of Guillain-Barre syndrome and osteoarthritis as well as his prior improvement from aquatic therapy all support the clinical appropriateness and medical necessity for the requested aquatic therapy.  Final Result: The reviewer determined that the requested water physical therapy is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

This was an otherwise healthy female with severe acne and a family history of factor II prothrombin deficiency. The pediatrician was considering oral contraceptive pills (OCP) as topical medications and trials of oral antibiotics had not been successful in treating the patients acne. The patient had factor II prothrombin gene mutation testing ordered. Testing for thrombophilic genes with a factor II prothrombin test before the use of OCP with a family history of blood clots, is indicated to assess risk and to allow education to the patient and family members on how to go forward with OCP. The patient was at increased risk of thrombosis based on a family history of factor II deficiency and the proposed treatment with OCP (which also increased the risk of clots).  Final Result:Three of the three reviewers decided that the genetic test, and procedure bill was likely to be more beneficial for your child than any available standard therapy.Credentials/Qualifications: The physician reviewers are board certified in hematology       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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Tepezza (teprotumumab-trbw) infusions every 21 days for eight total doses (dose 1: 10 mg/kg; doses 2-8: 20 mg/kg). Graves ophthalmopathy is a potentially sight-threatening ocular disease that occurs in patients with hyperthyroidism or a history of hyperthyroidism due to Graves disease (Bahn). Initial treatment with glucocorticoids has demonstrated limited efficacy and presents safety concerns. Tepezza is a monoclonal insulin-like growth factor-1 receptor (IGF-1R) antagonist that has demonstrated proptosis reduction, which is similar to that seen with decompression surgery. This patient is a good candidate for Tepezza, particularly because he has failed glucocorticoid therapy. Given these findings, the requested Tepezza (teprotumumab-trbw) infusions every 21 days for eight total doses (dose 1: 10 mg/kg; doses 2-8: 20 mg/kg) 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for ovarian vein and possible iliac vein branch embolization. Treatment options for pelvic congestion syndrome are limited, but data support favorable outcomes with specific interventions. Medical literature provided data demonstrating that ovarian vein and possible iliac vein branch embolization are safe and effective in well-selected patients. The available data suggests that although hysterectomy is one treatment modality for pelvic congestion syndrome, it may not be the most effective option. This patient continues to have pain one year after her procedure and has worsening radiological findings consistent with pelvic congestion syndrome. Therefore, the requested ovarian vein and possible iliac vein branch embolization 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 services are 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 obstetrics and gynecology 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

The guardian of an enrollee has requested authorization and coverage for mental health residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children and adolescents needing mental health treatment. The patients composite score corresponds with a Level 4: Medically Monitored Community Per CALOCUS, the length of stay at this level of care can last up to 60 days.In this case, the patient received 45 days of residential treatment before his discharge. This is well within the CALOCUS guidelines for length of stay at his recommended level of care. Therefore, mental health residential treatment center services provided from his date of admission through his discharge were medically necessary for the patients medical condition. However, further clinical information is not available after his date of discharge, and based on the patients history and status upon discharge, mental health residential treatment center services provided from the date following his discharge going forward are not medically necessary for the patients condition.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with sub-specialty 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for high intensity focused ultrasound (HIFU), or in the alternative, cryotherapy. Based on peer-reviewed medical literature and guidelines, standard techniques including radiation therapy and surgery are the most effective intervention options for this patients prostate cancer. Current literature does not support HIFU or cryotherapy in lieu of conventional techniques in this clinical setting. HIFU and cryotherapy may be considered in patients who have progressed despite treatment with proven interventions. The records do not report that the patient has failed treatment with radiation therapy or surgery. HIFU and cryotherapy are not likely to provide this patient with improved disease control and quality of life when compared to standard available therapies. For these reasons, the requested HIFU, or in the alternative, cryotherapy 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 reviewers 1, 2, and 3 are board certified in urology 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.