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

Nature of Statutory Criteria/Case Summary: The patient has requested skilled nursing facility (SNF) services. Findings:  The physician reviewer found that the records provided for review document that the patients medical condition has stabilized and he is ready for discharge from the hospital. He does not require skilled nursing or skilled therapy services on a daily basis. Although further rehabilitation services are appropriate to improve function, the daily skilled services can be provided at a lower level of care than a SNF. All told, admission to a SNF for inpatient skilled rehabilitation services is not medically necessary for treatment of this 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 internal medicine with expertise in skilled nursing facilities 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 is a 60-year-old male diagnosed with osteoarthritis (OA) of the left knee. The patient endorsed left knee pain for over six months. He has tried and failed physical therapy, analgesics, non-steroidal anti-inflammatory drugs, bracing, and corticosteroid injections. The patient reported difficulty sleeping due to pain. The patients provider reported that total knee arthroplasty would be an option if all conservative options have failed. At issue in this case is whether Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition. Intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit to knee OA patients and without major safety concerns. IAHA offers one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, gain in quality-adjusted life years and substantial delays in time to total knee replacement. Viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and for patients where conservative treatment has failed and the options are limited. In this case, standard treatments have been tried and failed with the alternative treatment being a total knee arthroplasty. Therefore, Euflexxa injections for the left 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

Nature of Statutory Criteria/Case Summary: The patient is requesting for speech therapy services for their medical condition of autism. Findings:  The physician reviewer found that She has received speech therapy since at least 2014. In 2014, the patients score on the Expressive One-Word Picture Vocabulary Test (EOWPVT) was 89, with a test age equivalent of eight years 11 months. In 2016, the patients EOWPVT score was 130, with a test age equivalent 14 years eight months. Also in 2016, a Receptive One Word Picture Vocabulary Test (ROWPVT) score was 105, with a test age equivalent of 11 years two months. In 2018, the patients EOWPVT score was 78, with a test age equivalent of seven years one month and a ROWPVT score of 105, with a test age equivalent of 11 years two months. The patient received eight sessions of adult speech therapy in 2018. On 8/6/18, the patient could correctly identify opposites six of 10 times and identify the remaining four opposites with maximal prompting. She correctly answered seven out of 10 picture memory questions and three of six general information questions. The patients speech therapist recommended discharge from speech therapy and implementation of a home-based program. At issue in this case is whether the requested speech therapy services are medically necessary for treatment of the patients medical condition. The influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism, and further development of therapy plans and interventions targeting pragmatics is strongly needed. Most cases of specific language impairment are diagnosed in childhood. The patient has received speech therapy since at least 2014. She has not made consistent progress according to her scores on the EOWPVT and ROWPVT, and had a deterioration in her scores from 2016 to 2018, despite receiving speech therapy. Based on the current guidelines, home-based speech therapy is appropriate for this patient. Therefore, the requested speech therapy services are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, neurology with special qualification child neurology, and hospice and palliative 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage of a PET scan and prostate saturation biopsy that were performed.  Findings: Two physician reviewers found that in the current peer-reviewed medical literature, an author reported that positron emission tomography (PET) is a valuable imaging modality in prostate cancer. The authors noted that the main role for PET imaging is for restaging of patients with biochemical recurrence after radical prostatectomy or external beam radiotherapy. Gleason score and prostate-specific antigen value, doubling time, and velocity can influence positivity of PET. However, conventional imaging that includes bone scan and computed tomography (CT) scan remain the gold standard for evaluation in this clinical setting. Therefore, a repeat biopsy within a year and PET scan were not indicated.Final Result: The reviewers determined that the requested services were not likely to have been 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: This patient has a history of sleep apnea, gastroesophageal reflux disease (GERD), and degenerative joint disease (DJD). A psychological evaluation was obtained on 8/15/17 and did not reveal any obvious barriers to surgery.  A dietary evaluation was obtained on 1/22/18 and did not reveal any obvious barriers to surgery. A sleep study was performed on 1/15/19 and revealed moderate obstructive sleep apnea hypopnea with an apnea hypopnea index (AHI) of 22.3.  Progress notes dated 3/20/19 reported the patient is 64 inches tall and weighed 217 pounds, resulting in a body mass index (BMI) of 37.25 kg/m2. There is no medication for hypertension noted. The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy. At issue in this case is whether laparoscopic sleeve gastrectomy is medically necessary for treatment of the patients medical condition.There is sufficient support for the requested services in this clinical setting. Researchers noted Obesity continues to be a major public health problem in the United States, with more than one-third of adults considered obese in 2009-2010, as defined by a BMI greater than or equal to 30 kg/m2. Nonsurgical management can effectively induce 5%-10% weight loss and improve health in severely obese individuals resulting in cardio-metabolic benefit. Bariatric surgery procedures are indicated for patients with clinically severe obesity. This patient has a BMI of 37 kg/m2 and history of GERD and DJD. The records document sleep apnea with AHI of 22.3, indicating moderate sleep apnea consistent with a diagnosis of morbid obesity.  She completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, medical or behavioral barriers to surgery. The patient has failed dietary efforts at weight loss with her primary care provider.  Therefore, she meets standard nationally accepted criteria for bariatric surgery, including the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines.  Therefore, the requested laparoscopic sleeve gastrectomy is medically necessary for treatment of this patients medical condition.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 general surgery with expertise in bariatric 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The submitted documentation supports the medical necessity of the requested services. The first appropriate imaging for the evaluation of low back pain with radicular symptoms are lumbar radiographs. According to the American College of Radiology, if the pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually the appropriate examination. This patient has had low back pain with associated right radiculopathy symptoms. She failed conservative management, including physical therapy, chiropractic therapy and corticosteroid injection. MRI of the lumbar spine could change the patients management, which may include surgical intervention. Therefore, the requested MRI of the lumbar spine is medically necessary for the 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 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:  This enrollee was receiving Applied Behavioral Analysis (ABA) services due to his developmental delays in social interaction, communication, and maladaptive behaviors. After review of the medical records it was determined that Applied Behavioral Analysis is medically necessary. Multiple sources support that applied behavioral analysis is an appropriate and effective treatment behaviorally and educationally for autistic spectrum disorder individuals with social delays, language and communication delays, and difficulties in adaptive functioning.  Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and Child and Adolescent Psychiatry and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the esophageal pH monitoring. The records provided for review document that this patient had multiple symptoms consistent with laryngopharyngeal reflux, but these symptoms can be caused by other diseases which need to be ruled out. As noted in the medical literature, pH and impedance testing assess a patient for proximal acid and non-acid refluxes as a cause for symptoms. Impedance testing may be useful in evaluation of endoscopy-negative patients with complaints of heartburn or regurgitation despite proton pump inhibitor (PPI) therapy in whom documentation of nonacid reflux will alter clinical management. The American Society for Gastrointestinal Endoscopy (ASGE) states that when combined with pH testing, impedance can identify whether the refluxate is acidic, and can provide correlation between reflux episodes and symptoms to help guide management. This data can be useful in patients with persistent symptoms on PPI therapy who have nonacid reflux as a cause for symptoms. This patient has failed PPI therapy and had an unremarkable esophagogastroduodenoscopy in the past. Determination of whether the patients symptoms were caused by laryngopharyngeal acid or non-acid reflux was important in order to determine effective therapy and to avoid unsupported long-term use of PPI therapy. For these reasons, the esophageal pH monitoring was medically necessary for evaluation of this patients symptoms.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 internal medicine with subspecialty 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

The patient is a male with Bainbridge-Roper syndrome. Due to feeding difficulties, he has required gastrostomy tube feedings. He has been receiving occupational and speech therapy to assist with oral feedings and is now taking a substantial amount of his calories by mouth. His tube feeds are made at home and blenderized. Per the providers notes, the patient was receiving a total of 16 ounces per day of blenderized tube feedings. Another provider has recommended Nourish formula, 48 ounces per day. In a letter, one provider stated the patient would benefit from liquid Nourish to help advance his nutrition. The use of powder introduces a lot of air, which causes distention and discomfort. At issue in this case is whether 48 ounces of Nourish Liquid Formula, every 24 hours, for a 12-month period (preferred), or any serving of Nourish Liquid Formula every 24 hours, is medically necessary for treatment of this patient. Blenderized tube feedings have been found to be helpful for a variety of gastrointestinal symptoms in tube-fed patients and are being used with increasing frequency. Blenderized tube feedings require access to equipment for both refrigeration and blending of feeds. The records provided for review document that this patient is receiving 16 ounces per day of blenderized tube feedings. He has been receiving occupational and speech therapy to assist with oral feedings and is now taking a substantial amount of his calories by mouth. As the patient is tolerating more oral intake, Nourish Liquid Formula is not required on a daily basis, and would only be expected to be needed a few times per month. As such, the requested 48 ounces of Nourish Liquid Formula, every 24 hours, for a 12-month period (preferred), or any serving of Nourish Liquid Formula every 24 hours is not medically necessary for treatment of this 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 pediatric 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: An enrollee has requested authorization and coverage for ganglion impar block.The patient has chronic pelvic pain, and the records noted pain in the rectum, vagina, and coccyx areas. Her pain is not localized. Therefore, treatment with ganglion impar block is likely to be inadequate. Coccydynia has been treated with ganglion impar block. The ganglion impar is a midline sympathetic ganglion located just anterior to the upper coccyx. Support for this treatment has only been demonstrated through case series. Medical literature evaluated a series of 22 patients with persistent coccydynia that failed to respond to initial conservative treatments. The researchers found that ganglion impar injection successfully provided greater than 50 percent relief in 82 percent of patients, with a mean duration of relief of six months. Although these results are promising, this treatment is not standard of care. At this time, further trials performed at a larger scale are needed. Therefore, the requested ganglion impar block 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 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

The patient is a male diagnosed with hypoglycemia. The patient reported several episodes of hypoglycemia. The patients provider noted that on review of the patients blood glucose readings and food log, his hypoglycemia was likely due to a previous gastric bypass procedure. The patient has requested coverage for a Freestyle Libre continuous glucose monitoring system. The Health Plan denied the request and reported the requested device is not medically necessary for the evaluation of this patient. At issue in this case is whether a Freestyle Libre continuous glucose monitoring system is medically necessary for the evaluation of this patients medical condition. Hypoglycemia is an increasingly common complication of bariatric surgery that may result in mild to severe adverse health consequences. A continuous glucose monitoring system (CGMS) is a U.S. Food and Drug Administration (FDA) approved device that records blood sugar levels at repeated intervals throughout the day and night. The Freestyle Libre is a new CGMS with a demonstrated reduction in hypoglycemic events for patients with diabetes. Although the FreeStyle Libre is currently FDA approved for patients with diabetes, it is helpful for detecting hypoglycemia for patients at risk for developing life-threatening hypoglycemia as well. Medical evidence supports the requested device in this clinical setting. Therefore, a Freestyle Libre CGMS is medically necessary for the evaluation 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.