Persius/hicric huggingface dataset:
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 exome sequence analysis. Exome sequencing is a comprehensive test that identifies changes in a patients DNA that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing will analyze the exons or coding regions of over 20,000 genes. Errors occur in DNA sequences causing genetic disorders are located in the exons. Exome sequencing is a diagnostic test with high sensitivity and specificity. Thus, sequencing the exome is an effective method of analyzing a patients DNA to determine the genetic cause of disease or disability. Neurodevelopmental disorders are often complex clinical scenarios attributable to single-gene mutations at more than 1,000 different loci within the genome. In a study found the 119 children affected by neurodevelopmental disorders who underwent exome sequencing, 45% received a molecular diagnoses leading to a change in the clinical care or impression of the pathophysiology. In a retrospective a of, 78 patients with neurodevelopmental disabilities and unrevealing work-up underwent testing with exome sequencing. The results yielded a presumptive diagnostic rate of 41%. In this case, several prior genetic studies have been conducted, all of which failed to reveal a unifying molecular diagnosis to guide treatment and surveillance strategies. The American College of Medical Genetics and Genomics support a role for whole exome sequencing for this patient. Therefore, the requested exome sequence analysis 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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

A patient has requested authorization and coverage for Amitiza 8 mcg capsules. Findings: The physician reviewer found that all patients with predisposing factors should be considered for prophylactic laxative therapy when opioid treatment is initiated. Conventionally, this is accomplished with a contact cathartic (such as senna), with or without a stool softener, or daily administration of an osmotic laxative (such as lactulose). All patients should be encouraged to increase fluid intake, mobility, and dietary fiber. There are numerous options for laxative therapy and no data to suggest that any one approach is superior to any other. In a systematic review of management of opioid induced constipation in a population with advanced illness, four randomized trials comparing different kinds of laxatives showed no significant differences among them.  In this case, the submitted medical records reflect that the patient has a predisposing factor for constipation because of the use of other constipating drugs. The submitted records do not reflect, however, that the patient has had prophylactic laxative therapy by a contact cathartic or an osmotic laxative. Under these circumstances, 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for in home nursing care services (CPT S9124) at a frequency of 40 hours per week. The enrollee has spinal muscular atrophy and acute and chronic respiratory failure.  She is dependent with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and is on feeding and aspiration precautions. She is at risk for skin breakdown due to her immobility, is wheel-chair bound and requires total care.  She was hospitalized for respiratory failure.  She cannot reposition herself; increasing her risk for decubitus ulcers. She requires multiple respiratory interventions throughout the day, such as supplemental oxygen when she desaturates, continuous pulse oximetry, nebulizer treatments and a CoughAssist machine to help expand her lungs and clear airway secretions. She uses a bi-level positive airway pressure (BIPAP) during the night, while asleep. According to the medical literature, private duty nursing services are considered medically necessary for patients who are confined to the home, the services are being provided under the treating practitioner's plan of care, and the services being provided require the professional proficiency skills of an RN or LPN/LVN and are not considered custodial in nature. Skilled services are services that have the potential to change a patients condition and require the knowledge and skill to identify and evaluate the patients need for possible modification of treatment or initiation of additional medical procedures until the patients clinical condition and/or treatment regimen have stabilized. The documentation indicates the enrollee was receiving care to include  vital signs, monitoring with pulse oximeter checks, nebulizer medications, cough assist care, BiPAP use, and supplemental oxygen when the enrollee desaturates.  There was insufficient evidence in the record the enrollee required services that could only be provided by skilled personnel, such as RNs or LPN/LVNs, after proper teaching.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and pediatric rehabilitation 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Optical Coherence Tomography (OCT) scan . The enrollee was diagnosed with corneal ectasia of the right eye (OD) and complaints of blurry vision.  He has a history of Radial Keratotomy (RK) OD 20 years prior.  The enrollee underwent OCT. Ectasia was confirmed; on exam, with tomography, and with anterior segment Optical Coherence Tomography (OCT).  There was significant thinning at the point of max ectasia; therefore, he is not a candidate for crosslinking. His ophthalmologist noted the enrollee would need a cornea transplant and cataract extraction OD; likely within the next five years.  The physician recommended cornea evaluation annually.  The enrollee was provided with a scleral lens, OD, for visual rehab. The medical literature describes the OCT scan as providing high definition, cross-sectional images of the cornea, angle, anterior chamber, and anterior lens.  This technique can provide imaging of retrocorneal structures.  It can be used to assess LASIK flap thickness in post-refractive ectasia. Studies show the OCT can aid in evaluating eyes with abnormal topography and in the differentiation between keratoconus and non-ectatic conditions. Literature shows the use of spectral domain OCT demonstrated significant differences in regional corneal epithelial thickness profiles in eyes with keratoconus and postoperative corneal ectasia compared to normal eyes. The technique provides information on corneal pathology; which can lead to improved diagnosis, classification and monitoring of the progression of corneal diseases. Studies have determined OCT can provide improved guidance over conventional tomography for treatment planning in post-refractive surgery for ectasia. Literature also shows anterior segment OCT can provide topographic maps of both the total cornea and the corneal epithelium, which allows for detecting the earliest changes in corneal stromal thickness.  Anterior segment OCT offers more comprehensive imaging than ultrasound pachymetry.  Anterior segment OCT provides highly repeatable pachymetry map measurements. Additionally, OCT images can provide information on corneal microarchitecture and regional epithelial thickness.  Central epithelial thickness is often significantly thinner in eyes with ectasia and is overall more variable and irregular in ectatic eyes as compared with normal controls, which possibly contribute to changes in corneal topographic values.  Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Ophthalmology and are actively practicing.  All three 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 parent of an enrollee has requested authorization and coverage for ursodiol powder and compounded vancomycin HCL 900 mcg/mg (not less than, USP) powder.Very early onset inflammatory bowel disease (VEO-IBD) and primary sclerosing cholangitis (PSC) are both highly morbid conditions, with 30% of pediatric PSC patients requiring liver transplant within 10 years of diagnosis. There are currently no medications with an FDA indication for management of pediatric PSC, and other than the medications already trialed by the patient, there are no medications for VEO-IBD which do not cause systemic immunosuppression. The data on the use of vancomycin and/or ursodiol in these conditions are relatively sparse, but encouraging.In regard to ursodiol for PSC, a recent retrospective review of 263 pediatric PSC patients (Deneau, M., et al.) found that the ursodiol use was associated with normalization of lab studies (GGT) in 46% of patients within the first year of diagnosis. Furthermore, those who achieved GGT normalization had a 99% 5-year survival with native liver, compared to 77% in those whose GGT did not normalize. A smaller review of pediatric patients from two Italian centers (Ferrari, F., et al.) included 45 children with PSC. Patients were all treated with ursodiol, and some also received steroids and azathioprine for concurrent IBD. After a mean follow-up of 8.7 years, there was 93% survival with native liver. A randomized trial of ursodiol for pediatric PSC has completed recruitment but data are not yet available.Vancomycin has been found to be beneficial for both VEO-IBD and pediatric PSC. A small study of vancomycin in PSC (Davies, Y., et al.) showed improvement of GGT, liver enzymes and inflammatory markers in 14 children with PSC. Although a randomized controlled trial of vancomycin for pediatric PSC is still recruiting patients and does not yet have published results, this treatment is already in widespread clinical use. Vancomycin has been reported to be effective in the treatment of VEO-IBD, in combination with other antibiotics (gentamicin, amoxicillin, doxycycline, metronidazole, ciprofloxacin), presumably due to modulation of GI flora. One report showed vancomycin (with or without gentamicin) to induce sustained remission in 3 of 5 patients with severe refractory VEO-IBD (Lev-Tzion, R., et al.).The physician reviewer found that  the ongoing use of compounded vancomycin and ursodiol powder for this pediatric male patient with Crohns disease and primary sclerosing cholangitis is warranted. The medical literature supports the use of these medications to treat pediatric patients with VEO-IBD and PSC, and the patient has already demonstrated excellent response to these treatments. Under these circumstances, ursodiol powder and compounded vancomycin HCL 900 mcg/mg (not less than, USP) powder are medically necessary to treat the patients medical conditions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 76-year-old female who has been diagnosed with severe degenerative arthritis of the right knee and left knee. On 8/19/16, the records noted that a right knee cortisone injection was administered on 7/27/16, with minimal pain relief. The patient has also been treated with physical therapy and medications, including Tylenol, Naprosyn, and ibuprofen. On 2/26/19, the provider noted an x-ray of the left knee revealed evidence of severe degenerative arthritis of the patellofemoral joint. On 4/24/19, the patient reported that her knees were tender and sore. A left knee steroid injection was administered. The provider noted a Synvisc injection and knee replacement were considered. On 5/29/19, the provider prescribed a Synvisc One injection for the left knee. In an application for independent medical review dated 7/9/19, the patient reported receiving a Synvisc One injection in the right knee two-and-a-half years ago, and this was beneficial. The patient has requested authorization and coverage for a Synvisc One injection to the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc One injection to the left knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The physician reviewer found that Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. Furthermore, she benefitted from a viscosupplementation injection of her right knee in the past. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc One injection to the left knee is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement and authorization and coverage for in-home nursing care, 40 hours a week. The enrollee has spinal muscular atrophy (SMA) and kyphoscoliosis secondary to SMAHer anatomic deformity and disability due to her SMA have compromised her respiratory status causing acute respiratory failure (ARF), which is chronic and requires daily pulmonary care to prevent reoccurrence of ARF. Placement of a CoughAssist device and a BiPAP machine does not require skilled nursing. The records indicate the skilled staff assist with performance of comfort and companionship, bathing, grooming, dressing daily, oral hygiene daily, shopping, laundry, meal preparation and assistance eating, housekeeping, privacy, and safety and security, which would be considered activities of daily living at the direction of the enrollee/family. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and pediatric rehabilitation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 28-year-old male who was diagnosed with an overactive bladder (OAB). On 3/27/19, the patient was noted to have a one-year history of urinary frequency and urgency. He was provided with Myrbetriq samples. On 4/30/19, the provider noted the patients voiding symptoms were essentially resolved with Myrbetriq. On 7/10/19, the provider noted the patient tried oxybutynin and Vesicare without success after Myrbetriq was denied. The patient reported voiding seven times during the day and four times at night. The patient also endorsed burning with urination and a strong uncontrollable urge to urinate. The patient has requested authorization and coverage for Myrbetriq 25 mg once daily. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Myrbetriq 25 mg once daily is medically necessary for the treatment of the patients medical condition. The 2019 American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) guidelines noted that the efficacy of mirabegron in patients who had used antimuscarinics compared to treatment-naive patients was similar across doses. Chapple and Siddiqui reported that mirabegron is established as an alternative monotherapy to antimuscarinics for the treatment of OAB symptoms. The authors noted that mirabegron has a favorable safety and tolerability profile compared with antimuscarinics. The physician reviewer found that mirabegron represents a new treatment option for a broad range of patients with OAB. In this case, the patient has failed treatment with Vesicare and oxybutynin. The medical evidence supports the requested medication in this clinical setting. Therefore, Myrbetriq 25 mg once daily is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting reimbursement for periprosthetic capsulectomy breast (breast implant removal). This enrollee has a history of breast augmentation with saline implants. The enrollee was satisfied with the procedure, and was doing well until about four years ago, when she started to experience what she reported as breast implant illness symptoms. A plastic surgery consultation note indicates the enrollee was concerned about anaplastic large cell lymphoma (ALCL), bilateral breast pain, and decline in health. She attributed her hormonal issues, trouble losing weight, joint pain, brain fog, migraines, blurry vision, abnormal labs, possible autoimmune, rashes, skin sensitivities, and extreme fatigue to her breast implant illness related symptoms. The enrollee felt her breasts were pulling on her muscles and tissue and the right breast seemed to be decreasing in size and shape making her believe there might be a small leak in her breast implant. However, physical exam did not support this finding as laboratory results and breast exam were both within normal limits. The record indicated the capsulectomy was the enrollees preference to decrease breast size. There were no results of a mammogram in the record. Breast implant illness associated with systemic harms, such as autoimmune disease has been reported for silicone but not for saline implants. The medical literature for breast implant illness and this enrollees history of saline implant does not support the enrollee having illnesses related to her breast implants. The physician reviewer found that  records provide insufficient evidence of evaluation by internal medicine, rheumatology or neurology specialists for her symptoms.  Additionally there are not any results of imaging or laboratory studies.  The enrollee was concerned about anaplastic large cell lymphoma (ALCL), but the records do not document she had textured implants.  Smooth implants have not been implicated in ALCL.  Peer studies do no support capsulectomies to prevent or treat a systemic inflammatory condition in this enrollees case.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for residential treatment center (RTC) services. He has a history of alcohol and benzodiazepine abuse. He started using Xanax and Klonopin daily. He has a history of seizures, a brain injury, post-traumatic stress disorder, post-concussion syndrome and hypertension. He entered a chemical dependency unit for detox, was placed on phenobarbital, completed detox and was discharged to a residential program. He left the residential program after a week but reverted to former alcohol consumption habits until he re-entered the chemical dependency unit. He successfully detoxed with Ativan and was discharged to residential treatment care (RTC) services. The admission assessment indicates post-acute withdrawal symptoms of anxiety, headache, anger, obsessive-compulsive thinking, depression, mood swings, cravings and panic. His admission diagnoses were alcohol dependency, uncomplicated; sedative, hypnotic or anxiolytic dependency, uncomplicated; major depressive disorder, single episode; and panic disorder. The progress note indicates agitation, cravings and a depressed feeling.  He had been experiencing some anxiety, was sweating and appeared paranoid. He successfully completed 30 days of residential treatment and was discharged for transition to sober living and an intensive outpatient psychiatric (IOP) program.  The physician reviewer found that  six dimensions of Level of Care Utilization System (LOCUS) include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the enrollees score is 3, due to continued alcohol abuse and benzodiazepine use. For functional status, the enrollees score is 3, due to the enrollees still working with chronic functional impairments. For comorbidity, the enrollees score is 3, due to alcohol abuse, benzodiazepine abuse and history of trauma. For recovery environment level of stress, the enrollees score is 3, due to maternal relationship acting as a trigger for addictive behavior. For recovery environment level of support, the enrollees score is 3, due to the enrollee having a sober friend who provides assistance. For treatment and recovery history, the enrollees score is 4, due to a history of relapse. For engagement and recovery status, the enrollees score is 3, due to the enrollee having limited engagement. The enrollees composite LOCUS score is 23, which correlates with residential treatment level of care.