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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an electric wheelchair with height lift (Vision Super Heavy Duty mid wheel drive base with captain seat) (HCPCS K0825 and E2300). The records do not demonstrate that this patients mobility deficit is unable to be safely resolved with the use of an appropriately fitted walker or manual wheelchair. The patient has been using an ill-fitting rollator walker. The documentation does not include a complete neuromuscular examination of the upper extremities indicating strength or range of motion deficits to suggest that an appropriately fitted walker or manual wheelchair would not alleviate the patients mobility deficit. In addition, there is no evidence of any upper extremity pathology that would render this patient unable to use a manual wheelchair. The provider noted that the patient has poor left hand control due to pain in the wrist. However, this does not establish that the patient cannot safely operate a manual wheelchair or appropriately fitted walker. Moreover, the patient reports pain in the hips with standing and sitting, but there is no indication that the patient is unable to stand from a seated position to support an indication for a height lift. The patients lower extremity motor strength on medical progress reports is intact. Without evidence of failure of an appropriately fitted walker or manual wheelchair, the request for a power mobility device is not medically necessary. Therefore, the requested electric wheelchair with height lift (Vision Super Heavy Duty mid wheel drive base with captain seat) (HCPCS K0825 and E2300) is not medically necessary for 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 with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammaplex 60 gm/10% IV, to be administered 30 gm daily for 2 days, every 4 weeks for 12 months.The submitted documentation does not support that the requested medication is medically necessary. The hyper-IgE syndrome (HIES) is a primary immunodeficiency characterized by infections of the lung and skin, elevated serum IgE, and involvement of the soft and bony tissues. In this case, the diagnosis of hyper IgE syndrome is not verified. Although the patient does have evidence of elevated IgE at 1164, this alone is not diagnostic of hyper IgE syndrome, as this finding can be associated with many other clinical conditions. There is no documentation that the patient has had recurrent sinopulmonary infections or skin abscesses in the submitted records. In addition to the necessary clinical and laboratory findings, the identification of a genetic defect through molecular testing is necessary to confirm a diagnosis of hyper IgE syndrome, and this has not been documented to have been performed for the patient. Furthermore, the laboratory data in regard to Epstein-Barr virus (EBV) and Human Herpesvirus 6 (HHV-6) demonstrates prior infection or exposure through positive IgG values, which is common in the general population. There is no evidence of active or acute infection clinically or objectively. In addition, the use of intravenous immune globulin (IVIG) has not been shown to provide significant benefit to hyper IgE syndrome patients, except in those with lowered immunoglobulin levels or significantly lowered vaccine responses to protein and/or polysaccharide antigens, which medical records do not reveal to be the case in this patient. Accordingly, the requested Gammaplex 60 gm/10% IV, to be administered 30 gm daily for 2 days, every 4 weeks for 12 months is not medically necessary to treat the patients medical condition.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 both internal medicine and allergy and immunology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for home nursing care totaling 16 hours per day, seven days a week for a total of 112 hours per week. The records document that this patient has congenital myasthenic syndrome, a cause of neuromuscular dysfunction. He has chronic respiratory failure and dysphagia that requires a feeding tube. The documentation suggests that the patient has been medically stable. He does not have any complications with his tracheostomy or feeding tube and he has not experienced an acute exacerbation of a chronic medical problem. He is able to attend school and attend to activities of daily living. The Health Plan has approved eight hours a day of skilled home health care for pulmonary management. Given his medical stability, eight hours of day of home nursing care is an appropriate amount of services. He does not require skilled home health for custodial care or daily skilled care for feeding tube and medication administration. For these reasons, the requested home nursing care totaling 16 hours per day, seven days a week, for a total of 112 hours per week was not and is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient acute rehabilitation treatment. The records provided for review do not demonstrate that the complexity of the nursing, medical and rehabilitation needs of this patient require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require the intensity of an inpatient rehabilitation facility, in the absence of acute medical issues that require close physician or nursing supervision. The patients vital signs are stable and his laboratory results do not require intensive monitoring. The patients general medical condition was stable for transfer per documentation. The patient may benefit and will likely participate in additional therapy of physical therapy and occupational therapy, but the patients functional status does not require these services in an acute inpatient rehabilitation setting. All told, the requested inpatient acute rehabilitation treatment is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued inpatient hospitalization. The records provided for review document that this patient was admitted to the hospital with confusion and possible sepsis. He continues to receive IV antibiotics for discitis of L4-5 and possible C4-5. His confusion was determined to be due to hepatic encephalopathy with delirium and weakness. At the time of admission, it was unclear if the patient had ongoing sepsis due to the discitis or another cause. The providers recommended continuing the patient on IV Cefazolin for six additional weeks. He did not have any active bleeding but was persistently anemic and therefore received a transfusion of one unit of blood. The patients white blood count was normal and there were no significant electrolyte disturbances. The patient was confused and having visual hallucinations. He was treated for possible Wernicke encephalopathy with high dose thiamine. He slowly had improved by the time of proposed discharge from the hospital. The patient was hemodynamically stable and afebrile. He was voiding appropriately and tolerating an oral diet. He no longer has a need for IV fluids and has a peripherally inserted central catheter (PICC) line for administration of antibiotics. He continues to have vague complaints of pain treated with oral medications. Treatment with Abilify has helped improve the patients mood and confusion. Recent progress notes indicate that the patient has been at the same baseline with confusion for the last couple of weeks, but he is more cooperative with Abilify and he has been participating with physical therapy. The patient was hemodynamically stable. He was voiding appropriately and was tolerating oral pain medications and an oral diet. He continues to require IV antibiotics and skilled rehabilitation services for continued weakness. However, these services can be provided at a lower level of care. All told, the requested continued inpatient hospitalization is not medically necessary for 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 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: An enrollee has requested reimbursement for cold cap (scalp cooling) therapy.The submitted documentation supports that the services at issue were medically necessary. Chemotherapy induced alopecia is a well-known side effect of taxane-based chemotherapy as well as anthracycline based treatments. In one study, about 80% of patients (80/98) had persistent alopecia from taxane therapy. Since alopecia is a known side effect from taxane based chemotherapy, the condition has its own diagnosis and treatment. The SCALP randomized clinical trial concluded that patients who underwent scalp cooling were more likely to have less than 50% hair loss after the 4th chemotherapy cycle compared with those who received no scalp cooling. In this case, the patient had taxane-based chemotherapy. Cold cap (scalp cooling) therapy thereby countered chemotherapy induced alopecia, one of the known side effects of taxane-based chemotherapy that impacts quality of life and mental well-being. Under these circumstances, cold cap (scalp cooling) therapy was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 dermatology 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 physical therapy two times a week for six weeks. This patient has shoulder and right knee pain. She has been diagnosed with maltracking of the right patella and right patellar chondromalacia. Management of patellofemoral pain syndromes is challenging, with high rates of persistent symptoms despite extended follow up. The mainstays of management include quadriceps strengthening and stretching. There is no proven benefit of bracing. Surgical interventions in this clinical setting include measures to optimize patellar tracking including lateral retinacula lengthening or release. The patient in this case underwent right knee surgery that included lateral retinacular release and tricompartmental synovectomy. She has been undergoing physical therapy for a long time but her knee pain has persisted. There are no documented specific goals of the proposed additional physical therapy. She has functional range of motion and normal strength about the knee. The patient has been trained in a home exercise program and there are no impairments precluding transition to an independent program. Although she has persistent symptoms, there is no expectation that further physical therapy would improve the patients outcomes over an independent program. Therefore, the requested physical therapy two times a week for six weeks is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the cervical spine.The submitted documentation supports that the requested services are medically necessary. Evidence based medical guideline criteria state that MRI is usually appropriate for patients with new or increasing cervical radiculopathy and for patients with chronic neck pain when radiographs show degenerative changes, and particularly after failure of conservative management or when surgery is contemplated, for operative planning. In this case, the patient presents with a history of neck and left shoulder pain. He reports increasing neck pain, headaches, and left upper extremity pain, weakness, numbness and tingling. Functional limitations are now reported affecting his work ability. There is prior imaging evidence of significant spinal degenerative changes with nerve root compromise and potential cord compromise. The patient is reportedly ready to pursue surgical intervention, which was previously recommended but delayed. He has failed long-term conservative treatment, including physical therapy, activity modification, injection therapy, and medications. He has been referred for neurosurgical consultation and a pre-consult updated cervical spine MRI is required by the neurosurgeon. Under these circumstances, the requested Magnetic Resonance Imaging (MRI) of the cervical spine is medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for group speech therapy for an hour, once a week and after school hours. Researchers  recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. The authors noted that further development of therapy plans and interventions targeting pragmatics is lacking. At present, per the description by the patients speech provider of his behavior, the requested group speech therapy is not medically necessary. While he should benefit from continued individual speech therapy, his behavior is not conducive to him benefitting from group speech therapy. His behavior is also likely to be disruptive to other children in the group speech therapy session. The provider reports that the patient has limited joint attention and his inability to be present prevent him from participating and being successful in a social learning group. The patient has also demonstrating grabbing behaviors that are interfering with the therapy process. With continued applied behavioral analysis (ABA) therapy and individual speech therapy, the patients behavior and verbal ability may improve to the extent that he may benefit from group speech therapy in the future. For these reasons, the requested group speech therapy for an hour, once a week and after school hours, is not medically necessary for 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 neurology with special qualification in child 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Korlym 300 mg tablets. Korlym is a glucocorticoid receptor antagonist approved by the U.S. Food and Drug Administration (FDA) for use in Cushings syndrome to control hyperglycemia in patients who are not surgical candidates. In this case, the diagnosis of Cushings syndrome has not been established. The patient has features suggestive of Cushings syndrome, but none of the signs or symptoms are characteristic of the syndrome. The patient is obese, she is under stress, and she has a diagnosis of major depression. The medical records showed no cortisol level results to support the presence of hypercortisolemia. There are two overnight dexamethasone tests with normal suppressed cortisol, adrenocorticotropic hormone (ACTH), and nighttime salivary cortisol. A computed tomography (CT) of the adrenals was normal without evidence of adenoma and the patient has normal prolactin levels. Given these findings, the patient does not meet the diagnostic criteria for endogenous Cushings syndrome. Accordingly, the requested Korlym 300 mg tablets are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Prolia injections. The enrollee has osteoporosis, osteoarthritis, and rheumatoid arthritis. She is on high doses of prednisone. Her medical history includes a diagnosis of glioma. A progress note indicated the enrollee has pain in multiple joints and her back. She has difficulty holding things and difficulty maneuvering. She reports muscle cramping. Records show the enrollees calcium level was 8.8. The assessment indicated age-related osteoporosis without current pathological fracture. She was prescribed Prolia, 60 nanograms per milliliter injections, to be given every six months. The physician indicates the enrollee cannot take bisphosphonates as she has had side effects, with very high creatine phosphokinase levels. The physician reports the enrollee is at high risk for fracture. Literature reports chronic glucocorticoid use causes bone loss; therefore, treatment with Prolia is justified, even if the enrollee only has osteopenia. Literature shows Prolia is approved for steroid-induced osteoporosis, and provides better improvement in bone density than bisphosphonates. Studies show denosumab significantly increased lumbar spine and hip bone mineral density, when compared to bisphosphonates.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 endocrinology, diabetes 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 similar medical condition.