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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone-acetaminophen 5-325 mg tablets. Findings: Per the Centers for Disease Control and Prevention (CDC), Opioids should be used only when benefits for pain and function are expected to outweigh risks. The CDC recommends that prior to starting opioids, providers should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. The records provided for review document that this patient presents with postsurgical pain following shoulder replacement surgery in January 2022. The provider noted that the patient was on a low dose of hydrocodone-acetaminophen following the surgical procedure. The patient is reported to be participating in a medication monitoring program with his pain management groups with urine drug testing and controlled substance utilization report review. The available records support that the patient is participating in all of the opioid safety and monitoring procedures for opioid analgesic therapy consistent with the current CDC guidelines. Therefore, the requested hydrocodone-acetaminophen 5-325 mg tablets are 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 physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left 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 tried and failed other conservative treatments including physical therapy and corticosteroid injections have been tried without lasting benefit. In the absence of mechanical symptoms, arthroscopy is not indicated. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for the management of cardiac risk and dyslipidemia do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing, and homocysteine.  Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable by treatment based on standard risk factor profiling and basic lipid analysis. While results from of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data in controlled trials demonstrating outcome benefits from treating routinely obtained abnormal results. Therefore, advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the advanced lipoprotein testing at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. Findings:  The physician reviewer found that This patient has a history of major depression and has not responded to treatment with multiple classes of antidepressants, adjunctive brexpiprazole treatment, and psychotherapy. The patients provider has recommended treatment with TMS for treatment resistant depression. Multiple randomized controlled trials have demonstrated the safety and efficacy of repetitive TMS therapy for the management of patients with severe depression non-responsive to pharmacotherapy. In addition, the U.S. Food and Drug Administration (FDA) has approved the treatment of TMS for the management of patients who have not responded to one adequate antidepressant trial in the current depressive episode (Cohen, et al.). This FDA recommendation is consistent with treatment guidelines from the American Psychiatric Association (McClintock, et al.). Based on the current guidelines, this patient meets the criteria for treatment with TMS. Moreover, the requested TMS is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested TMS services are medically necessary for 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 psychiatry with subspecialty certification in preventive 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: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Findings:  The physician reviewer found that records provided for review document that this patient has a history of melanoma. Pathology revealed melanoma of 2.1 mm extending to the specimen periphery and base. The patient underwent testing with DecisionDx-Melanoma to assess for likelihood of metastasis and/or recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state that gene expression profiling tests may provide information on individual risk of recurrence, as an adjunct to standard American Joint Committee on Cancer (AJCC) staging for patients with melanoma (Chan, et al.). However, the currently available prognostic molecular techniques have not been demonstrated to yield superior health outcomes when compared to standard pathologic staging procedures. Moreover, the use of gene expression profiling requires further prospective evaluation in large, contemporary data sets of unselected patients. Overall, the DecisionDx-Melanoma genetic test would not have been recommended to change the management of this patients disease in lieu of standard risk profiling and testing. All told, the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for oximeter. The records indicate that this patient has a history of epilepsy status epilepticus. The available details of the seizures suggest that each episode involved at least five minutes of generalized tonic-clonic activity. The seizures occurred at night, during sleep, and lasted over 20 minutes. The patient also vomited during the first seizure. These features place the patient at increased risk of further life-threatening unwitnessed episodes of status epilepticus (Abdel-Mannan, et al; Keller, et al.). The patients mother has attempted use of an over-the-counter pulse oximeter, which is not remaining in place to allow for proper readings. The provider has recommended an oximeter for home use. In order to determine the value of pulse oximetry in detecting seizures, Goldenholz and colleagues evaluated 193 seizures among 45 patients. The authors found that blood oxygen saturation level (SpO2) thresholds of 80%-86% were able to detect 63%-73% of generalized convulsions and 20%-28% of focal seizures. Although routine use of at-home pulse oximetry to detect seizures is not supported in the medical literature, in this patients specific case the device is supported as medically necessary. A medical-grade pulse oximeter would alert the patients parent to seizure activity occurring during sleep, allowing intervention. The patients multiple risk factors including generalized tonic-clonic seizures with status epilepticus at night during sleep, apnea with hypoxemia, vomiting with the potential for aspiration, and obstructive sleep apnea with Pierre Robin sequence, place her at high risk of unnoticed status epilepticus. All told, the requested oximeter is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 neurology with special qualification in child neurology and expertise in neurodevelopmental disabilities and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electron beam computed tomography. In this case, the patient has significantly increased coronary risk. The American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, advanced lipoprotein analysis, genetic testing, and homocysteine. While the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data from controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable with treatment based on standard risk factor profiling and basic lipid analysis. Therefore, electron beam computed tomography is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested electron beam computed tomography is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensity modulated radiation therapy (IMRT). Findings: The National Comprehensive Cancer Network (NCCN) guidelines for the management of breast cancer endorse the routine use of IMRT in patients undergoing partial breast radiation. In this case, the patient underwent treatment to the partial breast with a high dose per fraction. Notes reported a total to ten daily treatments with a total dose of 40 Gy, approximately 4 Gy per fraction. In this clinical setting, IMRT can be utilized to improve sparing of the underlying structures including the surrounding uninvolved breast and chest wall and would be expected to be associated with a decrease in complications when compared to treatment with three-dimensional (3D) conformal techniques. Therefore, IMRT was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the IMRT was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture visits, once a week, for six to eight weeks. The available records support a diagnosis of left shoulder pain. The patient has requested treatment with acupuncture. Vickers and colleagues noted that, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. The authors concluded that, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. As this patient has continued to be symptomatic, an acupuncture trial for pain management and function improvement was indicated and supported by the peer-reviewed medical literature. Eleven acupuncture sessions were completed. According to the patient, the acupuncture completed was beneficial. Despite such statement, no pre-acupuncture, and post-acupuncture baselines (activities of daily living-range of motion-medication intake-function) were documented by the patient, the acupuncturist, or the medical practitioner for comparison purposes. After prior acupuncture (11 sessions) was completed, the records reviewed failed to document any measurable, progressive, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture to support the necessity of the additional acupuncture. As no current physical examination was documented, the clinical findings, including the deficits (motor-sensory-functional) to be addressed by the additional acupuncture treatments, are unknown. Therefore, the goals to be obtained with the additional acupuncture are unclear. Additionally, there is no clear documentation indicating whether the patient is consistently undergoing an independent exercise program (conditioning-aerobic-stretching exercise program based on the patients tolerance) concurrent with the acupuncture care, which is supported by the peer-reviewed literature to avoid deconditioning and dependency on passive care. Given these findings, the requested acupuncture visits, once a week, for six to eight weeks 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 a licensed L.Ac., board certified in oriental medicine and acupuncture, 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech therapy services with a speech/language therapist that uses American Sign Language (ASL) as opposed to speech therapy services with an ASL interpreter. The records provided for review document that this patient presents with moderately severe hearing loss up to 4000 Hz on the left and normal hearing in the right ear up to 4000 Hz. On testing, the patients high frequencies showed severe hearing loss. As noted in the medical literature, patients with hearing loss can benefit from speech therapy. However, there is a lack of support for this patient to receive speech therapy with a provider who can communicate ASL. Fitzpatrick and colleagues noted that insufficient, high-quality evidence exists to determine whether sign language in combination with oral language is more effective than oral language therapy alone. Overall, the available data suggest that a speech therapist with an ASL interpreter can adequately and effectively communicate with the patient. Therefore, the requested speech therapy services with a speech/language therapist that uses ASL as opposed to speech therapy services with an ASL interpreter are 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.