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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right definitive transtibial prosthesis. This patient underwent a transtibial amputation in July 2016.  He received a prosthesis in November 2016, and this was described as a preparatory prosthesis. The providers rationale for replacement of this prosthesis is need for replacement of both the socket and ankle foot mechanism, the former due to fitment issues, and the latter due to improper weight rating. In this patients case, the records support the need for a replacement socket. His current prosthetic socket is too large and beyond further modification.  Additional sock plies would not be appropriate. A replacement definitive socket is appropriate and necessary, and is the expected development at this stage due to significant residual limb shrinkage and maturation during the first one to two years post amputation.  A well-fitting socket is generally considered the most important aspect of a prosthesis.  The following codes in question are medically necessary for a replacement definitive socket: L5620 test socket, L5629 acrylic socket, L5637 total contact, L5647 suction socket, L5645 flexible inner socket, L5679 gel socket insert, L5670 supracondylar suspension and L5685 suspension sleeve.  An elevated vacuum suspension is not necessary.  The peer-reviewed literature has not established that elevated vacuum suspension systems are marginally more effective than properly fitted conventional pin suspension systems. There have been reports of reduced skin issues and better tolerance of pin suspension systems versus elevated vacuum suspension systems.  Elevated vacuum suspension systems may also reduce range of motion at the knee in the transtibial amputee. The records do not support the need for a complete replacement of the prosthesis beyond the socket. The current Ossur Talux foot with multiaxial ankle has a weight rating of up to 325 pounds, as per Ossur, not 256 pounds.  This is a prosthetic foot that is appropriate for the patients K3 activity level and appropriate for use for the long-term. Thus, L5620, L5629, L5637, L5647, L5645, L5679, L5670 and L5685 are medically necessary for the treatment of this patient. The remaining aspects of the requested device are not medically necessary.Final Result: The reviewer determined that that a portion of the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Evekeo. The records indicate that this patient has been treated with dextroamphetamine/amphetamine (Adderall XR), lisdexamfetamine (Vyvanse), methylphenidate (Concerta), and dexmethylphenidate (Focalin XR). Lisdexamfetamine is a prodrug of dextroamphetamine and is not active until after it has been absorbed and been converted to dextroamphetamine and l-lysine. Although the active drug in lisdexamfetamine and Dexedrine are the same, the delivery, dose, and duration of the dextroamphetamine is different. Due to this difference, a patient could have a negative therapeutic benefit from Vyvanse and a positive therapeutic benefit from Dexedrine. Therefore, the patient may respond to well Dexedrine. Moreover, there is a lack of literature supporting a superior effect of Evekeo over Dexedrine. Accordingly, the requested Evekeo is not supported as medically necessary for treatment of this 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen treatment for treatment of the enrollees hearing loss.  Findings:  The physician reviewer found that superior efficacy of this treatment modality lacks support in current medical literature. There is a lack of strong data to show that hyperbaric oxygen therapy is beneficial for treating sudden hearing loss. The use of hyperbaric oxygen therapy for Menieres disease remains of unproven benefit and is not likely to be more effective than the standard methods of treating sudden hearing loss. In addition, upon review of the most recent audiograms, they indicate the patient had very mild loss/normal hearing. In sum, hyperbaric oxygen treatment is not likely to be more efficacious than the available therapy for treating this patients medical condition.Final Result: All three reviewers have determined that the requested services are not likely to be more beneficial for treatment of your medical condition than any available standard therapy.Credentials/Qualifications:  All three reviewers are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for consultation with an orthopedic surgeon. Ankle injuries can be misdiagnosed with potentially devastating effects on future performance. As noted in the medical literature, inversion injuries of the ankle are the most common and may result in chronic instability requiring surgical reconstruction. In this case, the patient describes an injury in 2013 and subsequent recurring episodes of painful subluxations of the same ankle, which is typical of instability. Thus, a consultation with an orthopedic surgeon is appropriate due to the chronic instability with painful subluxations of the joint. A negative x-ray does not rule out instability. In light of the foregoing, the requested orthopedic surgeon consultation is medically necessary for further evaluation and treatment of this patients recurrent ankle sprains. 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 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: An enrollee has requested reimbursement for stroller repairs for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the patients stroller is the primary source of mobility that the patient uses. The patient is quadriplegic and has cerebral palsy. Thus, the use of the stroller is mandatory for proper transport of the patient for activities of daily living (ADLs) and for routine daily travel. Based on the review of the current medical literature, the stroller repairs provided were medically necessary for treatment of this 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a compound of levofloxacin and betamethasone. The Health Plan has denied this request indicating that the requested compounded medication is considered investigational for treatment of the enrollees chronic maxillary sinusitis.Findings: Three physician reviewers found that the record fails to establish the superior effectiveness of the requested compounded medication. This patients examination and computed tomography scan were non-diagnostic for chronic sinusitis. Per the records, there was resolution of the signs of disease. Based on the literature, nasal irrigation with topical medications is not supported as a primary treatment for chronic sinusitis. Therefore, the requested compound of levofloxacin and betamethasone is not likely to be of greater benefit than other treatment alternatives.Final Result: The reviewers determined that the requested compounded medication is 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 reviewers 1, 2 and 3 are board certified in otolaryngology 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: An enrollee has requested authorization and coverage for Prolia. Osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain. Osteopenia is a condition in which bone mineral density is lower than normal, and this is considered to be a precursor to osteoporosis. While osteopenia is typically treated with lifestyle modifications and adequate dietary intake of calcium and vitamin D, some medications, such as certain bisphosphonates, have also been approved for treatment. A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. However, Prolia has not been approved as treatment for osteopenia. Further, although she may not be able to tolerate oral bisphosphonate therapy, she does not have a contraindication to intravenous zoledronic acid. Therefore, Prolia is not medically necessary for the 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 internal medicine with sub-specialty certification 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 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 vaser water assisted liposuction and tumescent liposuction. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient underwent bilateral lower and upper extremity liposuction in 2015.  It is unclear to what degree the patient had benefited from this surgery. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema. However, a detailed examination supporting the requested services was not provided in this patients case. Additionally, the photographs do not show evidence of a significant condition, and the proportion of the enlargement cannot be determined as well. The patient has reported functional impairment of the lower extremities. However, there has not been sufficient supporting documentation from the requesting surgeon to demonstrate that additional liposuction is medically necessary.  Therefore, the requested vaser water assisted liposuction and tumescent liposuction are 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Xeljanz 5 mg tablets twice a day. The Health Plan has denied this request indicating that the requested medication regimen is considered investigational for treatment of the patients alopecia universalis. Findings: Three physician reviewers found that there is sufficient support for the requested medication regimen in this patients case. Systemic therapies are occasionally used for severe alopecia areata. A high likelihood of relapse, limited efficacy data, and the potential adverse effects of these drugs limit their use to refractory cases. The results of trials with standard therapies, such as glucocorticoids, sulfasalazine, azathioprine, and phototherapy, show poor rates of regrowth and are often limited by side effects. Researchers performed a retrospective study of 90 patients with alopecia universalis who were treated with tofacitinib (Xeljanz). The researchers noted 77% of patients with duration of current episode of disease of ten years or less achieved a clinical response. Thus, Xeljanz 5 mg tablets twice a day is likely to be more effective than other available treatment options.Final Result: The reviewers determined that the requested medication regimen is likely to be more beneficial for evaluation 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 dermatology 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: A female enrollee has requested authorization and coverage for Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient has longstanding symptoms which are limiting despite treatment with acetaminophen, ibuprofen and corticosteroid injection. Based on the available documentation, hyaluronic acid injection is a reasonable treatment option. All told, the requested Synvisc One injections are supported as medically necessary for treatment of this patients knee osteoarthritis.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 ***. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy. Findings:  Two of the three physician reviewers found that guidelines now endorse the use of intraoperative radiation therapy in the treatment of breast cancer. The patient meets the criteria for the use of intraoperative radiation for the treatment of breast cancer. Studies have shown intraoperative radiation therapy is equivalent to standard external beam radiation therapy, but is associated with less treatment visits, making it easier for the patient. Therefore, intraoperative radiation therapy is likely to be of greater benefit than other treatment options. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral keratoconus. Findings:  Based on the patients vision loss and progression, the cross-linking procedure was the most appropriate and effective treatment available. The medical literature supports the use of cross-linking in patients who are diagnosed with keratoconus and progression.  There is a strong body of evidence that shows corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is a lack of other treatment options available to slow or halt disease progression. As such, corneal collagen cross-linking procedure was likely to have been of greater benefit than the standard methods for the treatment of this patients medical condition. Final Result: Two of the three reviewers determined that services at issue were 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:  All 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wireless capsule test. Findings:  Three physician reviewers found capsule endoscopy was performed to evaluate for a possible small bowel polyp or tumor in a patient with known history of small bowel lesions and Peutz-Jeghers syndrome. According to the American Society for Gastrointestinal Endoscopy, evaluation for suspected small intestinal tumors is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging. Capsule endoscopy is reported as having high sensitivity in identifying small bowel tumors. Therefore, the wireless capsule test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the wireless capsule test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.