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

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested authorization and coverage for MRI cervical spine without contrast, MRI thoracic spine without contrast, and MRI lumbar spine without contrast. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees scoliosis. A review of the records indicates that the enrollee is diagnosed with adolescent idiopathic scoliosis. Visit notes, indicated the enrollee had no associated back pain, and an x-ray is reported to have shown scoliosis of the thoracic lumbar spine, which had progressed from prior x-rays. The provider recommended magnetic resonance imaging (MRI) to rule out neurologic cause for the curvature. The American College of Radiation states magnetic resonance imaging (MRI) of the spine is a powerful tool for the evaluation, assessment of severity, and follow-up of diseases of the spine. Spine MRI should be performed only for a valid medical reason. Congenital abnormalities of the spine and spinal cord can be detected in screening tests of scoliosis, in patients with clinical suspicion or incidentally. MRI of the entire spine can be used as a screening test for anomalies. The National Imaging Associates (NIA) guidelines state any combination of (Cervical/Thoracic/Lumbar MRIs) are supported for scoliosis survey in infant/child. In this case, the patient was diagnosed with adolescent idiopathic scoliosis. The pediatrician noticed this curvature in March 2018. The doctor is trying to rule out neurologic cause or a congenital anomaly such as tethered cord, which may result in increased scoliosis. `Congenital abnormalities of the spine and spinal cord can be detected in screening tests of scoliosis, in patients with clinical suspicion or incidentally. MRI of the entire spine can be used as a screening test for anomalies. Furthermore, the NIA guidelines state any combination of (Cervical/Thoracic/Lumbar MRIs) are supported for scoliosis survey in infant/child. As such, the requested MRI of the lumbar, thoracic, and cervical, without contrast would be considered medically necessary.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 physical medicine & 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: An enrollee has requested authorization and coverage for shoe inserts (custom molded orthotics). The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Walther and colleagues noted that supportive orthotics are superior to non-supportive orthotics regarding pain reduction in treatment of plantar fasciitis. This patient has been diagnosed with plantar fasciitis bilaterally, metatarsalgia bilaterally, pes planus foot structure with overpronation, and posterior tibial tendon dysfunction. Orthotics may be utilized to treat these ailments. However, the progress notes do not support the need for custom orthotics in this patients case, as there is no physical examination discussing type of heel pain, exact location of heel pain, or any forefoot pain. The records do not support the requested equipment in this clinical setting. Therefore, the requested shoe inserts (custom molded orthotics) are not medically necessary.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 podiatry 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 fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) and medications prescribed in relation to and in preparation for fertility preservation services. Egg retrieval and egg and/or embryo freezing (cryopreservation) is now a recognized option for patients who have cancer who are undergoing treatment that can render them infertile. This option allows these patients to have children in the future. These patients are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of the chemotherapy. This treatment is supported by the American Society of Reproductive Medicine. When chemotherapy is anticipated to damage or destroy the patients eggs, fertility preservation is medically necessary. Researchers noted that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting that sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice. In this patients case, the services at issue and medications at issue were medically indicated and a part of their cancer care. Therefore, fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) and medications prescribed in relation to and in preparation for fertility preservation services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue and medications 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 45-year-old female enrollee has requested authorization and coverage for a refill of Norco for treatment of the enrollees pain.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. Guidelines offer specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Per the current guidelines, the lowest possible dose should be used. Additionally, providers should document the patients response to pain medication, including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications.  In this patients case, it is not clear that the use of the prescribed opioid medication  decreased the level of pain the patient reported from one visit to the next. In addition, there was no noted functional improvement noted. The current medical evidence does not support the requested medication in this clinical setting. All told, the requested refill of Norco is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Genotropin injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees Idiopathic Short Stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. In this case, based upon the data provided, the patient does not satisfy the above criteria. While the patients height is more than 2.25 standard deviations (SDs) below the mean for his age and gender, and his growth velocity is poor, there is no documentation of a recent pubertal exam or bone age. There is also no documentation that all other causes of growth fall-off have been ruled out. The FDA has approved GH therapy for children with short stature who are predicted to reach an adult height of <63 inches in males and <59 inches in females, but without information on a recent bone age examination, an up-to-date estimation of final adult height cannot be made. Updated information on pubertal examination, lab data ruling out other causes of short stature, and a bone age assessment, are needed to determine the medical necessity of GH administration. Accordingly, Genotropin injections are not medically necessary for treatment of the enrollees medical condition at this time.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty in pediatric endocrinology 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 Byetta 5 mcg pen-injectors. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes. A review of the records indicates the enrollee is diagnosed with type 2 diabetes. The enrollee has stated that she has been taking Byetta for type 2 diabetes for 9 years. The submitted documentation does not support that the requested medication is medically necessary. The requested medication, Byetta, is a GLP-1 agonist and has a similar mechanism of action as others in its class such as Trulicity or Victoza. GLP-1 agonists like Byetta are FDA approved for use in type 2 diabetes. Head-to-head clinical studies by Trujillo and Madsbad and colleagues have demonstrated that all GLP-1 agents are effective therapeutic options at reducing A1C in subjects with type 2 diabetes. In this case, there is no indication why the patient cannot use other available GLP-1 agents such as Trulicity or Victoza, which have a similar therapeutic profile, nor is there documentation that the patient has tried and failed other such medications. Furthermore, medical literature does not support that Byetta is superior to other available GLP-1 agonists. Under these circumstances, Byetta is not medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A request for reimbursement was received for psychiatric emergency medical services per air ambulance that was provided from a medical center to an acute center for eating disorders. The Health Plan has denied the request indicating that the enrollee did not receive psychiatric emergency medical services. The records documented a history of hospital admission for diagnoses including anorexia nervosa, severe hypokalemia and severe protein malnutrition.  The enrollee was transported from inpatient care for urgent impatient medical admission later. Documentation shows the patients severe protein malnutrition, refeeding syndrome, and Wernickes encephalopathy had resolved at the time transport was planned. The patients electrocardiogram (EKG) was normal and vital signs were stabilized. The patient's laboratory values had all normalized and there was no evidence that this patient was grossly orthostatic. The patient did not meet the standard definition of urgency or emergency risk involved in transportation. There was no evidence that a psychiatric emergency condition would exist during transport that would make it necessary to transport the patient via air ambulance. Psychiatrically, the patient did not express suicidal or homicidal ideation, was not self-harming, and was not gravely disabled. There was no documentation that the patient was subject to falls on standard commercial transport that could not be adequately managed by a non-skilled companion travelling with them on a standard airline.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of a 6-year-old male enrollee has requested authorization and coverage for one-on-one speech therapy, for 30 minutes per week for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that review of the records indicates the enrollee has an individualized education program (IEP). The records note that while the enrollee has had speech services through his school district, his parent feels that he has made very minimal measurable progress with this program. The enrollee is reported to have limited verbal communication with others, which is noted as affecting his relationships with peers and school activities.The submitted documentation supports the medical necessity of the requested therapy. Intelligibility of speech can be markedly impaired in individuals with Down syndrome. Yoder and colleagues have described how speech comprehensibility is malleable in school-age students with Down syndrome. According to Barbosa and colleagues, adolescents with Down syndrome who have speech-language therapy during vocational training experienced positive changes in social behavior, as evidenced by an increase in their autonomy and communication. In this case, while the patient has received group-based speech therapy in his school program, he has been documented to have made great progress since he began one-on-one speech therapy on 5/24/18. The medical literature also supports the value of speech-language therapy for individuals with Down syndrome. Under these circumstances, the requested one-on-one speech therapy, for 30 minutes per week, is medically necessary for treatment of 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 pediatrics and 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: An enrollee has requested authorization and coverage for tramadol 50 mg, immediate release, 90 tablets for 90 days. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees restless leg syndrome.The submitted documentation does not support that the requested medication regimen is medically necessary. Recent practice guidelines on the management of RLS from the International Restless Legs Syndrome Study Group and the American Academy of Neurology do not readily indicate a role for narcotics in the management of RLS. Likewise, earlier guidelines from the American Acdademy of Sleep Medicine only made reference to the use of narcotics with a lower level of recommendation. Current practice guidelinse recommend the preferrential use of other agents as preferred therapies for the management of RLS. These other preferred agents also have more favorable safety profiles and greater bodies of literature to generally support their use. Under these circumstances, where current practice guidelines do not support the frequent use of narcotics in the management of RLS, the requested medication regimen of tramadol 50 mg, immediate release, 90 tablets per 90 days, is not medically necessary for treatment of the enrollees 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 neurology, with subspecialty certification in sleep 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: An enrollee has requested authorization and coverage for a Monosvisc Injection for the right knee. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees right knee osteoarthritis.The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. In addition, A reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use 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. As such, the requested Monovisc injection of the right knee is medically necessary for treatment of this patients right knee osteoarthritis. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an oral appliance. The Health Plan has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees mild obstructive sleep apnea (OSA).Current practice guidelines uniformly recommend the use of CPAP as the first-line of treatment for OSA. However, not all patients are tolerant of CPAP. In that setting it is generally agreed in clinical practice that the use of alternative therapies to CPAP be available and utilized in patients with OSA who do not tolerate or respond well to CPAP. In the medical literature researchers noted that a systematic review of the evidence has shown that oral appliances reduce AHI, arousal index, and oxygen desaturation index, and increase oxygen saturation; however, OAs have shown no significant effect on sleep architecture and sleep efficiency. The overall improvement in physiologic sleep parameters with the use of OAs in adult patients with OSA should result in an improvement in daily function and quality of life. In this case, the records provided for review contained a positive diagnosis based on the results of the home sleep testing that was performed. The patient had also previously had a trial of CPAP. In this setting, the provision of an oral appliance in this case was consistent with current practice guidelines and standard of care. Thus, the oral appliance was medically necessary for treatment of this patients OSA. 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 neurology with sub-specialty in sleep 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.