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 Latuda, 80 mg, quantity 105, being titrated up to 240 mg. Based on the clinical documentation provided, the patients diagnoses may include bipolar disorder with treatment-resistant depression, or schizoaffective disorder. The provider has diagnosed the patient with a bipolar spectrum illness, which supports treatment with a mood stabilizer, especially considering the patients residual symptoms are mood instability and anxiety. The patient is on Seroquel at a low dose, from which she has previously benefited. Concomitant treatment with multiple atypical antipsychotics is not recommended outside of a scenario of treatment-resistant schizophrenia in patients unable to tolerate clozapine. The U.S. Food and Drug Administration (FDA) has approved Latuda with a maximum dose of 160 mg daily Overall, the medical literature supports treatment with Latuda at a ceiling dose of 160 mg daily, which has been approved by the Health Plan. The records do not support an indication for Latuda dosed above the recommended maximum dose of 160 mg daily. Moreover, the requested Latuda dosing is not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of frequency. For these reasons, the requested Latuda 80 mg, quantity 105, being titrated up to 240 mg, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested authorization and coverage for Botox injections.Botulinum toxin injection is a spasticity /dystonia treatment modality commonly used in children with neurological disorders, such as cerebral palsy, stroke and multiple sclerosis. A study by researchers found that adding botulinum toxin A injections did not significantly enhance the goal to walk either flat foot or with heel strike at 24 months posttreatment. In this case, there is no diagnosis of hypertonia or neurological disorder. The patient has idiopathic toe walking and a family history of toe walking. Serial casting is a reasonable option; however, there is no indication for botulinum toxin injection based on current quality literature. Therefore, Botox injections are not medically necessary for the treatment of the patients 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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee's parent has requested authorization and coverage for physical therapy, once a week.Congenital muscular torticollis is a common deformity apparent shortly after birth characterized by one-sided cervical lateral flexion and opposite side cervical rotation due to shortening of the sternocleidomastoid muscle. According to medical literature, Outcomes are best when infants are diagnosed early and start comprehensive physical therapy management before three months of age. If untreated or treated after early infancy, congenital muscular torticollis (CMT) can lead to craniofacial deformities, cervical spine dysmorphism, and painful limited cervical motion, requiring more invasive interventions such as botulinum neurotoxin injections and surgery. In this case, the patient was brought to medical attention at two months of age and per the current standard of care was referred to physical therapy. The medical evidence supports the requested services in this clinical setting. Therefore, physical therapy, once a week, is medically necessary for the 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 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 skilled nursing facility services from month-to-month and physical therapy services five times per week from month-to-month.The submitted documentation fails to demonstrate the medical necessity of the requested services. The patient has a history of chronic spinal cord injury. The primary goals of rehabilitation in this clinical setting are to maximize function, given the impairments. This patients lower limb strength is below the antigravity level. This is not a level of strength consistent with functional ambulation. He has been undergoing physical therapy at the skilled nursing facility but has remained at an essentially stable functional level of supervision for self-care, independence with wheelchair mobility, and nonfunctional short-distance ambulation. There is no medical necessity for further therapy services as he is at his functional baseline. Therefore, skilled nursing facility services from month-to-month and physical therapy services five times per week from month-to-month 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 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: The patient has requested authorization and coverage for da Vinci robotic-assisted mitral valve repair. The records provided for review document that this patient has undergone a thorough work-up and findings have been consistent with mitral valve regurgitation. Based on the current information, the patient is a candidate for mitral valve repair. However, multiple approaches for mitral valve repair exist including full sternotomy, partial sternotomy, or a thoracotomy with da Vinci robotic assistance. Although the patient has requested the provider use the da Vinci robot for assistance in the mitral valve procedure, the medical literature has not established that this technique is medically necessary for use in this patients clinical setting in lieu of sternotomy. All told, the requested da Vinci robotic-assisted mitral valve repair is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in thoracic 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 Intracept procedure at L3-S1. This patient presents with chronic midline low back pain and bilateral sciatica. Recent imaging revealed multilevel disc desiccation and disc height loss as well as Modic endplate changes. Treatment over the last six months has included Norco, non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, and epidural steroid injections without adequate symptomatic relief. The provider has recommended the Intracept procedure at L3-S1. A review of the peer-reviewed medical literature suggests that the Intracept procedure has been demonstrated to be safe and effective for the treatment of patients with vertebrogenic pain who have failed conservative treatment modalities. De Vivo and colleagues reported successful treatment at three- and 12-month follow-up. The authors noted that clinical success was achieved in 54 of 56 patients for pain and disability. Similar results were reported by Khalil and colleagues, who concluded that, minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of pain and function at three-months in patients with chronic vertebrogenic related low back pain. Given this support, the requested Intracept procedure at L3-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Intracept procedure at L3-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 orthopedic surgery 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:  An enrollee has requested authorization and coverage for consultation with an endocrinologist.Singhi and Saini stated that syncope is not a disease in itself but a symptom of an underlying disorder; hence, children with syncope require assessment to exclude an underlying life-threatening cardiac or non-cardiac disorder. Syncope describes a sudden and brief transient loss of consciousness (TLOC) with postural failure due to cerebral global hypoperfusion. The term TLOC is used when the cause is either unrelated to cerebral hypoperfusion or is unknown. According to Bassetti, the most common causes of syncopal TLOC include cardiogenic syncope (cardiac arrhythmias, structural cardiac diseases, others), orthostatic hypotension (due to drugs, hypovolemia, primary or secondary autonomic failure, others), and neurally mediated syncope (cardioinhibitory, vasodepressor, and mixed forms). Rarely, neurologic disorders (such as epilepsy, transient ischemic attacks, and the subclavian steal syndrome) can lead to cerebral hypoperfusion and syncope. Non-syncopal TLOC may be due to neurologic (epilepsy, sleep attacks, and other states with fluctuating vigilance), medical (hypoglycemia, drugs), psychiatric, or post-traumatic disorders. In this case, the patient has had two syncopal episodes that are possible of non-cardiac origin per cardiology evaluation. The patient has been evaluated by multiple specialists for different problems. He does not have diabetes. However, the diagnosis of hypoglycemia as a cause of syncope has not been ruled out. An endocrinology evaluation to rule out reactive hypoglycemia as a cause of syncope and pre-syncopal symptoms is reasonable. Therefore, the requested consultation with an endocrinologist is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Diclegis.Nausea and vomiting are common symptoms associated with early pregnancy. Hyperemesis gravidarum is defined as severe vomiting resulting in hypovolemia and weight loss and is less frequent. Symptom severity and impact on quality of life largely dictates the management options for nausea and vomiting. Treatment approaches include dietary/lifestyle changes, prescribed medication, and, if needed, hospitalization for parenteral fluids for patients who fail to respond to outpatient management. The American College of Obstetrics and Gynecology supports combination doxylamine-pyridoxine when other treatments fail to improve symptoms. Formulations of doxylamine-pyridoxine are available under various names, including Diclegis. Combination doxylamine-pyridoxine has been shown to be effective for the treatment of nausea and vomiting of pregnancy, and the combination appears to be more effective than either drug alone. There is sufficient support for the requested medication in this clinical setting. Therefore, Diclegis is medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for auditory rehabilitation services once a week. The records provided for review document that this patient presents with hearing impairment status post placement of cochlear implants. The patients provider has recommended auditory rehabilitation services to help the patient achieve functional hearing and avoid development of a long-term communication disorder. Dazert and colleagues reported that, Hearing impairment that is too severe to be adequately treated with conventional hearing aids can lead, in children, to severe developmental disturbances of hearing and language, and, in adults, to communicative and social deprivation. Pediatric cochlear implant patients tend to be delayed in communication skills. Auditory rehabilitation will help close the gap between patients with cochlear implants and those without cochlear implants. Given this support, the requested auditory rehabilitation services once a week 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 otolaryngology 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 proton beam radiation therapy services. The submitted documentation does not support the medical necessity of the requested services. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of prostate cancer. Vapiwala and colleagues report that in a large, multi-institutional analysis of 1,850 patients with early-stage prostate cancer, treatment with moderately hypofractionated intensity-modulated radiation therapy and proton beam therapy both resulted in low rates of toxicity. The authors further noted that no difference was seen in late genitourinary and gastrointestinal toxicity between the modalities during long-term follow-up. The American Society of Radiation Oncology (ASTRO) notes, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. In this clinical setting, given the lack of evidence to support the use of proton beam therapy, the requested services are not medically indicated. Therefore, proton beam radiation therapy services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 home health nursing visits of 30 minutes once a week.Medical literature stated, Patients outcomes who managed with VAC therapy were better than the other group who managed with the traditional wound dressing. Medical literature also stated, VAC was more effective than wet to moist dressings in terms of reduction in wound surface, depth and degree of granulation tissue formation. VACs thus can be usefully employed for achieving speedy wound healing. In this case, the patient underwent VAC therapy for treatment after evacuation of the infected hematoma of his right lower leg. During the VAC application, he was reported to have difficulty with activities of daily living and to require an assistive device, special transportation, or another person to leave home. The wound VAC was discontinued after an evaluation by the provider stated that wound VAC was no longer necessary. The patient required home health care when he was disabled from a VAC on his leg wound because he had difficulty with activities of daily living and required an assistive device, special transportation, or another person to leave home. The VAC was able to be discontinued in mid-April 2021. While the wound was not completely healed, there is no report or documentation that he continued to have difficulty with activities of daily living, was unable to change his dressings, or was unable to attend physician visits for wound care. Therefore, the requested home health nursing visits of 30 minutes once a week are not medically necessary to treat the patients 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xifaxan.Scarpellini and colleagues state that Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. In a study by Scarpellini and colleagues, bacterial overgrowth eradication was demonstrated in 80% of patients taking Xifaxan versus 54% for patients taking a placebo. Additionally, the medication has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones, according to Lauritano and colleagues. Results are sustained for several weeks after treatment. More recent studies have corroborated these findings, including in patients with a positive breath test for SIBO. In this case, the patient has SIBO documented with testing, and has persistent associated symptoms. For these reasons, the requested Xifaxan is medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.