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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for itraconazole. Oral antifungals such as itraconazole are indicated for the treatment of onychomycosis and also severe, recalcitrant, or widespread fungal infections of the skin. The U.S. Food and Drug Administration (FDA) has approved itraconazole for the treatment of dermatophyte infections. In this patients clinical setting, there is evidence of trichophyton rubrum (T. rubrum) dermatophytic fungus. Moreover, this diagnosis is supported by clinical examination, the photographs provided for review, and fungal culture data, which demonstrated T. rubrum, among other fungal organisms. Given these findings, itraconazole 100 mg capsules two capsules daily were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 dermatology with subspecialty certification in dermatopathology 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 Elite Seat patient-controlled end range of motion stretching device. Mechanical devices for flexion and extension are recommended as an option in conjunction with continued physical therapy when six weeks of physical therapy alone has been unsuccessful in adequately correcting range of motion limitations secondary to postoperative arthrofibrosis within three months of major knee surgery. The goal is to address specific range of motion limitations that cause functional limitations. In this case, the patient is status post a right anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft in January 2020. At the time of the request for this device, the patient was five months status post ACL surgery. While there are some limited evidenced based indications for this type of device, use is not supported beyond three months after knee surgery. The records do not support that the patient has a diagnosis of arthrofibrosis, which is the primary supported diagnosis for the Elite Seat device. High-quality research is lacking for indications other than postoperative arthrofibrosis. As such, the Elite Seat patient-controlled end range of motion stretching device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Elite Seat patient-controlled end range of motion stretching device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was 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 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: The patient has requested authorization and coverage for Monovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of excellent long-term relief with prior viscosupplementation, lasting over six months. The patients treatment options are limited. The patient has been treated with and failed multiple conservative treatments including bracing, taping, NSAIDs, physical therapy, and corticosteroid injections, with the alternative being bilateral total knee arthroplasties. Given these findings, the requested Monovisc injections in both knees 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for two pairs (4 units) of custom shoe inserts (for 6 total units/3 total pairs). Ahmed and colleagues note that in people with diabetes, offloading high-risk foot regions by optimizing footwear, or insoles, may prevent ulceration. The authors further note that custom-made insoles with metatarsal additions and a high degree of contact between the insole and foot reduce plantar pressures in a manner that may reduce ulcer occurrence. Patients are generally supplied with multiple custom diabetic shoe inserts and instructed to replace their inserts frequently, as the inserts are made of a soft, shock-absorbing material that wears out quickly, causing the insert to lose its effectiveness. In this case, the patient has a diagnosis of diabetes. Given that custom shoe inserts may help in the management of foot neuropathy, biomechanical changes of the foot, foot ulcerations, and lower extremity peripheral vascular disease in patients with diabetes, the requested equipment is medically indicated. Therefore, two pairs (4 units) of custom shoe inserts (for 6 total units/3 total pairs) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: The patient has requested authorization and coverage for Jardiance. Jardiance is a highly selective sodium glucose cotransporter-2 (SGLT2) inhibitor that has been demonstrated to be an effective and well tolerated antihyperglycemic agent (Frampton). The U.S. Food and Drug Administration (FDA) has approved Jardiance for the treatment of adults with type 2 diabetes. In addition to its glucose lowering benefits, recent data suggests that Jardiance may also be beneficial for patients with heart failure or kidney disease (Packer, et al.; Kelly, et al.). The records provided for review document that this patient has type 2 diabetes and a history of hypertension. He has not been able to tolerate treatment with metformin or Lipitor. This patient has not been able to tolerate two diabetic medications and he has a history of hypertension. In this clinical setting, Jardiance is supported as medically necessary. Given these findings, the requested Jardiance is 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 internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Zoll LifeVest wearable cardioverter defibrillator. The documented high risk of sudden cardiac death in patients with severely reduced left ventricle ejection fraction (LVEF) has led to the recommendation of implantable cardioverter defibrillators in this patient population. Current data from multiple trials have advocated the use of a Zoll LifeVest wearable cardioverter defibrillator for patients with an LVEF of 35% or less, along with guideline directed medical therapy. This patients LVEF was estimated at 30-35%. The recommended timing of placement of a LifeVest based on current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines is within 40 days of an acute myocardial infarction or within 90 days of guideline directed medical therapy for an initial diagnosis of congestive heart failure with a severely reduced LVEF. Per the guidelines, the Zoll LifeVest is appropriate for this patient for a period of 40 days. Therefore, the Zoll LifeVest wearable cardioverter defibrillator for a period of 40 days was and 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 Zoll LifeVest wearable cardioverter defibrillator for a period of 40 days was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the services at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fioricet. Findings: A study noted that there is a lack of data to support treatment with butalbital-containing agents in the treatment of patients with migraine. Similarly, another study found inadequate evidence for butalbital and butalbital combinations in the treatment of migraine in adult patients. Within the medical records available for review, there is documentation that this patient is undergoing treatment for chronic neck pain with a history of cervical spinal surgery. They also have a history of other chronic postprocedural pain, chronic pain syndrome, and dorsalgia. The provider indicated that Fioricet was recommended for the patients diagnosis of chronic pain. The patient has reportedly been treated with several medications for migraines without substantial improvement. However, there is a lack of support for a diagnosis of migraine in the records provided for review. Overall, the records do not support an indication for treatment with Fioricet. Therefore, the requested Fioricet is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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 acupuncture services. The submitted documentation supports the medical necessity of the requested services in this clinical setting. The records document a history of right shoulder pain. The patient has participated in physical therapy, but remains symptomatic. The clinical notes document loss of function. In this setting, an initial trial of acupuncture is medically appropriate. Given that the patient continues to be symptomatic despite prior treatment modalities, the requested acupuncture services are indicated for pain management and function improvement. Therefore, the requested acupuncture services are medically necessary for the 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 licensed acupuncturist, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Octagam intravenous immunoglobulin (IVIG). Findings: While the medical records do indicate low pneumococcal antibody titers for this patient, there is a lack of documentation of whether pneumovax was administered prior to checking the patients antibody titers and when the vaccine was administered in relation to the blood work. Without this information, the patients low antibody titers do not support an indication for treatment. Overall, this patient does not qualify for the diagnosis of specific antibody deficiency. Furthermore, the medical records report a history of recurrent infections. However, the records do not document a history of the type of specific infections that qualify for IVIG replacement therapy in the treatment of specific antibody deficiency. A history of small intestinal bacterial overgrowth (SIBO) and mast cell activation syndrome (MCAS) does not support an indication for IVIG treatment as these are not manifestations of specific antibody deficiency. Given these findings, the requested Octagam IVIG is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Veltassa. Findings:  The physician reviewer found that per (FDA), Veltassa is approved for the treatment of patients with hyperkalemia. However, this patients records do not document failure, intolerance, or contraindication to sodium polystyrene sulfonate for the treatment of hyperkalemia. The sodium in sodium polystyrene sulfonate is not absorbed and has not been found to increase blood pressure levels in patients with hypertension. In addition, there is a lack of documentation that the patient has failed treatment with a low potassium diet prior to consideration for treatment with Veltassa. All told, the requested Veltassa is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 an enrollee has requested reimbursement for intensive outpatient program services provided at The Feinberg Institute from 6/10/20 through 6/16/20.At issue is whether all or any of the intensive outpatient program services provided at The Feinberg Institute from 6/10/20 through 6/16/20 were medically necessary for treatment of the patients condition. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to recent passive suicidal ideation, urges to self-harm, emotional dysregulation during arguments with parents, and risky impulsive behavior. In terms of functional status, the records support a score of 3. The documentation noted moderate impairments in judgment due to social withdrawal, inconsistent school attendance, failure to complete school assignments, and conflict with parents.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to reported cannabis use in treatment, as well as depression, anxiety, ADHD, and PTSD. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to sexual assault and school difficulties.With regard to level of support of the recovery environment, the records support a score of 2 due to parents' active participation in treatment.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to inconsistent or equivocal capacity to deal with stressors and maintain normal development. With regard to treatment acceptance and engagement, the records support a score of 2 as the patient expressed motivation to treatment but some continued risky behaviors and emotional dysregulation.Thus, the patient has a total score of 19. In this case, the recommended level of care was high-intensity community-based services. This is consistent with the intensive outpatient (IOP) level of care that patient received at The Feinberg Institute. Therefore,  intensive outpatient program services provided at The Feinberg Institute from 6/10/20 through 6/16/20 were medically necessary for treatment of the patient.Final Result: The reviewer determined that the requested services 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 psychiatry with sub-specialty certification in child and adolescent 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: An enrollee has requested authorization and coverage for bilateral custom foot orthotics.Mortons neuroma is a benign neuroma or lesion of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces. Custom orthotics have been considered a standard of care treatment for Mortons neuroma for many years. Custom orthotics, specifically with a metatarsal raise pad, allow for alteration in the biomechanics of the foot, allowing for reduction in stress, strain, and pressure to the Mortons neuroma. Current studies advise that custom orthotics with a metatarsal raise pad are indeed efficacious and alter the biomechanics of the foot to allow for pain-free ambulation for patients with neuromas. In this case, physical examination and MRI evaluation demonstrate a painful neuroma to the second intermetatarsal space. The patient has failed numerous conservative treatments. There is sufficient support for the requested equipment in this clinical setting. Therefore, the requested bilateral custom foot orthotics are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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.