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 Euflexxa injections in the left knee. There is sufficient support for the requested services in this clinical setting. The records document mild osteoarthritis of both knees. The right knee was symptomatic in the past and responded to viscosupplementation, with resolution of the pain. The left knee has been symptomatic despite corticosteroid injections. An exhaustive review of the medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma and other agents to make it more effective. Viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this case, the patient had an excellent response to viscosupplementation of the right knee in the past. Furthermore, she has not responded to recent corticosteroid injections to her left knee. This patients options are limited, with the alternative being a total knee arthroplasty. Therefore, Euflexxa injections in the left knee 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 orthopedic surgeyr 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 and prospective authorization and coverage for acute inpatient hospitalization services.The submitted documentation supports that acute inpatient hospitalization was medically necessary for a period, however, it does not support admission beyond that date. During the approved period, the patient had persistent but intermittent vomiting attributed to excessive secretions. Records document that there was concern for a central cause for vomiting, such as brain tumor. The hematology-oncology consultation was warranted to evaluate the patient and an attempt of diphenhydramine to decrease secretions, which could address the root cause of vomiting. Once the patients hematology-oncology evaluation had been performed, the skilled nursing facility level of care would be appropriate for management of secretions and to prepare for the patients eventual transition to home, which the patient expressed a desire for on several occasions. No specific documentation is provided about further interventions which would require the inpatient level of care beyond past the approved dates. Therefore, acute inpatient hospitalization services were initially medically necessary to treat the patients medical condition. Later acute inpatient hospitalization services were not and are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the services at issue 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto. Entresto has been shown to be helpful in patients with Congestive Heart Failure despite treatment with optimal medical therapy. Based on the records, this patient has cardiomyopathy with reduced ejection fraction but no current heart failure symptoms or physical examination findings of congestive heart failure (CHF). Without evidence of CHF, the patient does not have an indication for Entresto. Entresto tablets are 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 cardiovascular disease 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 facial feminization surgeries.  The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that, although facial feminization procedures are generally labeled aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. The WPATH supports facial feminization surgery and breast augmentation as medically necessary for the treatment of a patients gender dysphoria. The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria, which the surgery does through harmonization with regard to other modified structures...achieving an aesthetic result beyond gender difference. Researchers demonstrated that facial feminization surgery, similar to genital surgery, improved mental health related quality of life. This patient meets the WPATH criteria for gender dysphoria to support an indication for facial feminization surgery and breast augmentation. This is based upon clinical documentation of persistent gender dysphoria related to masculine facial and body features associated with clinically significant symptoms of depression. Given the WPATH support for the requested procedures, the requested facial feminization surgeries are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 a power wheelchair and components. The records indicate that the patient has multiple chronic medical conditions but her primarily mobility-related issue is thoracolumbar scoliosis. This is a condition that can be addressed conservatively, but can also significantly benefit from surgical intervention. The patient has no documented impairments that preclude the use of a manual wheelchair for accomplishing mobility-related activities of daily living. Therefore, a power wheelchair and components are not medically necessary for this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Aimovig. The records provided for review document that this patient has refractory chronic migraine without aura. She has not received benefit from multiple medications from different classes including anticonvulsants and antidepressants. She has experienced significant side effects from several medications. Her provider stated that further trials of alternative medications are contraindicated. Aimovig is a calcitonin gene-related peptide (CGRP) receptor monoclonal antibody. CGRP has been found to play a primary role in the pathogenesis of migraine. Further, researchers concluded that Aimovig showed consistent efficacy in episodic migraine patients who had failed prior preventive treatments and was well tolerated across subgroups. Although there is limited data on the use of Aimovig in patients under 18 years of age, the available studies support its safety and effectiveness in patients with refractory chronic migraine without aura. Therefore, Aimovig 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 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: The patient has requested authorization and coverage for sinus surgery prior to his current surgery date. The records provided for review document that this patient has experienced chronic sinusitis for several months. The patient has been treated with nasal and oral steroids as well as sinus irrigation and oral antibiotics. Sinus surgery for nasal polyps is a known treatment modality.  The records support surgical intervention. However, there is a lack of urgency documented to support an urgent change of the scheduled surgery to an earlier date. Therefore, the scheduling of sinus surgery prior to his current surgery date is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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 parent of an enrollee has requested authorization and coverage for residential treatment center services. Recent progress notes indicate the patient is participating in a partial hospitalization program. The partial hospitalization program notes indicate that the patient has been cooperative in treatment. He has not reported suicidal or homicidal ideation while in the program. It appears that his symptoms overall have been well-controlled while in the partial hospitalization program. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm. The medical records indicate that the patient was not actively suicidal. He does have impulsive behaviors with physically aggressive impulses. The patient has had issues with level of function due to mental illness, but overall showed appropriate daily functioning while in treatment, including cooperation in treatment and intact activities of daily living. The patient does not have active medical problems or substance use that affects his primary psychiatric issues. This correlates with intensive outpatient services. Therefore, residential treatment center 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 treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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 Xifaxan 550 mg, three times daily for 30 continuous days.This patient has small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. Per the medical evidence, Xifaxan has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and ciprofloxacin. The results may be sustained for several weeks after treatment. Boltin and colleagues performed a prospective trial of patients with irritable bowel syndrome and a positive breath test. The authors noted that 86% responded to Xifaxan. There is a lack of controlled trials to guide the duration of treatment or management of recurrent bacterial overgrowth, and recommendations are based on clinical experience. This patient has failed multiple 14-day courses of Xifaxan. Thus, a longer course of 30 days is supported. Therefore, Xifaxan 550 mg, three times daily for 30 continuous days 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 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.
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 Dupixent Syringe 200 mg/1.14 ml. AD is an itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and their families (Paton). Treatment of AD usually starts with corticosteroids as well as phototherapy. Protopic ointment and pimecrolimus cream have also been shown be safe and effective in the treatment of patients with AD. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate to severe AD. Vangipuram and Tyring reported on clinical studies demonstrating that Dupixent substantially reduced the clinical manifestations of moderate to severe AD. The records provided for review document this patients AD has been resistant to systemic antihistamines, corticosteroids, and immunosuppressant medications. Given these findings, the requested Dupixent syringe 200 mg/1.14 ml 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 dermatology 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 patients parent has requested authorization and coverage for residential treatment center (RTC) services at a facility that treats children. Researchers found provided guidelines to help determine whether behavioral health services are medically necessary. Based on the presenting information, this patient does not meet the criteria for RTC placement at a facility that treats children. Specifically, the requested services are not required to meet the essential health needs of the patient, are not consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research, and is a more intensive setting than is appropriate for the delivery of health care. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a board certified BCBA, is board certified in psychology 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 enrollee is requesting reimbursement for four continuous weeks of Xifaxan. The enrollee has irritable bowel syndrome. He completed a lactulose breath test, which tested positive for hydrogen, resulting in a diagnosis of small intestinal bacterial overgrowth (SIBO). Xifaxan was prescribed for four weeks on the basis that hydrogen is best treated with this medication. The physician notes metronidazole is effective only in treating methane.  Cipro and tetracycline have not proven to be effective in treating hydrogen.  The patient indicates his condition has improved since starting Xifaxan and continues to improve over time. Literature supports the treatment of small intestinal bacterial overgrowth (SIBO) for patients with irritable bowel syndrome with diarrhea (IBS-D) who are positive for hydrogen on the lactulose breath test. The current research on antibacterial treatment for SIBO is predominately focused on rifaximin (Xifaxan). Review of data from multiple studies on antibiotic therapy for SIBO showed a limited amount of studies existed investigating the use of metronidazole, ciprofloxacin, or tetracycline for SIBO. Subsequent studies on antibacterial therapy for SIBO focused on rifaximin. Rifaximin is approved for the treatment of diarrhea-predominant irritable bowel syndrome; thus this treatment is prescribed for patients with methane-positive SIBO breath tests. Rifaximin was equally effective for treating patients with hydrogen-positive SIBO breath and methane-positive SIBO breath test, supporting the preferential use of rifaximin for this purpose. Further trials led to provision of the drugs licensing for this use. Other antibiotics have not been the focus of such research. As a result, only rifaximin has the safety and efficacy profile available for proper clinical dosing and treatment duration for irritable bowel syndrome with diarrhea (IBS-D) treatment. This patient has small intestinal bacterial overgrowth. Rifaximin has been shown to be beneficial in patients with this condition.  It is the preferred antibiotic and it is not necessary to have failed metronidazole, tetracycline and either ciprofloxacin or moxifloxacin. However, the medical literature supports a two-week course of therapy is proven safe and efficacious for the treatment of IBS-D.Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 similar medical condition.