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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for positron emission tomography (PET) scan (with concurrent acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh) provided 9/14/20.National Comprehensive Cancer Network suggests that patients should consider multiphasic abdominal/pelvic computed tomography/magnetic resonance imaging (CT/MRI) with intravenous (IV) contrast and chest CT with contrast every three to six months for two years, then every six to twelve months for up to five years, or as clinically indicated. In this case, the patient was diagnosed with cholangiocarcinoma in 2014. The recommended 5-year follow-up period had been completed. Based on the records, there were no clinical signs that he had a recurrence. No other clinical indications for repeat imaging outside the usual 5-year follow-up period were identified. As such, PET scan (with concurrent acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh) provided on 9/14/20 was not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service was 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 diagnostic radiology 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 traditional duodenal switch surgery. Findings:  The physician reviewer found that records provided for review document that this patient has a history of obesity status post Roux-en-Y gastric bypass surgery in 2015. The patient states that she was able to lose weight from 340 pounds down to 220 pounds, but then she regained weight to 290 pounds. The patient has regained weight since the bariatric surgery, but she has not developed additional complications of morbid obesity. There is no report of additional metabolic complications, such as diabetes mellitus, as a post bariatric surgery complication to support an indication for duodenal switch surgery (OBrien, et al.). Therefore, the requested traditional duodenal switch surgery 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 general 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for acupuncture visits twice a week.Vickers and colleagues state, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Further, Yin and colleagues state, Acupuncture is effective and safe for treating several chronic pain conditions when performed by well-trained healthcare professionals. However, the use of acupuncture for maintenance, prophylactic or custodial care is not supported by the peer-reviewed literature. In this case, although the patient reported a temporary reduction of symptoms from prior acupuncture care, no pre-acupuncture, and post-acupuncture functional improvement baselines were documented for comparison purposes. After prior acupuncture sessions were completed, the total number of sessions completed, and any measurable, progressive, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture to support the necessity of the additional acupuncture requested were not documented. Per the records, the patient is not presenting a flare-up of the condition or a re-injury. Additionally, there is no clear documentation indicating whether the patient is currently undergoing an independent exercise program. Therefore, based on the lack of documentation demonstrating quantifiable medication intake reduction, measurable activities of daily living improvement directly attributable to prior acupuncture, or any extraordinary circumstances, additional acupuncture sessions are not recommended. Thus, the requested acupuncture visits twice a week 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 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 anterior L3-S1 lumbar interbody fusion followed by posterior L3-S1 fusion with instrumentation. Researchers noted that conservative therapy for patients with degenerative lumbar spondylolisthesis may include physical therapy, epidural steroid injection, and pain medications. The authors noted that if pain and symptoms remain unresolved, surgical options may include decompression alone or decompression and fusion. Researchers described that as a result of decompression, the instability associated with spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints requiring fusion. The records provided for review document that this patient is being treated for lumbar disc degeneration, lumbar radiculopathy, and arthropathy of lumbar facet. The patient reports pain with walking, turning in bed, and sitting. Physical examination revealed normal strength and sensation and pain with straight leg raise bilaterally. The records suggest that the patients pain generator has not been easily identified. In addition, the imaging studies do not support instability in the lumbar spine or severe stenoses that requires surgery leading to intraoperative instability. For these reasons, the request for anterior L3-S1 lumbar interbody fusion followed by posterior L3-S1 fusion with instrumentation 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) (CPT codes 72146 - MRI spinal canal thoracic without contrast material x 1, and 72148 - MRI spinal canal lumbar without contrast material x 1).The American College of Radiologists (ACR) Appropriateness Criteria for lumbar imaging generally recommend MRI without contrast for patients with subacute or chronic low back pain with or without radiculopathy and surgery or intervention candidates with persistent or progressive symptoms during or following six weeks of conservative management. ACR guidelines recommend MRI only if severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition are present, or if the patient is a candidate for invasive interventions. Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic deficits. In this case, the patient is being treated for scoliosis and back pain. He noted that the back pain is worsening. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Detailed documentation is not evident regarding severe and/or progressive neurological abnormalities. Furthermore, there are no objective findings provided corroborating the noted scoliosis. No x-rays were noted or provided of the thoracic and lumbar spine. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested magnetic resonance imaging (MRI) (CPT 72146- MRI spinal canal thoracic without contrast material x1; 72148- MRI spinal canal lumbar without contrast material x1) is not medically necessary for the evaluation 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fasenra 30 mg auto injector pen. The medical records provided for review document that this patient complains of dyspnea, asthma, and chest congestion. The provider charted that the patient has been diagnosed with systemic eosinophilia. Based on current medical literature, it is medically appropriate to treat this patient with a type 2 targeted therapy, given his eosinophilia in the setting of severe asthma. However, there is a lack of data to support the treatment with Fasenra over other type 2 targeted medications. Mepolizumab has been demonstrated to be safe and effective for use in this clinical setting. Bel and colleagues noted that, In patients requiring daily oral glucocorticoid therapy to maintain asthma control, mepolizumab had a significant glucocorticoid-sparing effect, reduced exacerbations, and improved control of asthma symptoms. Pavord and colleagues concluded that, Mepolizumab is an effective and well-tolerated treatment that reduces the risk of asthma exacerbations in patients with severe eosinophilic asthma. Overall, there is a lack of data supporting that Fasenra is superior to mepolizumab. This patients records do not document that the patient has failed an adequate trial with mepolizumab. Therefore, the requested Fasenra 30 mg auto injector pen 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lymphovenous anastomosis (LVA) procedure to the an upper extremity. The records provided for review document that this patient developed lymphedema after initial lumpectomy, chemotherapy, re-excision and completion lymphadenectomy with radiation therapy.  The provider noted that the patients progressive symptoms resulted in an episode of severe cellulitis, which required inpatient hospitalization and prolonged antibiotics. This patient meets the accepted indications for surgical management of secondary lymphedema. The patient failed nonoperative management with compression garments, manual lymphatic drainage, and daily use of an intermittent pneumatic compression device. They experienced recurrent episodes of cellulitis, the worst of which required inpatient hospitalization and prolonged antibiotics. Based on the current medical evidence, the requested LVA procedure to the upper extremity 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 reviewer 1 is board certified in surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in plastic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryosurgical ablation of the left breast (CPT 19105). The National Comprehensive Cancer Network guidelines for the treatment of breast cancer note that the use of pembrolizumab is limited to intravenous therapy and may be used in combination with chemotherapy. The U.S. Food and Drug Administration (FDA) notes that Keytruda (generic name pembrolizumab) injections may be used in combination with chemotherapy. Current medical literature and guidelines do not support the use of pembrolizumab as a direct intratumoral injection. In this case, the records did not indicate that the patient was participating in clinical trials, and the use of cryoablation and an intratumoral injection is not supported over conventional care options such as a mastectomy. Therefore, cryosurgical ablation of the left breast (CPT 19105) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found cryosurgical ablation of the left breast (CPT 19105) was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology 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 Otezla. This patients symptoms of psoriasis have persisted for several years with worsening over the last two years. The patient is also being treated for androgenetic alopecia. His psoriasis primarily involves the scalp and feet. He was treated with excimer laser for the scalp, which responded. However, the patients feet have been refractory to excimer laser. Ketoconazole cream was added to the patients regimen given the unresponsiveness of his plantar disease. The patients provider has recommended treatment with Otezla. Otezla is a phosphodiesterase 4 inhibitor that reduces the inflammatory process associated with psoriasis. In a recent article by Kt and colleagues, methotrexate is as effective and well tolerated as Otezla in the treatment of palmoplantar psoriasis. On review of this patients records, he has not failed an adequate trial and there is no reported contraindication to treatment with methotrexate. All told, the requested Otezla 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 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: An enrollee has requested reimbursement for inpatient hospital services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was hospitalized for treatment of DKA and its sequelae. Her documented medical history was significant for having type 2 diabetes mellitus and headaches. The patient reportedly presented to her primary care providers outpatient office. A diagnosis of urinary tract infection was reportedly determined. Laboratory testing was performed, and the patient was subsequently directed to the emergency department. The patient was admitted for inpatient care. The treating provider notes indicated that the patient had been diagnosed with DKA, an acute urinary tract infection, diarrhea, high anion gap metabolic acidosis, hyponatremic dehydration, elevated blood pressure and heart rate, and a migraine headache. In this case, the records do not support the medical need for inpatient care. Some factors and circumstances can complicate DKA treatment and worsen outcomes, necessitating both emergent treatment and hospitalization, such as evidence of shock, certain arrhythmias, or an insufficient response to initial treatment. In this patients case, there was no submitted documentation or suggestion that such issues played a significant role, necessitating inpatient care. Although emergent treatment and monitoring was required initially to prevent the development of potentially life-threatening complications from her condition, inpatient services were not medically necessary. The patients sodium had normalized, white count had normalized, urinary tract infection was mild, glucose was coming down, and the patient was hemodynamically stable. As such, although additional monitoring may have been needed, this could have been accomplished in an observation setting rather requiring inpatient admission. Therefore, inpatient hospital services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 (1) Percocet 10 mg tablets, two tablets, three times per day, and (2) Norco, 10 mg tablets, one tablet, five times per day. On determining when to initiate or continue opioids for chronic pain, researchers report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic pain secondary to paraplegia. He was completing a home exercise plan and there was no note of aberrant behavior or abnormal drug screens. The treating provider has determined that the benefits of opioid therapy outweigh potential risks. The records noted an unspecified allergy to Percocet and the patient reported that he preferred continued pain management with Norco over a buprenorphine patch. The records note that the patient has been on hydrocodone 10-325 mg, four tablets daily (120 tablets monthly), and the notes indicate that the treatment plan is to continue hydrocodone without changes. The patient has been referred to pain management. The submitted records do not indicate a plan for increasing opioid therapy or changing agents. In this clinical setting, (1) Percocet 10 mg tablets, two tablets, three times per day, and (2) Norco, 10 mg tablets, one tablet, five times per day are not medically necessary for the treatment of this patient. However, the treating physicians prescription of Norco, 10 mg tablets, one tablet, four times per day, are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication 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 anesthesiology 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.