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 physical therapy services, including aqua therapy, cold therapy, and land therapy, within a 10-minute drive of the patients home address. Researchers report on the benefits of exercise for chronic pain in the setting of fibromyalgia. Researchers report that physical activity and exercise in the setting of chronic pain showed some favorable effects in reduction in pain severity and improved physical function. Researchers note that exercises in general, and specifically aquatic exercises, are beneficial for reducing pain and disability in many musculoskeletal conditions. However, there is a lack of evidence in current medical literature that formal aqua therapy programs result in marginally superior pain, health, or functional outcomes over water-based exercises that are pursued independently or performed in informal group exercise settings. In comparing AquaStretch, a form of assisted stretching in water, to supervised land based stretching for patients with chronic low back pain, Keane concluded that AquaStretch had key additional benefits including time efficiency, cost effectiveness and the ability to be performed by qualified individuals other than physiotherapists. Formal aquatic therapy, as opposed to generalized water-based exercise, is medically indicated only in specific circumstances, such as for patients who require therapy in a partially body weight unloaded environment and who are unable to perform the applicable exercises safely without formal therapist guidance, instruction and supervision. In this case, the patient has chronic, generalized pain, and has already undergone extensive physical therapy without significant, durable benefit. Due to her persistent symptoms, she underwent recent right hip surgery. The records do not document impairments that would preclude exercises and modalities on an independent basis, including self-applied, self-administered, passive, or palliative measures. Given that no marginal difference in clinical outcomes is expected under an independent program over continued formal physical therapy, whether aquatic or land-based, the requested services are not medically indicated. Therefore, physical therapy services, including aqua therapy, cold therapy, and land therapy, within a 10-minute drive of the patients home address 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for bladder augmentation surgery. Szymanski  and colleagues note that bladder augmentation is a long-lasting treatment for patients with spina bifida. The authors further note that while benefiting continence and renal outcomes, this operation frequently requires additional surgeries, necessitating close follow-up. In this case, the patient has spina bifida with continued incontinence that is managed with clean intermittent catheters five times daily. Ongoing urinary leakage and incontinence in young adults may lead to psychological issues, depression, and poor self-esteem, and result in adverse physical impacts including the breakdown and infection of skin. Standard of care for the treatment of incontinence in young adults with spina bifida includes intervention and consideration of surgical options. Given that current medical literature supports bladder augmentation as a treatment option for patients with spina bifida, the requested service is medically indicated. Therefore, bladder augmentation surgery is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology with sub-specialty certification in pediatric urology 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 reimbursement and prospective authorization and coverage for acupuncture services. Clark and Tighe report, There is evidence supporting the effectiveness of acupuncture for plantar heel pain (PHP). This is comparable to the evidence available for conventionally used interventions, such as stretching, night splints or dexamethasone. Therefore, acupuncture should be considered in recommendations for the management of patients with PHP. Vickers and colleagues note that, Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. In this case, the patient reported benefits from prior acupuncture, but the records did not document pre-acupuncture and post-acupuncture baselines for comparison purposes, the total number of acupuncture sessions completed, and measurable, progressive, significant, or objective functional improvement. The documentation did not demonstrate significant medication intake reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. Given that measurable, progressive, significant, objective functional improvement has not been documented, the services at issue were not and are not medically indicated. Therefore, acupuncture services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One injection in the left knee. Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. 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 standard 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 good relief of knee symptoms with prior viscosupplementation. Furthermore, the patients remaining treatment options are limited to total knee arthroplasty. The patient has tried and failed other conservative treatments including cortisone injections. For these reasons, the requested Synvisc-One injection in the left knee is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Librax. Findings: The U.S. Food and Drug Administration (FDA) reports that Librax is possibly effective as adjunctive therapy in the treatment of irritable bowel syndrome. A study noted that, Certain antispasmodics provide symptomatic short-term relief in irritable bowel syndrome. However, the the same study does not recommend treatment with Librax. In addition, current literature does not support Librax as a primary therapy for chronic diarrhea. The records provided for review do not demonstrate that the patient has exhausted standard therapies for diarrhea predominant irritable bowel syndrome. Furthermore, there is a lack of clinical rationale to support treatment with brand name Librax in lieu of the generic formulation. For these reasons, the requested brand name Librax 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 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 physical therapy. Findings:  The physician reviewer found that symptoms beyond the generally accepted time frame of two weeks for recovery of concussion is referred to as post-concussion syndrome. The mainstay of treatment for concussion and post-concussion syndrome include rest, gradual return to activities, and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns for this condition, but there is a lack of data to draw conclusions about the effectiveness of individualized rehabilitation for post-concussion syndrome patients. The records provided for review document chronic, persistent symptoms following remote head traumas. The patient has some subjective clinical benefit from rehabilitation efforts. Treatment has included adequate rehabilitation and education to be independent with a home exercise and self-management program. Although the patient reports ongoing symptoms, there is a lack of expectation that additional formal physical therapy will result in a marginally significant benefit over an independent program. All told, the requested physical therapy 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 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: An enrollee has requested reimbursement for Intensity-Modulated Radiation Therapy (IMRT).Standard treatment for rectal cancer is with 3D conformal techniques. Currently, there is no clinical data in the medical literature to suggest that treatment with IMRT offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the rectum. NCCN Clinical Practice Guidelines for rectal cancer do not support the use of IMRT in this setting. A phase II study which examined the use of IMRT in patients with rectal cancer found no benefit when compared to historical controls (Hong, T., et al.). In this case, the patient had a diagnosis of a T4N2M0 rectal adenocarcinoma. He received neoadjuvant therapy with chemotherapy and radiation therapy and received intensity modulated radiation therapy. As noted, guidelines do not support the use of IMRT in this setting, and planning documents showed no clinically significant benefit with the use of IMRT over standard 3D techniques. Under these circumstances, the Intensity-Modulated Radiation Therapy (IMRT) services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat 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: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The patient has been diagnosed with major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder, and body dysmorphic disorder. The records provided for review document that the patient has undergone trials of at least two antidepressants, although the provider noted concern given the patients statements about medication nonadherence. The patient was referred to an IOP, but he did not follow-up with the program. The documentation suggests that the patient has intermittently participated in individual psychotherapy and he continues to use 1-2 grams of cannabis daily. The records do not demonstrate that the patients major depressive disorder is treatment refractory given that he is not engaged in regular individual psychotherapy with a cognitive behavior therapy (CBT) or dialectical behavior therapy (DBT) approach to enhance his ability to tolerate distress and his issues with frustration. Moreover, the patient denied any significant sobriety from cannabis during which time his major depressive disorder, generalized anxiety disorder, and obsessive compulsive disorder could have been evaluated. For these reasons, the requested TMS 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR perirectal hydrogel spacer procedure. The records provided for review document that this patient presents with intermediate risk prostate cancer with Gleason score 4+3. The patients provider has recommended treatment with radiation therapy with use of SpaceOAR perirectal hydrogel spacer. One important consideration during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. A mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. Karsh and colleagues reported on a phase 3 study evaluating the safety and effectiveness of the SpaceOAR Hydrogel perirectal spacer in the treatment of prostate cancer. The authors found that the patients who underwent radiation therapy with SpaceOAR placement experienced reduced rectal radiation and rectal toxicity as well as improved bowel quality of life. The National Comprehensive Cancer Network (NCCN) recently endorsed the use of perirectal spacers and noted that their use can improve sparing of the adjacent rectum in patients undergoing radiation therapy for prostate cancer. Based on these findings, the requested SpaceOAR perirectal hydrogel spacer procedure is 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 requested SpaceOAR perirectal hydrogel spacer procedure 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 radiation oncology 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 patients parent has requested authorization and coverage for Dupixent. Findings: A study found that dupilumab and topical corticosteroids were effective and well tolerated in children aged 6 to 11 with severe atopic dermatitis, significantly improving symptoms and quality of life. Another study report that dupilumab, approved for the treatment of atopic dermatitis, has been well studied in patients aged six and older, with expanded indication down to six years of age. In this case, the patient has severe atopic dermatitis and has tried and failed topical therapies, including steroidal and nonsteroidal therapies, of varying strengths and systemic agents, such as prednisone and Xolair. Given that current medical literature reports that Dupixent is safe, well tolerated and effective in treating children with atopic dermatitis, the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly speech therapy. Researchers describe autism spectrum disorder (ASD) as a neurodevelopmental disorder defined by deficits in social communication and the presence of restricted and repetitive behaviors and interests. The authors note that treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Researchers report that the Coronavirus disease (COVID-19) pandemic has created a high degree of disruption to life and stress to families living with an individual with ASD. Researchers report, `The ongoing COVID-19 emergency has resulted in a challenging period for most ASD individuals and their families, with increased difficulties in managing daily activities and at least one in every three children presenting with more frequent or more intense behavior problems. In this case, the patient has ASD, and while repeated administration of standardized testing has not documented progress, the provider reports significant improvement in functional speech. Children with ASD may have attention difficulties using remote services such as telehealth services that the patient has been receiving during the pandemic. Given current medical literature and the providers recommendation for continued therapy, the requested services are medically indicated. Therefore, weekly speech therapy is 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 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 parent of an enrollee has requested authorization and coverage for myofunctional therapy.The submitted documentation does not support that the requested services are medically necessary. In this case, records reflect that the patient is suffering from nasal obstruction adenoid hypertrophy causing 90% obstruction of the nasopharynx and resultant obstructive sleep apnea and speech issues. Records indicate that the patient's problem is due to near complete nasal obstruction caused by adenoid hypertrophy and allergic rhinitis. Orofacial myofunctional therapy cannot improve an obstructive lesion in the nose, as the therapy is concentrated on the mouth and pharynx. Studies of myofunctional therapy have not shown significant benefit in sleep apnea especially in children (Rueda, et al.; Hsu, et al.). Under these circumstances, the requested myofunctional therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology  head and neck 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.