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 Acthar Gel 80 unit/ml (15 ml). At this time, the guidelines do not support the use of Acthar Gel for the treatment of non-renal systemic lupus erythematosus (SLE) or patients with SLE-APS [antiphospholipid syndrome]. A study noted that repository corticotropin injection (RCI) has anti-inflammatory and immune-modulatory effects and is approved for multiple indications, including several rheumatologic conditions. This study revealed that, RCI was used primarily as late-line therapy in patients with rheumatologic diseases. Medical resource use was significantly lower in the three months after therapy compared with three months prior. The authors concluded that, this finding suggests that RCI may improve disease control and warrants further evaluation. However, no studies have been performed exclusively on patients with SLE-APS, with several studies excluding secondary APS due to lupus. Thus, with current knowledge, treatment of APS in the context of SLE should not differ from treatment of primary APS . The guidelines recommend rituximab for refractory non-renal disease. Rituximab has been shown to be safe and effective in the treatment of non-renal SLE, especially in terms of disease activity, immunologic parameters and steroid-sparing effect. 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 certifications in allergy and immunology and rheumatology 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 reimbursement for Residential treatment center (RTC) services. Medical literature shows a criteria for adolescents is useful to determine the appropriate level of care of mental health services. Dimension 1 requires documentation of acute withdrawal. The patient did not demonstrate symptoms of acute withdrawal as evidenced on physical examination. Dimension 2 evaluates a patients biomedical conditions, which were not present in this case. Dimension 3 requires documentation of emotional, behavioral or cognitive conditions. The patient meets this criterion as he had sufficient mental status to permit participation and demonstrated an inability to control his impulses. The patient also demonstrated significant functional deficits including refusal to attend school and the presence of family conflict. For Dimension 4, readiness to change, he demonstrated opposition to addressing substance use problems and attributed his substance use problems to other people. For adolescents, ASAM 3.5 criteria require that the patient meet two out of six-dimensional criteria. After reviewing the documentation, the patient met the criteria in the emotional, behavioral, cognitive conditions and readiness to change dimensions. Therefore, the RTC services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue 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 subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal optical coherence tomography.Findings:  Three physician reviewers found that Descemet membrane endothelial keratoplasty is a partial thickness cornea transplant where the host Descemet membrane and endothelium are replaced by donor Descemet membrane and endothelium. Given the delicate nature of the transplanted tissue and postoperative edema, it may be difficult to assess the position of the graft tissue. Anterior segment optical coherence tomography is beneficial in the postoperative care in this setting, as it helps to visualize the graft tissue in relationship to the host cornea. Optical coherence tomography can confirm the position of the graft in relationship to host stroma. This imaging modality can assist in cases of significantly edematous stroma, which may indicate the graft is not functioning well or is upside down. In sum, corneal optical coherence tomography was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation 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 ophthalmology 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 is a 59-year-old female with a history of osteoporosis. Findings:  The physician reviewer found that bone densitometry of the hip and lumbar spine revealed a hip T-score of -2.2 and lumbar spine T-score of -2.8. The bone mineral density of the left hip was noted to be osteopenic, and the bone mineral density of the lumbar spine was noted to be osteoporotic. In a letter, the patients provider noted a bone density test in 2017 revealed osteoporosis of the lumbar spine, and the left hip was osteopenic. The patient had previously been treated with Evista. She has requested authorization and coverage for a bone density test (dual energy x-ray absorptiometry, also called DEXA scan). The Health Plan denied the request and reported that the requested services are not medically necessary for the evaluation of this patient. At issue in this patients case is whether a bone density test (dual energy x-ray absorptiometry, also called DEXA scan) is medically necessary for the evaluation of the patients medical condition. Per the International Society for Clinical Densitometry, bone mineral density (BMD) testing is indicated for women 65 years of age and older and post-menopausal women younger than age 65. A bone density test is indicated if the patient has a risk factor for low bone mass, such as low body weight, prior fracture, high-risk medication use, and a disease or condition associated with bone loss. BMD testing is also indicated for women during the menopausal transition with clinical risk factors for fracture, such as low body weight, prior fracture, or high-risk medication use. Finally, BMD testing is indicated for anyone not receiving therapy in whom evidence of bone loss would lead to treatment. In this case, the patient is premenopausal with a previous history of osteoporosis based on 2010 and 2017 DEXA scans.  Previous therapy has included Evista. The medical evidence supports the requested services in this clinical setting. Therefore, a bone density test (dual energy x-ray absorptiometry, also called DEXA scan) is medically necessary for the evaluation 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 internal medicine with sub-specialty certification in rheumatology 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 applied behavior analysis (ABA) therapy using Early Start Denver Model (ESDM). ABA continues to be the most evidence-based intervention to treat the symptoms of autism. While many early intensive behavior intervention models incorporate ABA, ESDM utilizes ABA loosely among other eclectic approaches from teaching and psychology. Evidence on the effectiveness of ESDM is limited, as much of the research regarding its effectiveness has come from its developers. Further, much of the research that has been published has been identified to be weak in scientific rigor. There where 15 studies that evaluated ESDM as an early intervention program for a total of 209 children with autism spectrum disorder. The authors noted that although ESDM is a potentially promising intervention, the limited number of high-quality studies indicates the need for additional research to evaluate its effectiveness. At this time, there is insufficient data to draw firm conclusions about its use. The Health Plan has offered coverage for ABA therapy with an in-network provider, which is medically appropriate in this case. Therefore, ABA therapy using ESDM is 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 a licensed B.C.B.A., 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Hybrid Maze procedure, atrial fibrillation. The enrollee has a history of atrial fibrillation for the past five years. He had a transient ischemic attack (TIA) which resulted in right-sided weakness and speech problems that lasted half an hour. At this time he was found to have atrial fibrillation. He underwent cryoablation and subsequently developed atrial fibrillation again and underwent cardioversion. He has had recurrence of atrial fibrillation and is short of breath, dizzy and unable to tolerate physical exertion. He is exhausted all the time.  His condition is getting progressively worse and he has exhausted all avenues of conservative medical management. His cardiothoracic surgeon advised the hybrid maze procedure to treat the enrollees persistent atrial fibrillation. According to recent published literature the use of the Hybrid Maze procedure offers improved clinical benefit for reduction in recurrent atrial fibrillation, when compared to widely-used catheter-based endocardial ablation procedures. Given this enrollee has already failed an attempt at rhythm control with a prior catheter-based ablation, and has a history of significant symptoms, a surgical based approach, such as the Hybrid Maze procedure is appropriate and offers improved clinical efficacy and freedom from atrial fibrillation compared to endovascular catheter-based procedures. Conventional treatments for controlling this enrollees atrial fibrillation have been ineffective. Literature supports the Hybrid Maze procedure can be a successful alternative to catheter ablation and open surgical procedures in enrollees who have been unresponsive to other treatments. This enrollee is symptomatic despite medical therapy, ablation and multiple direct current cardioversions. The literature cited shows that it is reasonable to consider this procedure in a symptomatic enrollee who has failed other commonly used procedures. Literature also indicates that it is more likely to be beneficial than cardioversion and ablation; which have failed. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Two reviewers are board certified in Cardiovascular Disease and one reviewer is board certified in Thoracic and Cardiac Surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing (Mitochondrial Full Genome Analysis MT-TL1 m.3243A>G). Findings: The reviewer found that the submitted documentation supports that the requested genetic testing is medically necessary. This patient has a family history of MELAS (mitochondrial encephalopathy lactic acidosis and stroke-like episodes) due to m.3243A>G mutation in the mtDNA. This is present with varying degrees of heteroplasmy in her daughter and grandchildren, who have varying degrees of symptoms. As mtDNA is maternally inherited, it can be presumed that this patient has some degree of mtDNA mutation herself. While blood heteroplasmy levels are not fully indicative of levels throughout other organs, they can be suggestive and are easiest to obtain. This patient does have some symptoms consistent with milder forms of MELAS, including type II diabetes, migraines, exercise intolerance, and memory concerns, though these are common and can have complex causes. In this case, however, use of certain medications is not recommended in those with MELAS due to risk, and determining this patient's heteroplasmy levels can help define her risk of additional complications. The requested mtDNA sequencing for a single variant is a genetic test that will provide much benefit for this patient. Under these circumstances, the requested genetic testing is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in medical genetics and genomics, with primary specialty certification in clinical biochemical genetics, 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 an ankle walking cast boot.The submitted documentation supports that the requested ankle walking cast boot is medically necessary. In this case, the patient was diagnosed with posterior tibial tendinitis on the right side. The patients initial treatment included a high CAM walking boot. The patient was noted to be obese, and he explained that not only did he have difficulty ambulating because of that fact, but he found that the originally dispensed high CAM walking boot was so heavy that he was unable to get his foot off of the ground to ambulate. The patient requested a lighter, low CAM walking boot. Both a high and a low CAM walking boot will immobilize not only the ankle joint but the subtalar joint, thereby reducing and/or halting motion of the posterior tibial tendon and allowing for healing. Under these circumstances, because of the patients comorbidities, an ankle walking cast boot is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device 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 podiatric 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Society of Addiction Medicine (ASAM) criteria can be applied to this patients presentation to determine the appropriate level of care. Based on the records provided for review, the patient does not meet the criteria for treatment at the RTC level of care. Dimension 1 requires documentation of acute intoxication and/or withdrawal potential. Dimension 2 required evidence of biomedical condition and complications. According to the ASAM 3.5 criteria, all six dimensions must be met for placement in this level of care. These two criteria are not met according to the patients presentation. Consequently, the patients presentation does not meet the required six out of six ASAM dimension criteria. Therefore, the RTC services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the left knee. Findings:  The physician reviewer found that the evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. Campos and colleagues concluded that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. However, viscosupplementation was not superior to the use of a corticosteroid injection. In their randomized controlled trial, Di Martino and colleagues found that the early postoperative application of viscosupplementation did not lead to significant improvement in clinical scores after ACL reconstruction. This patient is status post left knee ACL reconstruction with allograft, partial medial and lateral meniscectomy, and arthroscopy with debridement and chondroplasty, synovectomy, and partial meniscectomies. The patient underwent pre-operative cortisone injections, which did not help. She presented with a moderate effusion and underwent aspiration of fluid. There is no documentation of the patients response to aspiration, lab results, or failure of a post-operative cortisone injection. There is no current crepitus or tenderness to palpation. Therefore, Orthovisc injections in the left knee are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three 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 enrollee is requesting reimbursement for Zio Patch. The enrollee has a history of cerebrovascular accident (CVA), hypertension, and hyperlipidemia. The record indicates an emergency department (ED) visit with complaints of right-sided numbness to his face, feet, and fingers. The symptoms varied in intensity and had been present over three hours. He was significantly hypertensive in the ED. He was treated with clonidine, Lisinopril, and intravenous (IV) metoprolol. A computerized tomography (CT) scan of the brain showed no acute intracranial process. At a follow-up visit, he reported minimal numbness in the right side of his face; no weakness or facial droop. A magnetic resonance imaging (MRI) scan showed an acute left thalamic infarct and his physician scheduled a Zio Patch monitor to identify any significant arrhythmias. The fourteen day Zio Patch recording showed predominantly sinus rhythm with no episodes of atrial fibrillation. There was no AV block or significant pause. An echocardiogram demonstrated a left ventricular ejection fraction of 65%. There was mild, increased left ventricular wall thickness mild diastolic dysfunction. The valves were normal and there were no intra-cardiac sources of emboli identified. Review of the record indicates the enrollee experienced a cerebrovascular accident (CVA) which could be classified as cryptogenic. Cryptogenic ischemic strokes are symptomatic cerebral infarcts for which no probable cause is identified after adequate diagnostic evaluation. Investigation in enrollees with cryptogenic stroke typically includes evaluation for cardiac sources of embolism (structural and rhythm abnormalities). Atrial fibrillation may be asymptomatic. A work-up to rule out episodes of atrial fibrillation in an enrollee such as this one is medically necessary and standard practice. The medical literature shows positive results of the Zio Patch monitor in diagnosing episodes of atrial fibrillation. One study shows the substantial proportion of atrial fibrillation detection beyond the first 48 hours of monitoring which suggests the patch is superior to conventional 48 hour Holter monitors for the detection in enrollees with stroke or transient ischemic attack. Age >60 was a predictor of finding atrial fibrillation on prolonged monitoring. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in cardiology 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.