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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for EBI Electric Bone Growth Stimulator (HCPCS Code E0748). This patient has a history of cervical myelopathy. She underwent C4-7 anterior cervical discectomy and fusion. Operative findings documented severe central stenosis due to disc osteophyte complex, as well as cervical kyphosis and degenerative disc disease. The patients provider recommended an EBI electric bone growth stimulator. Researchers concluded that there was moderate quality evidence supporting the use of post-operative electrical stimulation as an adjunct to spinal fusion surgery. The authors found that patients treated with electrical stimulation have significantly greater rates of successful fusion. Overall, the evidence based medical literature supports the use of bone growth stimulator as safe and effective for patients undergoing multiple cervical or spinal fusion procedures. Given the operative findings and multilevel fusion, the requested EBI Electric Bone Growth Stimulator (HCPCS Code E0748) is medically necessary for treatment of this patient.   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 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

The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 2.1 criteria for IOP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the IOP services were not medically necessary for 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 psychiatry with expertise in addiction 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: The patient has requested reimbursement for transcranial magnetic stimulation (TMS). TMS therapy is U.S. Food and Drug Administration (FDA) approved for the treatment of patients in the acute phase of major depressive disorder. The criteria for TMS therapy includes persistent depressive symptoms as well as failure of four trials of psychopharmacologic agents, including two different agent classes, and two augmentation trials. This patient has been treated with at least five different antidepressants including a selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI). She also underwent two augmentation trials, which included Wellbutrin and Abilify. Perera and colleagues reported that TMS is supported for patients with major depressive disorder who have not responded to antidepressant medications. The authors concluded that TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Given these findings, the TMS services were medically necessary for 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 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 the Zoll LifeVest (HCPCS K0606). The documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with a left ventricle ejection fraction (LVEF) less than or equal to 35%. This patients LVEF was 30-35%. The recommended timing of placement of a wearable cardioverter defibrillator based on guidelines from the American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Rhythm Society (HRS) is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of congestive heart failure with a low ejection fraction. This patient underwent follow up echocardiography beyond the 40-day window and had an improved LVEF of 50-55%. Given the improvement in the patients LVEF, the placement of the LifeVest was appropriate for 40 days, as the patients LVEF would no longer have met the criteria for a wearable cardioverter defibrillator by that time. Therefore, the Zoll LifeVest (HCPCS K0606) provided for 40 days was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Zoll LifeVest (HCPCS K0606) provided for 40 days was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: This is a patient with bilateral primary osteoarthritis (wear and tear of the cushion between the bones) of the knees. The patient experiences bilateral knee pain and swelling. The provider requested bilateral hyaluronan injections for bilateral knee osteoarthritis. The patient has had both hyaluronan and corticosteroid bilateral knee injections in 2017-2019. The provider reports that the patient experiences better pain relief and increased activity level with the hyaluronan injections rather than the corticosteroid injections. During several visits, the provider documented the patients positive results to the injections. 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 orthopedic surgery and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. 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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying CALOCUS guidelines, this patient meets the criteria for mental health RTC services. This gives the patient a composite score which is consistent with high intensity community based treatment. However, due to the patients score on risk of harm, the recommended level of care is Level Five, medically monitored residence based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence based services given his impulsivity, co-occurring substance use and mental health disorders, and lack of response to lower levels of care. Per CALOCUS, the length of stay at this level of care is up to 60 days. Given these findings, the mental health RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Motegrity 2 mg, 30 tablets for 30 days. Medical literature states that prucalopride treatment relieves symptoms of chronic constipation by targeting the underlying impaired colonic motility; prucalopride is not a disease modifying or curing drug. Researchers reported that prucalopride is effective, has a good safety profile, and is well tolerated for the treatment of men with chronic constipation. In this case, the patient has been diagnosed with diagnosed with CVID associated colitis, gastroparesis and functional abdominal pain/IBS and has failed treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Motegrity 2 mg, 30 tablets for 30 days are 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 and allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for HP Acthar Gel 80 units/mL (2 x 5 vials), inject 80 units subcutaneous (SQ) every day for five days. The records provided for review support a diagnosis of relapsing remitting multiple sclerosis. The patient demonstrates left-sided lower extremity weakness with spasticity. The provider noted that there is intolerance to intravenous Solu-Medrol consisting of side effects of worsening fatigue, speech/swallowing difficulties, weakness, spasticity, disorientation and hallucinations. These effects are consistent with worsening of disease rather than drug effect. There is documentation that the patient has successfully received a five-day course of treatment with intravenous Solu-Medrol, with positive response. Acthar Gel, which is a depot version of steroid, is appropriate when there is difficulty obtaining intravenous access or inability to travel to an infusion center. The patient does not meet either of these two criteria. Therefore, the requested HP Acthar Gel 80 units/mL (2 x 5 vials), inject 80 units subcutaneous (SQ) every day for five days 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 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for left knee arthroscopic surgery with meniscus repair and meniscectomy. The patient has been diagnosed with a left knee medial meniscus tear. Researchers reported a complete radial tear of the meniscus posterior root, which can effectively cause a state of total meniscectomy via loss of hoop tension, requires that the torn root be repaired. In this case, the patients left knee mechanical symptoms dictate arthroscopic repair or resection of the torn and unstable posterior horn of the medial meniscus. The patients provider is not requesting debridement of osteoarthritis but will address the medial meniscus, which appears to be the cause of mechanical symptoms. Conservative treatment has failed, and there is MRI evidence of a left knee medial meniscus tear. If repair is not feasible, partial resection of the medial meniscus will be necessary to manage the patients mechanical symptoms. The medical evidence supports the requested services in this clinical setting. Therefore, left knee arthroscopic surgery with meniscus repair and meniscectomy 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Motegrity 2 mg tablet.The submitted documentation supports the medical necessity of the requested medication for the treatment of this patients constipation. Per the records, she has had chronic constipation symptoms and failed Linzess. Motegrity has shown efficacy for the treatment of constipation and irritable bowel syndrome symptoms, including bloating and abdominal pain. The medical evidence indicates that Motegrity is safe and effective for the treatment of constipation, and this medication has proven effective in this patients case. Therefore, Motegrity 2 mg tablet is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for one-on-one (1:1) bedside sitter services, 24-hours per day, seven days a week. The medical literature supports a role for a bedside sitter as part of the management of patients with delirium, which is not present in this patient. The records provided for review document that the patient is able to communicate her needs with her providers. The patients current respiratory status is stable. She has a capped tracheostomy and there is no evidence of infection, coughing, or respiratory distress. She requires oral suctioning per documentation. Her treatment plan includes a 1:2 sitter. The documentation does not report extenuating factors to support a 1:1 sitter to maintain or improve her neuromuscular disease and her current medical condition. All told, the requested 1:1 bedside sitter services, 24-hours per day, and seven days a week are 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 with subspecialty certification in neuromuscular 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

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) mental health treatment. 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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with low intensity community based services. Per CALOCUS, at this level of care, treatment intensity ranges from one hour every four weeks, to up to two hours per week. In this case, the patients symptoms had improved and she was a candidate for low intensity community based services. Thus, the IOP mental health treatment was not and is 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Bactroban 2% nasal ointment. The records provided for review report that this patients complaints include nasal crusting and bleeding. The provider noted that the treatment plan includes over-the-counter antibiotic ointment, and if the patients condition does not resolve, then treatment with Bactroban ointment. However, there is a lack of documentation that the patient has been treated with conservative therapy such as over-the-counter antibiotic ointment and saline spray to support an indication for Bactroban. All told, the requested Bactroban 2% nasal ointment 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees representative has requested reimbursement for intensity modulated radiation therapy (IMRT) services (CPT 77014 and G6015). Standard treatment for rectal cancer is with three-dimensional (3D) conformal radiation therapy. Currently, there is a lack of 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. The National Comprehensive Cancer Network (NCCN) guidelines do not support the use of IMRT in this clinical 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, et al.). In this patients case, the dose-volume histogram showed no clinically significant benefit with the use of IMRT over standard 3D conformal radiation therapy. Therefore, IMRT services (CPT 77014 and G6015) were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the IMRT services (CPT 77014 and G6015) were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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.