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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and coverage for a CPAP device with accessories. The Health Plan denied the request and reported the equipment at issue was not and is not medically necessary for the treatment of this patient. At issue in this case is whether a CPAP device with accessories were and are medically necessary for treatment of the patients medical condition. Findings:  The physician reviewer found that suspicion of OSA triggers evaluation with a comprehensive sleep evaluation. Once the diagnosis is established, the treatment strategy includes CPAP, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. CPAP is the treatment of choice for mild, moderate, and severe OSA. The American College of Physicians recommend CPAP as initial therapy for patients diagnosed with OSA. The standard first-line OSA treatment involves CPAP devices, which deliver compressed air into the airway to keep it open. The benefits of CPAP based on meta-analyses include reduction in OSA severity, improvement in patient symptoms, particularly sleepiness, sleep-related quality of life, and reduction in blood pressure. In this case, the patient was diagnosed with OSA through a sleep study. Therefore, the CPAP device with accessories were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment was and 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 neurology with subspecialty certification in sleep 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: An enrollee has requested authorization and coverage for Xarelto. This patient has severe multi-territory vascular disease with prior cardiovascular, lower extremity vascular disease and brainstem stroke. Given the extensive vascular disease, he is at risk for recurrence of ischemic disease in both the cardiovascular and peripheral vascular systems. The use of lower dose Xarelto has been shown to decrease the recurrence of vascular events in individuals with this type of medical history. This therapy may be more effective in individuals with extensive disease who are at very high risk for recurrent vascular events, like this patient. The current medical evidence supports the requested medication in this clinical setting. Therefore, Xarelto is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Novolog Mix 70/30 Flexpen 100 u/mL, or in the alternative, Humalog Mix 75/25 Kwikpen U-100. This patient has been prescribed NovoLog 70/30 insulin Flexpen at a dose of 80 units three times a day before meals. According to the 8/16/18 office note, the patient is noted to have blurry vision when reading. This office visit notes the patient has been compliant with treatment. There is no documentation of difficulty reading the vials or drawing up the prescribed dose of insulin. There are no visual acuity measurements documented or ophthalmology exam notes provided. There are also no reported dexterity issues that would interfere with use of insulin vials. Applying the recommendations from the American Diabetes Association (ADA), the records do not support the medical necessity of insulin pens in lieu of standard insulin vials. Thus, the Novolog Mix 70/30 Flexpen 100 u/mL, or in the alternative, Humalog Mix 75/25 Kwikpen U-100 are not medically necessary for treatment of this patients type 2 diabetes.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 diabetes, endocrinology and metabolism 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 is a female diagnosed with coronary artery disease, hypertension, hyperlipidemia, mitral stenosis, aortic stenosis, and type 2 diabetes. An echocardiogram showed normal left ventricular function and significant aortic and mitral valve disease. A stress echocardiogram showed evidence of anterior wall ischemia at a low workload (metabolic equivalents of task). The heart rate achieved was beats per minute, which was reported as of target for her age. The patient also showed inability to raise her systolic blood pressure with exertion. The patient reported occasional chest pain with dizziness. The patient had requested coverage for myocardial perfusion imaging. The Health Plan denied the request and reported that the requested service is not medically necessary for the evaluation of this patient. At issue in this case is whether myocardial perfusion imaging is medically necessary for evaluation of this patients medical condition. The patient has angina-like chest pain with multiple risk factors for coronary disease, including type 2 diabetes mellitus, hypertension and hyperlipidemia. An echocardiogram, showed significant valvular heart disease with moderate to severe mitral stenosis and mild to moderate aortic stenosis. The patients valvular heart disease is a contraindication to any stress testing. The stress echocardiogram was notable for poor exercise tolerance and failure to raise her systolic blood pressure with exercise, in both resting and stress wall motion imaging, which indicates significant ischemic heart disease. Evidence of ischemia is produced at less than of heart rate target and at a modest workload. The patients stress echocardiogram results indicate a high risk of future cardiac events. Further non-invasive testing will not clarify the patients cardiovascular risk or change the clinical management and decision making. Medical evidence does not support the requested service in this clinical setting. Therefore, the requested myocardial perfusion imaging is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 a subspecialty certificate in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a male diagnosed with type 1 diabetes mellitus and is currently using an insulin pump. The patient reported checking his blood glucose levels four to five times daily. He has experienced wide glycemic fluctuations from 58-370 mg/dL. His most recent body mass index was. Laboratory results showed a creatinine level, hemoglobin A1C level, and urine microalbumin/creatinine level. The patients current insulin pump is noted to have false delivery alarms, not deliver the correct dose of insulin, and is no longer in warranty. The patient has requested coverage for a Tandem T Slim X2 insulin pump. The Health Plan denied the request and reported the requested device was not medically necessary for the treatment of this patient. At issue in this case is whether the Tandem T Slim X2 insulin pump is medically necessary for the treatment of this patients medical condition. The American Diabetes Association (ADA) position statement on standards of medical care in diabetes states that continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower hemoglobin A1C in selected adults with type 1 diabetes. Hybrid closed-loop insulin delivery improves glucose control while reducing the risk of hypoglycemia across a wide age range in patients with sub-optimally controlled type one diabetes and was also demonstrated to be safe. A randomized crossover trial comparing day-and-night closed-loop insulin delivery with usual pump therapy in patients with controlled type one diabetes as defined as a hemoglobin A1C less than 7.5%, compared with usual pump therapy, closed-loop delivery reduced hypoglycemia. A trial to evaluate in-home use of the hybrid closed-loop insulin delivery system over three months in type one diabetes showed a significant decrease in the time patients spent in hypoglycemia. The patient has fluctuating blood glucose levels along with hypoglycemia. The Tandem T slim insulin pump along with CGM has the capability of suspending insulin delivery to avoid hypoglycemia. Therefore, the request for a Tandem T Slim X2 insulin pump is medically necessary for the 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 internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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 a left thumb prothesis.Findings:  Two physician reviewers found that there is sufficient support for the requested device in this patients case. The records document that the patient is post-amputation. The thumb affects 40% of hand function, and any type of device should afford length, stability, and opposition. The thumb contributes to grasping function. This patients condition creates significant impairment in completion of activities of daily living. Given this patients shortened thumb, lengthening with a prosthesis is medically appropriate. In this clinical setting, the requested device is likely to assist in future functional recovery. In sum, the requested left thumb prothesis is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device is 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 plastic surgery with sub-specialty certification in surgery of the hand 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 was diagnosed with autism spectrum disorder who has been treated with applied behavior analysis (ABA). The patient's Vineland Adaptive Behavior Scale 3 (Vin-3) scores were noted to be low for his age group. The patients parent has requested reimbursement and coverage for 36 hours per week of direct 1-on-1 ABA services. The Health Plan denied the request and reported the services were not and are not medically for the treatment of this patient. At issue in this case is whether the 36 hours per week of direct 1-on-1 ABA services that the patient received from are medically necessary for the treatment of his medical condition. ABA services are being provided for this patient in the least restrictive setting, with an emphasis on generalizing to a more natural setting. The patient has made improvements since baseline as shown in scores on the Vin-3 assessment, and reports from the patients provider. Based on the Vin-3 assessment, the patient is still approximately two standard deviations below the mean. The patients goals will not be met and the level of interfering behavior will not be reduced if the intensity of care is reduced. Therefore, 36 hours per week of direct 1-on-1 ABA services that he received were and are medically necessary for treatment of this patients autism.Final Result: The reviewer determined that the requested services 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 psychologist and behavior analyst 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 is requesting Tymlos for the treatment of osteoporosis. Findings: The physician reviewer found the medical evidence does not support the requested medication in this clinical setting. The patient is reported to have GERD and is unable to take oral bisphosphonates. Current guidelines recommend intravenous bisphosphonates when oral bisphosphonates cannot be tolerated. Tymlos is a novel synthetic analog of human parathyroid hormone-related protein (PTHrP) that has been shown to be effective for the treatment of osteoporosis. Studies report that Tymlos can stimulate bone formation with less of the accompanying bone resorption and hypercalcemic effects that can occur with parathyroid hormone (PTH). Tymlos was recently approved by the U.S. Food and Drug Administration (FDA) and has limited safety data. In addition, the risks associated with Tymlos include hypocalcemia, osteonecrosis of the jaw, atypical femur fractures, and serious infections. There is a lack of evidence that the anti-fracture efficacy of PTH is superior to bisphosphonates. The patient has not demonstrated failure or contraindication to standard therapies with proven safety and effectiveness. 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, 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: Upheld Decision of Health Plan

A male enrollee with a diagnosis of plantar fasciitis and hypertension. An examination dated reported that the patient complained of pain to the second and third toes and the right foot when walking. The patient is noted to be using orthotics currently as well as ice as needed for pain. The patients plantar fascia is noted to be stable according to the examination. There was no physical exam of the foot during the office visit. X-rays of right foot that were taken revealed no fracture or joint space abnormality. The soft tissues are normal. The patient has used orthotics for roughly six years according to a note written by the patient. He advised that for six years he has received new orthotics for plantar fasciitis, which inhibited his normal comfortable ambulation. It has been recommended that patient obtain a new pair of custom orthotics. This has been denied by the health plan as not medically necessary. At issue is whether orthotics are medically necessary for treatment of this patients medical condition. There are certain foot structures that require orthotic therapy in order to maintain a neutral position, therefore deferring the onset of plantar fasciitis. However, there is no biomechanical examination to advise that this patient has such a foot structure. Current medical documentation does not support the need for orthotics in this clinical setting. It has been recommended that the patient obtain a new pair of orthotics for a diagnosis that was made over six years ago. However, there is no documentation that a physical examination has been performed on the foot within the past year. There is no biomechanical evaluation of the foot and no current radiographic abnormality of the foot. Due to the lack of medical documentation and medical evaluation of this patients foot, the requested orthotics are not medically necessary for treatment of this 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 podiatry 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 is requesting authorization and coverage of residential mental health and substance use treatment in a wilderness residential program. Findings:  The physician reviewer found that the patients presentation had a composite score of 17 on the Adolescent Level of Care Utilization System (CALOCUS). A score of 17 correlates with a treatment intensity level of three, which is consistent with intensive outpatient services. Given these findings, the patient did not require the supervision and monitoring of 24-hour residential mental health treatment. Thus, the residential mental health and substance use treatment was not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with 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 prophylactic mastectomy on left breast. for In the medical literature, the removal of the unaffected breast in most patients diagnosed with breast cancer has not been shown to prolong survival. Overall, the widespread use of adjuvant therapy, even for small node-negative breast cancers, has resulted in a decrease in the incidence of contralateral breast cancer. However, specific subgroups of patients with breast cancer who are at increased risk for development of contralateral cancer, and in whom having the non-affected breast removed could improve survival, have been identified. The Society of Surgical Oncology suggests that contralateral prophylactic mastectomy should be considered in patients at higher than average risk for developing contralateral breast cancer, specifically those patients with either: (1) a genetic mutation of BRCA1 or BRCA2, or another known mutation; or (2) a strong family history of at least two first-degree relatives with breast or ovarian cancer with no demonstrable mutations. Since not all of the genetic information responsible for breast cancer has been defined, the NBN gene has been studied and identified as statistically significant in certain patient populations. Effective variants of the NBN gene on the breast cancer risk remain to be determined, although the available data suggests an increased spontaneous chromosomal instability in the cells of NBN heterozygote carriers. Based on current data, this NBN variant may contribute to breast cancer, particularly in young women. This patient has a known diagnosis of right breast cancer and is status post mastectomy and sentinel node biopsy. She is premenopausal. She has undergone genetic testing and is positive for a NBN pathogenic mutation. These findings support the requested contralateral prophylactic mastectomy for breast cancer risk reduction. Accordingly, the requested prophylactic mastectomy on left breast is medically necessary for treatment of this 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 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.