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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the hips.The submitted documentation fails to demonstrate the medical necessity of the requested service. Ward and colleagues noted, In adults with ankylosing spondylitis of unclear activity while receiving a biologic, we conditionally recommend obtaining a spinal or pelvis MRI to assess activity. (Ward, M., et al.). In this case, the patient has ankylosing spondylitis with a history of biologic therapy use. The patient reports of pain in the hips and buttock area. On 1/13/21, the records indicate that the patient had bilateral sacroiliac joint tenderness on palpation during physical examination, which is suggestive of sacroiliitis. No abnormality of hip examination was reported. According to current guidelines, obtaining an MRI of the hip joints to assess ankylosing spondylitis disease activity is not recommended. Thus, the requested MRI of the hip joints is not medically necessary for evaluation of the patients medical condition.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 subspecialty 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 Nutropin AQ Nuspin.Findings: Standard of care for evaluation of short stature in a prepubertal girl includes magnetic resonance imaging (MRI) with and without contrast of the pituitary and hypothalamic anatomy to exclude a lesion as well as circulating karyotype to exclude Turner syndrome. The submitted records do not document that an MRI with and without contrast of the pituitary and hypothalamic anatomy was performed, so sufficient diagnostic criteria for an FDA-approved indication for growth hormone (GH) therapy have not yet been met. The FDA-approved indications for somatotropin include growth hormone deficiency and idiopathic short stature. The current medical evidence does not support the requested medication in this clinical setting. Therefore, Nutropin AQ Nuspin is not medically necessary for the treatment of the patients medical condition.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 pediatrics with sub-specialty certification in pediatric endocrinology 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 chiropractic services and prospective authorization and coverage for future chiropractic services.The submitted documentation fails to demonstrate the medical necessity of the services at issue. According to a systematic review, the results from 19 clinical trials did not support the existing evidence for the clinical value of Eastern or Western manipulative therapy for neck pain of short-term follow-up according to minimally clinically important difference of the Visual Analogue Scale. In this case, the diagnosis submitted by the chiropractor is segmental dysfunction of the cervical and thoracic spine. Records indicate that the patient reported neck and back pain. Notes from x-rays showed that there were mild chronic degenerative changes with no acute findings in the lumbar spine and mild asymmetric degenerative changes of lower lumbar posterior facet joints. However, the evidence from medical literature does not support a significant benefit from manipulation therapy in this setting. Thus, chiropractic services provided and onward were not and are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in chiropractic 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee.The American College of Radiology guidelines state that MRI is indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. It is not indicated before complete physical examination and radiography, or for the following conditions: severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. (American College of Radiology). Matar and colleagues noted, The management of patients with knee pain is non-operative both for degenerative meniscal tears and degenerative joint disease in its initial stages. Magnetic resonance imaging has little added value in the management of middle-aged and elderly patients with degenerative disease. Failure to respond to non-operative measures warrants orthopedic assessment with radiographic studies and counselling on managing degenerative joint disease both non-operatively and operatively. (Matar, H., et al.). In this case, the patient is noted to have had a mechanical fall in November 2020, resulting in left knee pain. The patient reported clicking in the joint and noted that the knee felt loose. The records noted a prior history of knee pain October 2019, with reported diagnosis of meniscus tear. Per the records, the patient was treated conservatively in October 2019, with no imaging performed. Examination of the left knee revealed lateral joint line tenderness, normal range of motion, and no ligamentous laxity with varus or valgus stress. The patient did not tolerate McMurrays maneuver. The patient was noted to have been prescribed meloxicam on 1/25/21; however, the records dated do not document 3/1/21 benefits with this medication. There are no x-rays provided or noted to have been completed. There is limited documentation of any trial and failure of conservative care modalities provided for review. Advanced imaging is not indicated without failure of conservative treatment and non-diagnostic x-rays. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested MRI of the knee is not medically necessary for the evaluation of the patients medical condition.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 subspecialty certification 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 reimbursement for air ambulance services. Sardaro and colleagues describe epithelioid hemangioendothelioma as a rare vascular neoplasm whose etiology is still a dilemma. Jue and colleagues note that telemedicine may allow a surgical oncologist to manage and treat complex cancer diseases. In this case, while the patient has a rare diagnosis, the submitted records do not show that the services offered by the University of Texas MD Anderson Cancer Center in Houston, Texas, could not have been provided by a local provider or with the assistance of telemedicine. There are sarcoma centers in tertiary care centers in California that the patient could have been transferred to without air ambulance services. Given that the records do not demonstrate that a closer tertiary care center offering appropriate services were unavailable, the services at issue were not medically indicated. Therefore, the air ambulance services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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 all or any of the requested durable medical equipment (DME) accessories (power seat elevation system (E2300) and battery (E2361)).At issue is whether all or any of the requested durable medical equipment (DME) accessories (power seat elevation system (E2300) and battery (E2361)) are medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or outside of the home, including access to the community. A power mobility device that allows for independent mobility is an appropriate and medically necessary device for individuals with spinal cord injuries according to a study. For some patients, power seat elevation can be an appropriate component for a power wheelchair in order to allow a user to independently transfer into and out of the chair according to another study. In this case, the records do not indicate the patient is able to safely and independently transfer with power seat elevation. There is no documentation of an actual transfer trial where he was able to transfer himself independently, effectively, and safely by using a power seat elevation feature or in equivalent conditions. The patients environment can otherwise be adjusted as needed to optimize his independence with respect to reach in his home. Thus, a power seat elevation is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. In this case, the records noted that the patients current power mobility device has various broken parts. The Health Plan has approved coverage for a power wheelchair. A battery is required to power the wheelchair. Therefore, the requested battery (E2361) is medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that some of the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (CPT 43284). The current medical literature lacks randomized controlled clinical trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX  both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al.). When compared to surgical fundoplication, LINX has been associated with severe dysphagia requiring endoscopic intervention (Sheu, et al.). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial for this patients GERD than standard treatment including surgical fundoplication. For these reasons, the requested LINX procedure - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (CPT 43284) is not 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 LINX procedure - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (CPT 43284) is 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 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83695). In this patients clinical circumstance with a history of hyperlipidemia, Hashimotos thyroiditis, and chronic inflammatory eczema, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations (Stone, et al.; Arnett, et al.). These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk, including advanced lipoprotein testing (Stone, et al.). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For these reasons, the advanced lipoprotein testing (CPT 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 83695) was not likely to be more beneficial for evaluation 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 internal medicine with a 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: The patients parent has requested authorization and coverage for a second round of fertility preservation services. As part of education and informed consent prior to cancer therapy, oophorectomy, or any procedure that may jeopardize a womans ability to conceive in the future, health care providers should address the possibility of infertility. fertility preservation options exist for both female and male prepubertal and pubertal patients, and discussion of such options with patients and their families prior to the initiation of therapy and/or before further deterioration of gonadal function is crucial. In this case, the patient is status post left oophorectomy and requires surgery on the remaining ovary due to a large dermoid cyst. A prior egg retrieval procedure did not yield the recommended eight to ten oocytes. Given that upcoming surgery may jeopardize the patients ability to have biological children, the requested services are medically indicated. Therefore, a second round of fertility preservation services are 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 parent of an enrollee has requested authorization and coverage for the medication oxcarbazepine.Findings: Three out of three physician reviewers found that the requested medication oxcarbazepine is not likely to be more beneficial than any other available standard treatments for the patients medical condition.According to the International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder, the anticonvulsants divalproex sodium and carbamazepine have not fared well head-to-head with second-generation antipsychotics (SGAs). The Task Force report noted that in two meta-analyses, treatment effect was less robust with anticonvulsants than with SGAs. The report stated that a randomized controlled trial (RCT) of divalproex extended release was negative, as was a large RCT of oxcarbazepine, and a topiramate RCT in youth was interrupted prior to its completion due to negative results in adult studies. According to a 2011 Cochrane Database of Systematic Reviews, there are insufficient trials of adequate methodological quality on oxcarbazepine in the acute treatment of bipolar disorder to inform us on its efficacy and acceptability. The Cochrane authors stated that, From the few studies included in this review, oxcarbazepine did not differ in efficacy compared to placebo in children and adolescents. It did not differ from other active agents in adults. It may have a poorer tolerability profile compared to placebo. The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults states that the use of oxcarbazepine in treating bipolar disorder is a fourth line treatment, after the second generation antispychotics, lithium, and electroconvulsive therapy. Therefore, the current evidence does not support the use of oxcarbazepine in treating pediatric bipolar disorder. Furthermore, there is no evidence that oxcarbazepine is superior to treatments that include second generation antipsychotics and lithium. Thus, the requested medication oxcarbazepine is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.