Persius/hicric huggingface dataset:
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 home health private nursing services. The records provided for review document that this patient has global developmental delay, hypoxic-ischemic encephalopathy, seizure disorder, dystonia, and chronic lung disease. The patient has feeding difficulties and is gastrostomy tube dependent. He requires oxygen and suctioning, as often as once per hour. One provider reported that the patients vital signs were not taken during a recent office visit due to the patients severe movement disorder. Per the American Academy of Pediatrics (AAP), the requested home health services are consistent with current recommendations. The patients primary care provider and his movement disorder specialist have documented the presence of severe hyperkinetic movements, which place the patient and his caregiver at risk during the performance of routine care including intermittent gastrostomy tube feeds, administration of medication, dressing, bathing, and transfers. Home health private nursing services are indicated for this patient to prevent injury and disability resulting from the patients severe hyperkinetic movements. Therefore, the requested home health private nursing services are medically necessary to decrease disability and correct or ameliorate the patients behavioral health conditions.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for enzalutamide (Xtandi) 40 mg quantity of 360 for the duration of 90 days. Findings:  The physician reviewer found that  Xtandi is a potent androgen receptor inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of castration-resistant prostate cancer and metastatic castration-sensitive prostate cancer. Traina and colleagues evaluated Xtandi for treatment of patients with metastatic triple-negative breast cancer. The authors evaluated 118 patients with androgen receptor-positive metastatic triple negative breast cancer. The authors found that their study supports additional development of Xtandi for patients with advanced triple negative breast cancer. This patient does not reportedly have metastatic disease and she has received neoadjuvant and adjuvant therapy for her triple negative breast cancer. Therefore, the requested enzalutamide (Xtandi) 40 mg quantity of 360 for the duration of 90 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 internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a home birth. The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice note that while each woman has the right to make a medically informed decision about delivery, the ACOG supports the hospital setting for delivery over planned home birth due to the availability of physicians, blood transfusions, antibiotics, anesthesia, and other resources for intensive and emergency maternal and newborn care. While acknowledging that many patients are concerned about leaving their home because of the COVID-19 pandemic, the ACOG continues to recommend existing evidence-based guidance regarding hospitals and accredited birth centers as the safest setting for delivery. In this case, the patient has chosen to receive care from a midwife and is planning a home birth. Based on current medical literature, planned home birth is not medically indicated. Therefore, a home birth is not medically necessary for the treatment 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 obstetrics and gynecology 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 and authorization and coverage for inpatient post-acute neuro-rehabilitation.Methamphetamine use disorder is a major public health problem associated with high rates of attrition, crime, relapse, morbidity and mortality. Methamphetamine can be neurotoxic, and chronic abuse is associated with behavioral problems and cognitive deficits, particularly with respect to executive functions.In this case, the patient has a history of chronic methamphetamine abuse, substance abuse treatment, and recidivism. She also has a remote history of frontal lobe cerebral insult due to a hemorrhage, a condition well associated with acquired personality disturbances. These pathological processes have resulted in a chronic history of poor overall social function, with chronic cognitive deficits, behavioral problems and safety awareness impairments. The patients physical impairments are likewise chronic, but mildly impairing. Records reflect that prior to her stay at the residential facility, the patient was already physically independent for all of her self-care and community-level mobility. Her functional deficits were predominantly cognitive and behavioral in nature.The patient has been undergoing an extensive and intensive rehabilitation program. There are some reported improvements in some domains, but the patient largely remains significantly impaired with respect to her cognition, behavior and safety awareness. It is not anticipated that she will be able to return to the community without significant levels of supervision. It is not clear, moreover, whether the modest reported improvements in the various tests that have been employed in the formal therapy setting are likely to translate to practical, meaningful benefits in the community setting, or that these benefits would be sustained for a meaningful duration. Records reflect that the patient, overall, is at a custodial level of care. She is, and has been, physically independent for all of her self-care and basic mobility. She is receiving supervision for her safety. She is also receiving therapy services that can be provided on an outpatient basis if she elects to continue these services on an empiric basis on her own. Under these circumstances, the requested inpatient post-acute neuro-rehabilitation was not, and is not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis in both knees and of relief using viscosupplementation every six to twelve months. She has tried other conservative treatments including activity modification, bracing, corticosteroid injections, and NSAIDs, and is not a candidate for bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections in both knees 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 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: The patients parent has requested authorization and coverage for a cranial helmet. In a systematic review on the role of cranial helmet therapy for patients with positional plagiocephaly, Tamber and colleagues concluded, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). In this case, the patient has severe skull deformity with greater than 90% cranial index and has been diagnosed with plagiocephaly. Given the current medical literature, the requested device is medically indicated for the treatment of this patient. Therefore, a cranial helmet 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 pediatrics with sub-specialty certification in pediatric critical care 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 surgical implant device hypoglossal nerve stimulation. Findings:  The physician reviewer found that Woodson and colleagues performed a multicenter prospective cohort study and concluded that improvements in sleepiness, quality of life, and respiratory outcomes were observed with five years of upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Woodson and colleagues noted that serious adverse events were uncommon, and they stated that UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure treatment. Multiple additional studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate to severe obstructive sleep apnea patients who have failed medical therapy. Meta-analysis has demonstrated clinically significant decreases in observed mean apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and Epworth sleepiness scale (ESS), combined with improvements in quality-of-life scales. The STAR (Stimulation Treatment for Apnea Reduction) trial also showed that UAS provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a five-year follow-up.In this case, the patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his obstructive sleep apnea. The alternative, no treatment, would lead to potential harms such as increased medical co-morbidities including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. Under these circumstances, the requested surgical implant device hypoglossal nerve stimulation is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic otolaryngology, 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for durable medical equipment (DME) (wearable cardioverter defibrillator). Findings:  The physician reviewer found that American College of Cardiology (ACC) and American Heart Association (AHA) guideline for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death noted that an alternative to an implantable cardioverter-defibrillator (ICD) is the wearable cardioverter-defibrillator. The guideline found that wearable cardioverter-defibrillators were appropriate in patients with ventricular fibrillation. In this case, a cardiac catheterization demonstrated complete right coronary artery occlusion, and an echocardiogram report reported cardiac wall hypokinesis. Electrocardiograms (EKGs) demonstrated ventricular tachycardia that required defibrillation and new left bundle branch block which reversed on subsequent EKGs.  In this clinical setting, the risk of sudden cardiac death (SCD) is significant and the LifeVest was appropriate. Therefore, the durable medical equipment (DME) (wearable cardioverter defibrillator) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the durable medical equipment (DME) (wearable cardioverter defibrillator) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device was likely to have been 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 internal medicine with sub-specialty 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: An enrollee has requested reimbursement for Breast Ultrasound (CPT 76641) services.Annual screening mammography reduces mortality from breast cancer in women over the age of 40. The sensitivity of screening mammography in women with non-dense breast tissue is approximately 85%, however, the sensitivity of screening is significantly decreased in women with dense breast tissue to approximately 48-64%, as cancers can be obscured by the dense tissue. There is also a 4.7 fold increased risk of breast cancer in women with dense tissue compared to non-dense counterparts. Therefore, screening ultrasound in this population can be used to detect mammographically occult cancers.Women with dense breast tissue are considered at intermediate risk for breast cancer. ACR guidelines state that screening breast ultrasound can be used to detect more cancers in this population in addition to screening mammography. Melinkow and colleagues state that evidence suggests that more breast cancers will be diagnosed with the addition of ultrasound or MRI screening in women with dense breast tissue. Also, most of these additional detected cancers will be invasive cancers. According to the ACR appropriateness criteria for breast cancer screening, mammography is recommended as a first line screening tool. In patients with dense tissue, ultrasound can be used as an additional screening tool. Additional screening with ultrasound in the patient population with dense breast tissue will increase the sensitivity of invasive cancer detection. In this case, the patient had a personal history of dense breast tissue and had bilateral mammography screening performed. Upon referral, the patient had bilateral breast ultrasound performed one year later due to dense breast tissue. Under these circumstances, the Breast Ultrasound (CPT 76641) services at issue were medically necessary for this patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 a consultation with an orthopedic surgeon. Current evidence-based peer reviewed literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. In this case, the patient has a history of low back pain. She was initially evaluated in the emergency room. She did not report radicular symptoms at that time, and a clinical examination did not document focal neurologic deficits. While a CT scan showed a questionable posterior disc bulge at L5-S1, there were no findings of lumbar scoliosis. The patient reported persistent symptoms. While the provider referred the patient for an orthopedic surgery consultation, the records do not indicate that the patient had failed to improve with conservative treatment or had any red flags warranting an urgent referral. As such, the requested service is not medically indicated for the initial evaluation and management of the patients symptoms. Therefore, a consultation with an orthopedic surgeon 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 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 patients parent has requested authorization and coverage for brand name medication, Zovirax cream. Findings: Researchers conclude that for episodic treatment of herpes labialis, oral antiviral agents are superior to topical antiviral therapy. The authors noted that while topical agents, such as acyclovir, can also be used for episodic treatment, these topical agents are not effective in the prevention of recurrent herpes labialis. Given the current medical literature, the requested medication is not medically indicated. Therefore, brand name medication, Zovirax cream is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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.