Persius/hicric huggingface dataset:
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 orthopedic specialist consult. Findings:  The physician reviewer found that Kane and colleagues state, Double crush syndrome is a distinct compression at two or more locations along the course of a peripheral nerve that can coexist and synergistically increase symptom intensity. The authors conclude, Treating practitioners should be aware of the possibility of concomitant cervical radiculopathy and carpal tunnel syndrome, as well as the presence of underlying systemic neuropathy. In this case, the patient had positive Tinels test and Phalens test. Additionally, the patient has been treated with nonsteroidal anti-inflammatory drugs (NSAIDs), wrist brace, and gabapentin, without significant improvement. X-rays of the cervical spine revealed moderate encroachment right C5-6 level, further complicating the diagnosis. Given that there were sufficient records supporting carpal tunnel syndrome, along with the uncertainty of cervical spine involvement, an orthopedic hand/upper extremity specialist consult would be appropriate. Therefore, the requested orthopedic specialist consult is medically necessary for treatment of the patients medical condition.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 overturn.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 patient has requested authorization and coverage for physical therapy services. Medical literature note that the Department of Health and Human Services physical activity guidelines for Americans recommend that people with chronic conditions remain physically active as their abilities and conditions allow. In this case, the records note that the patient was discharged from physical therapy following completion of interventions and reaching his maximum potential. The patient is limited in the physical activity he can tolerate due to his chronic illnesses, and the recommendation in this clinical setting is to maintain levels of function as allowed, such as bed mobility and sit to stand transitions.  While researchers note that aerobic and resistance exercise may potentially benefit patients with obesity, such therapies may be provided by caregivers as a home exercise program. Given that the patients current goal is to maintain his status through caregiver or certified restorative nurse (CRN) assistance, current medical literature does not support the use of professional physical therapy services. Therefore, physical therapy services are 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulicity (0.75 mg/0.5 mL per injector). Findings:  The physician reviewer found that  glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as Trulicity, are one of the preferred approved treatment options for people with type 2 diabetes (T2D) and inadequate glycemic control. The author further notes that GLP-1 RAs help in regulating insulin secretion in proportion to environmental glucose levels, have a low risk of hypoglycemia, facilitate weight loss, and may also have beneficial effects on the cardiorenal system, including reducing cardiovascular risk and improving renal outcomes. Nauck and colleagues report that given the effectiveness for hemoglobin A1c (HbA1c) reduction with additional weight reduction and without intrinsic risk of hypoglycemic episodes, GLP-1RAs are recommended as the preferred first injectable glucose-lowering therapy for type 2 diabetes, even before insulin treatment. In this case, the records note that the patients glycemic control is not currently at goal and that her endocrinologist recommended Trulicity. In this clinical setting, the requested medication is medically indicated. Therefore, Trulicity (0.75 mg/0.5 mL per injector) 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 endocrinology, diabetes, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology (ACR) appropriateness criteria note that an MRI of the lumbar spine is usually appropriate for patients with subacute or chronic low back pain, with or without radiculopathy, who are candidates for surgery or intervention and who have persistent or progressive symptoms during or following six weeks of optimal medical management. Given that an MRI of the lumbar spine is strongly recommended in patients with persistent low back pain with neurologic symptoms to evaluate for a surgically correctable cause, such as a mass or herniated disk, and for consideration of surgery or an epidural steroid injection, the requested service is medically indicated. Therefore, an MRI of the lumbar spine 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 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 brand name Paxil. There is a lack of evidence in current medical literature that generic paroxetine hydrochloride has a diminished efficacy in comparison to brand name Paxil. Carbon and Correll note that the generic substitution of branded medications is common and that these replacements are based on the concept of bioequivalence, which is considered equal to therapeutic equivalence. Under the U.S. Food and Drug Administration, the active ingredient in the psychotropic brand name Paxil and the generic paroxetine hydrochloride must be comparable to be marketed. McInerney and Kennedy note regarding the use of antidepressants in the treatment of bipolar depression that only when mood stabilizer or atypical antipsychotic monotherapy has failed should adjunctive treatment with an antidepressant be considered. In this case, the patient has a diagnosis of bipolar I disorder, with persistent manic symptoms. Given that the records noted that the patient was not medication compliant and laboratory testing showed sub-therapeutic lithium levels, the use of generic or brand name Paxil for this patient, whose mood is not stabilized fully, is not medically indicated. In this patients case, brand name Paxil is not accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, brand name Paxil 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clonazepam 0.5 mg daily. Although the requested dose of clonazepam is low, two of the patients providers have recommended that the patient be weaned off clonazepam. The recommendation to wean the patient off clonazepam in this clinical setting is consistent with the medical literature. Long-term treatment with benzodiazepines is not recommended in patients over 64 years of age, given the potential risks, including cognitive impairment, falls, respiratory problems, and dependence. This patient reports that clonazepam has been beneficial in managing his insomnia. However, the records provided for review do not include a sleep study fully evaluating the patients symptoms of insomnia. In addition, there is no report that the patient has been treated with doxepin. One of the patients providers recommended cognitive behavioral therapy (CBT), which is considered first-line therapy in the treatment of insomnia and is likely to be effective for this patient. For these reasons, the requested clonazepam 0.5 mg 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 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 authorization and coverage for pegfilgrastim 6 mg (Neulasta) injections. The U.S. Food and Drug Administration (FDA) approves the use of pegfilgrastim (brand name Neulasta) to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. Researchers note that there is a high incidence of febrile neutropenia post adjuvant chemotherapy with docetaxel, carboplatin and trastuzumab for early-stage breast cancer. In this case, given that the patient reports significant burden and fatigue from filgrastim, the requested medication is medically indicated. Therefore, pegfilgrastim 6 mg (Neulasta) injections 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 certifications in medical oncology and in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of right perforator vein adjacent to the right medial malleolus ulcer (CPT 36475-RT, including image guidance and monitoring). Traditional treatment options for recurrent venous ulceration have consisted of prolonged compression, wound debridement, and elevation. The current treatment guidelines from the Society for Vascular Surgery (SVS) and American Venous Forum (AVF) recommend correction of reflux, especially when the source of reflux is in close proximity to the ulcer. Based on the SVS and AVF guidelines, this patient meets the requirements for the requested RFA treatment. The guidelines state that, In a patient with venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veinswe suggest ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence (ODonnell, et al.). In this case, two incompetent perforator veins have been identified in close proximity to the ulcer. RFA of the incompetent perforator veins is likely to accelerate wound healing and may also lessen the likelihood of recurrence. All told, the requested RFA of right perforator vein adjacent to the right medial malleolus ulcer (CPT 36475-RT, including image guidance and monitoring) is 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 RFA of right perforator vein adjacent to the right medial malleolus ulcer (CPT 36475-RT, including image guidance and monitoring) is 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 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 reviewer 1 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in general surgery with subspecialty certification in vascular surgery and is 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The parents of an enrollee has requested authorization and coverage for dermatology services (including office visit and biopsies) at a clinic offering pediatric tertiary care.Removal of benign nevi for biopsy is a very common procedure that is performed by all dermatologists. Cohen states, Most dermatologists evaluate children and adolescents who have changing moles. Moreover, most of those patients are evaluated by general rather than pediatric dermatologists. Nevi or moles affect all ages and a board certified dermatologist is qualified to treat these conditions. A board certified dermatologist is qualified to treat children and adults and can adequately assess and biopsy or treat patients of all ages. As moles occur in adults and children, there is no medical reason, this patient needs to be seen by the tertiary care pediatric dermatologist. Therefore, dermatology services (including office visit and biopsies) at a clinic offering pediatric tertiary care are not medically necessary for treatment of 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for language therapy services five times per week using the PROMPT method. Findings:  The physician reviewer found that records provided for review document that this patient has a history of chromosome 5 deletion with submucosal cleft palate, bifid uvula, abnormal oral frenulum, and corpus callosum abnormalities. The patient has received speech therapy using the PROMPT method five times per week for the past 12 years for the treatment of apraxia of speech. The American Speech-Language-Hearing Association (ASLHA) reported that in the treatment of childhood apraxia of speech, The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody. The PROMPT method involves a tactile approach where the provider helps guide a patients jaw, lips, and tongue to move correctly to form speech. This patients documentation does not include standardized evaluations of the patients speech and language function. The providers notes indicate that the patients progress has been inconsistent and minimal, which suggest that the patient has likely plateaued. The provider charted that the patient demonstrates significant fluctuation in her performance from day to day, typically imitating two-word phrases with 65-90% accuracy. The patient has intellectual disability and does not do well with unfamiliar people and settings. The medical literature supports maintenance speech therapy services using the PROMPT method at a frequency of twice per week, which is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the requested language therapy services two times per week using the PROMPT method are medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. This patient presents with chronic back pain that has not substantially improved despite conservative treatment. The patients provider has recommended treatment with the Intracept procedure. The peer-reviewed medical literature has demonstrated that the Intracept procedure can provide long-term improvement of chronic low back pain in patients who fail to improve with conservative care. The current treatment modalities for this patient population includes fusion or artificial disc replacement. The Intracept procedure offers a less invasive outpatient procedure that maintains the structural integrity of the spine. Patients have been shown to have significant improvements in pain and overall return back to high functioning level with the Intracept procedure (Truumees, et al.; Khalil, et al; Markman, et al.). All told, the requested Intracept procedure is 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 Intracept procedure is 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 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is 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.