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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for an MRI of the cervical spine. The enrollee has diagnoses of immune thrombocytopenic purpura (ITP) and immunoglobulin A (IgA) deficiency. The enrollees medical history includes Klippel-Feil syndrome, cervicalgia, spondylosis of the cervical region, fibromyalgia and scoliosis. At an earlier office visit, the enrollee reported neck pain radiating to his shoulders, with dizziness, and with weakness to his hands, which caused him to drop objects. The progress note from the visit indicated the enrollee would require a C 5-6 fusion in the future. At a recent office visit, the enrollee reported several months of frequent episodes of neck pain; especially if he tipped his head backwards. This led to intermittent dizziness. The enrollee has a history of C5 retrolisthesis, which had not been re-imaged for some time. There was no radiculopathy noted in the upper extremities that could correspond with his neck complaint. Magnetic Resonance Imaging (MRI) of the cervical spine for re-imaging of the C5 retrolisthesis has been prescribed. The enrollee has a complex history. Klippel Feil Syndrome is a rare autosomal dominant condition in which there is a congenital fusion of the cervical vertebrae.  He has a history of chronic neck pain and degenerative changes, common in these patients.  Studies found these patients were at an increased risk for developing myelopathy.  The enrollee does not have radicular symptoms, but he does complain of persistent pain and headaches, consistent with upper cervical spine issues.  Given these findings in a high-risk enrollee, an MRI is medically necessary to guide management and prognosis decisions.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 10 hours per week of applied behavior analysis (ABA). Based on the presenting information, the requested 10 hours per week of ABA services are not medically necessary for treatment of this patient due to the absence of a current evaluation and treatment plan. The patient received negative autism diagnosis across several years from providers that included structured autism assessments such as the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). The positive assessments were performed without use of standardized measures. While a standardized measure alone is insufficient to make a diagnostic determination, they are an important aspect to accurately assess a patients symptoms, rather than relying solely on caregiver reports. In this case, the patient did not meet the criteria for autism utilizing standardized autism measures. The providers who diagnosed the patient with autism did not include standardized testing. In addition, the supporting documentation does not include a treatment plan outlining treatment goals to determine whether the requested 10 hours of ABA services would be sufficient, or excessive. The Behavior Analyst Certification Board (BACB) highlights that a treatment plan is important to identify the scope and intensity of treatment. There is no treatment plan assessing and outlining the patients skill deficits, rate of problem behavior, and goals to address the patients current diagnoses. Without a treatment plan covering these areas, the requested 10 hours per week of ABA 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 a BCBA and board certified in psychology, 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 enrollee has requested authorization and coverage for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient benefitted from prior viscosupplementation. Furthermore, her options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Medical evidence supports the requested services in this clinical setting. Therefore, bilateral knee Orthovisc injections 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

The patient has requested authorization and coverage for Yescarta therapy (CAR-T immunotherapy). Prior studies of autologous or allogeneic stem cell transplantation for relapsed DLBCL DHL demonstrate poor health outcomes and no significant clinical benefit following induction chemotherapy (Herrera, et al.; Landsburg, et al.). In a study of outcomes for patients with DHL who achieved a first complete remission following induction chemotherapy, consolidative autologous stem cell transplant was not associated with improved three-year relapse-free survival or overall survival (Landsburg, et al.). Studies on Yescarta CAR-T (chimeric antigen receptor T-cell) therapy have demonstrated induction of durable responses and manageable long-term safety. One recent study reported significant benefit for relapsed or refractory DLBCL, including DHL with Yescarta CAR-T therapy at two-year follow-up (Locke, et al.). All told, Yescarta therapy (CAR-T immunotherapy) is medically necessary for 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 subspecialty certification in medical oncology 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 Stelara infusions every eight weeks. A large randomized controlled trial demonstrated the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al.). A majority of these patients were able to discontinue steroids. The mechanism of Stelara is different that anti-TNF medications, which this patient has failed (Tuskey and Behm). Stelara is U.S. Food and Drug Administration (FDA) approved and recommended by guidelines for the treatment of Crohns disease (Lichtenstein, et al.). In this case, the patient has failed of Remicade in the setting of a high Remicade level without anti-Remicade antibodies. Per the American College of Gastroenterology guidelines, Individuals who have therapeutic drug levels and no antibodies with the presence of active mucosal ulceration are considered to have mechanistic failure and a medication with another class should be considered (Lichtenstein, et al.). The physician reviewer found that the American Gastroenterological Association guidelines state that in patients on an anti-TNF medication such as Remicade with therapeutic drug concentration and low or undetectable anti-drug antibodies, the recommended course of action is to switch to another drug class. For these reasons, Stelara infusions every eight weeks are medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 The patient has requested authorization and coverage for skilled nursing facility (SNF) services. At the time of admission, the patient required skilled rehabilitation services to improve her function but she did not have any documented skilled nursing needs. The patient received skilled care and improved. Subsequently, the patient did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable timeframe and she did not require skilled therapy to prevent deterioration with mobility or activities of daily living. Moreover, the patient did not require skilled therapy to establish a safe and effective maintenance program. The patient did not have any parenteral medications, complex wound care or nutrition given via a feeding tube. Her function had plateaued and she did not require further inpatient skilled rehabilitation services. The physician reviewer found that  SNF services provided were not and are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast augmentation. Bilateral breast augmentation is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) acknowledged that medically necessary gender confirming surgical interventions might include chest reconstruction or augmentation as appropriate for each patient, including nipple resizing or placement of breast prostheses. WPATH noted that for some patients, relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity. Clinical notes from this patients multidisciplinary transgender care team support a diagnosis of gender dysphoria. The records suggest that the patients distress related to her gender dysphoria would be greatly improved with a bilateral breast augmentation. All told, the requested bilateral breast augmentation is medically necessary for 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 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 20-24 acupuncture sessions. Current evidence suggests that most acupuncture therapies, including acupuncture combined with other therapies, are effective in decreasing pain and in improving physical function. Research found that acupuncture might be efficacious in terms of pain relief and reduction of muscle irritability in myofascial pain syndrome patients. The data support an initial trial of five to six acupuncture sessions in combination with a conditioning program of aerobic and strengthening exercises. Future treatment based on improvements in objective measures may justify an additional six sessions. Peer-reviewed medical literature indicates that passive care with acupuncture should be combined with active care such as a home exercise program. Additional acupuncture treatments should occur based on progressively greater, incremental objective gains. In this case, prior acupuncture sessions were reported as beneficial in reducing the patients symptoms. However, the records do not document the number of sessions completed and specific measurable, sustained, and objective functional improvement obtained with previous acupuncture. Moreover, the request for 20-24 sessions of acupuncture exceeds the current recommendations. The records do not document a reduction in medication intake or work restrictions, or an improvement in performing activities of daily living directly attributable to prior acupuncture. All told, the requested 20-24 acupuncture sessions 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 oriental 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:  The enrollee is requesting reimbursement and authorization and coverage for Botulinum toxin (Botox) injections. The enrollee has diagnoses of gingival recession, limited range of motion, temporomandibular joint (TMJ) disorders, sleep-related bruxism, muscle spasm, atypical facial pain, myofascial pain, headache and dystonia. The enrollee has been treated for painful bruxism, which has been causing persistent facial pain, dystonia, and headaches. She has demonstrated improvement, indicating the treatments have been effective in alleviating pain due to bruxism. The enrollee notes she has nighttime teeth clenching, in addition to bruxism with no evidence she grinds her teeth. Most of the pain she has experienced from clenching her teeth, which is involuntary, occurs during the day. The enrollee maintains Botox injections are the only thing that has helped stop the teeth clenching and the pain it causes. Evidence-based review on the therapeutic usage of botulinum toxin (Botox) in non-cosmetic head and neck conditions indicates the need for more randomized controlled studies to confirm Botox is safe and reliable for routine clinical use in bruxism. Literature also describes the risk that administration of Botox into the lateral pterygoid muscles to treat TMJ disorders may bring about a fixed smile because of dissemination of the toxin into the superficial facial muscles. The current evidence regarding interventions for the management of bruxism is still inconclusive and does not support botulinum toxin therapy for any of the enrollees co-existing conditions associated with bruxism. A review of the use of botulinum toxin for myofascial pain syndrome (MPS) in adults shows more high-quality randomized controlled trials (RCTs) of botulinum toxin for treating MPS are needed before firm conclusions on its effectiveness and safety can be drawn. There is a lack of consensus on the therapeutic effects of botulinum toxin on TMJ disorders, whereby the medical necessity is not substantiated.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for MRI of the spine (CPT 72157, 72156, and 72158). The enrollee is status-post wide excision of a left medial thigh myxoid liposarcoma. Margins of resection were negative. His post-operative course was complicated by development of a seroma, which improved on interventional radiology drain placement and antibiotics, but re-accumulated once his drain was removed. The enrollee completed radiation therapy. His recent computed tomography (CT) of the chest, abdomen and pelvis was negative for metastatic disease. His physician ordered a magnetic resonance imaging (MRI) scan of the femur and spine. His provider noted an MRI is necessary when screening for spinal metastasis because there have been multiple case reports of spinal metastases being discovered on MRI that were not noted on other imaging modalities. The medical record demonstrates the enrollee has a unique and unusual condition. He had undergone resection of a myxoid liposarcoma complicated by seroma. He is also morbidly obese; with a weight greater than 400 pounds.  He continues to have problems with fluid accumulation at the surgical site.  His physician most recently aspirated 500cc.  This is significant for chronic inflammation of unknown etiology. Subsequent imaging was negative for metastatic disease.  These findings were suggestive of no evidence of metastatic disease to the chest and abdomen; however, they do not rule out spread to the primary site and bone. Literature describes studies that reported spread of the disease to the bone and spine.  Studies show how an MRI can provide tumor identification in the spine status-post surgery to an extremity. These studies support imaging of the entire spine to rule out metastatic foci.  Although the enrollee has received radiation to the primary site, it is unknown whether skeletal metastasis has occurred.  The only way to determine metastasis would be with an MRI.  Literature  notes it would be the most sensitive; studies concur with this conclusion. An MRI to the entire spine would allow for grading for prognosis and management.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for skilled nursing facility (SNF) services. At the time of admission, the patient required skilled rehabilitation services to improve his level of function. There were no skilled nursing needs. Subsequently, the patient did not require any skilled nursing or rehabilitation services on a daily basis as. He was not expected to make measurable gains within a reasonable and predictable timeframe and he did not require skilled therapy to prevent deterioration with mobility or activities of daily living. The patient did not require skilled therapy to establish a safe and effective maintenance program. Subsequently, the patient did not have any parenteral medications, complex wound care or nutrition given via a feeding tube. He received skilled care and he improved. By the date of denial, his function had plateaued and he did not require any further inpatient skilled rehabilitation services. Therefore, the SNF services provided 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 internal medicine with expertise in skilled nursing facilities 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.