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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for lumbar spine magnetic resonance imaging (MRI). Findings: Given this patients age and presentation, conservative management is recommended. Surgical interventions should be reserved for use if the patients condition fails to improve with conventional measures.  The patients plain x-rays ruled out dramatic anatomic abnormalities. Although the patient has degenerative changes and short pedicles, in a young active patient who has a recent history of hurting their back after exerting themselves, MRI was unlikely to provide significant information that would change their plan of care. As has been shown in multiple studies, incidental findings of degenerative disease or disc abnormalities are common in asymptomatic patients. The American College of Radiology (ACR) has established criteria to help providers obtain efficient use of imaging modalities to evaluate various clinical presentations. Per the ACR, MRI is not usually appropriate in the management of chronic pain without other concerning signs or symptoms. On physical examination, the provider did not detect any abnormalities in strength, muscle tone, or reflexes. In addition, there is no evidence of tumor or infection. All told, the lumbar spine MRI  was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: An enrollee has requested authorization and coverage for an ultra-lightweight manual wheelchair and accessories.In this case, the records do not establish that the patient has the physical capacity to self-propel a manual wheelchair safely and effectively, or to perform pressure relief without power tilt-in-space functionality. This is consistent with the patients current need, as a person with a C6-7 level spinal cord injury, residual tetraplegia and prior history of coccygeal pressure ulcer, for a power wheelchair with tilt-in-space as his primary mobility device. There is no documented, detailed physical examination and functional evaluation related to his hand function to establish that he is an appropriate ultralight weight manual wheelchair user. There is also no documented, pertinent, detailed physical examination and functional evaluation related to his ability to perform effective, reliable and consistent pressure relieving and repositioning maneuvers using his own body power, which is critical to mitigate pressure injury risk, as well as to address posture/positioning for comfort and fatigue management. The patient, notably, is reported to be obese, which would make independent pressure relieving and repositioning maneuvers more challenging. The patients primary means of mobility is reported to be his power wheelchair. The patient has or should have a device that is reliable enough to provide his mobility needs on a daily basis. In the event that the patients power wheelchair breaks down or becomes non-operational, an equivalent, loaner power wheelchair should be provided by the durable medical equipment vendor until the primary wheelchair is fixed. If the patients power wheelchair is frequently non-operational (i.e., defective), it should be replaced altogether by the durable medical equipment vendor with a new device that works reliably. If non-operational power wheelchairs are a consistent problem, a different vendor should be considered. Under these circumstances, the requested ultra-light weight manual wheelchair and accessories are not medically necessary to treat the patients condition (C6-C7 spinal cord injury with paraplegia).Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to treat the patients 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Labiaplasty Hypertrophy Correction surgery.Findings:  The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. In this case, the patient underwent bilateral labiaplasty for labial hypertrophy four years ago. She was seen post-operatively with no documented complaints or asymmetry on exam. The submitted medical records reflect that the patient had a Gynecology office visit 17 months ago for confirmation of pregnancy, however, these records do not include any report of symptoms of asymmetry or pain. Based on the patients clinical documentation, the patient has not had her reported symptoms of asymmetry or pain evaluated or examined by a clinician. Under these circumstances, the requested Labiaplasty Hypertrophy Correction surgery is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient has reported that following bilateral labiaplasty for labial hypertrophy, she has noticed asymmetry with an elongated left labia that is causing discomfort for her, both mentally and physically. The patients submitted Gynecology records do not reflect that the patient has seen a specialist in Obstetrics and Gynecology to review her symptoms and examine her labia for asymmetry and scarring. There is therefore no documentation of an abnormal structure of the body at this time. Accordingly, the requested Labiaplasty Hypertrophy Correction surgery is not reconstructive in nature for treatment of the patient at this time.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's medical condition and not reconstructive in nature for treatment of the patient at this time. 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: The patient has requested authorization and coverage for three sessions per week of speech therapy and three sessions per week of occupational therapy, or in the alternative fewer sessions per week of speech therapy and occupational therapy. Functional impairments due to acutely acquired brain insults improve with time and are also amenable to rehabilitation interventions. Skilled therapy services are appropriate following an acute brain injury to promote recovery, maximize function, transition patients to an independent program when feasible, or to train caregivers for supervising a patients convalescence in the community (Lee, et al.). Deficits can persist, particularly in the setting of severe brain insults, including cognitive deficits and behavioral manifestations (Brasure, et al.; Smania, et al.). However, the benefits of long-term cognitive rehabilitation in this clinical setting remain unclear (Chung, et al.; Eshel, et al.). The records provided for review document that this patient sustained a traumatic brain injury in a motor vehicle accident in October 2020. She underwent extensive inpatient level care including acute inpatient rehabilitation, where she made significant functional progress for her with severe impairments. She was discharged home where she requires some supervision for tasks such as bathing. The patient has lingering higher level cognitive deficits and judgment impairments consistent with the nature of her injuries, which included frontal lobe intraparenchymal injury. The patients speech and functional memory are otherwise functional. While impairments and functional deficits persist, there is no reasonable expectation of improvement in outcomes with further formal speech and occupational therapies. The patient has maximized the benefit that she is expected to obtain from these types of services. For these reasons, the requested three sessions per week of speech therapy and three sessions per week of occupational therapy, or in the alternative fewer sessions per week of speech therapy and occupational therapy, 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 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 frovatriptan succinate 2.5 mg tablet as needed. Researchers note that migraine is a common neurovascular disorder, and that current guidelines recommend triptans, such as frovatriptan, as first-line treatment for moderate-to-severe migraine attacks. The choice of serotonin agonist may depend on the patients response to different triptans, taking into consideration different pharmacologic properties and delivery routes. In this case, given that the patient has tried and failed sumatriptan and Migranal, and has responded well to frovatriptan, the requested medication is medically indicated. Therefore, frovatriptan succinate 2.5 mg tablet as needed 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 neurology with sub-specialty certification in neuromuscular 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 authorization and coverage for Octagam 30 grams daily for 3 days (loading dose) then 75 grams every 3 weeks for 3 cycles. Findings:  The physician reviewer found that standard management of small fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain. Liu and colleagues note that small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. The authors further noted that IVIG was safe and effective for the treatment of small-fiber polyneuropathy. In this case, the patient has small fiber polyneuropathy with laboratory evidence of autoimmunity. Given that she has tried and failed conventional medical therapy, her autoimmune small fiber neuropathy may improve clinically with IVIG. Therefore, Octagam 30 grams daily for 3 days (loading dose) then 75 grams every 3 weeks for 3 cycles is likely to be more beneficial for treatment of this patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Octagam 30 grams daily for 3 days (loading dose) then 75 grams every 3 weeks for 3 cycles 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 medication 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 reviewer 1 is board certified in neurology with sub-specialty certification in vascular neurology and is actively practicing. Physician reviewers 2 and 3 are board certified in neurology 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 has requested authorization and coverage for Tbo-filgrastim (Granix), 1 microgram injections (J1447). Findings:  The physician reviewer found that white blood count growth factors are supported to reduce a patients risk of neutropenic fever when the anticipated risk of neutropenic fever for a chemotherapy regimen is approximately 20% (Smith, et al.). This patients records document chemotherapy-induced neutropenia. Based on current data, prophylactic white blood count growth factors are indicated for this patient to help lower her anticipated neutropenic fever risk. Moreover, per the National Comprehensive Cancer Network (NCCN), to minimize possible emergency care needs during the COVID-19 pandemic, it is reasonable to provide prophylactic white blood count growth factors to patients with a 10% or greater anticipated neutropenic fever risk, such as this patient. All told, the requested Tbo-filgrastim (Granix), 1 microgram injections (J1447) 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. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a dosing regimen for the medication, Cialis. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Cialis (generic name tadalafil) for the treatment of erectile dysfunction (ED). A study notes that in a randomized, double-blind study of patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), treatment satisfaction was greater with tadalafil over placebo. The authors further found that in patients with LUTS from BPH, tadalafil improved flow rates by 2.4 mL per second, compared with an improvement of around 2.2 mL per second with alpha blockers such as tamsulosin. The FDA dosage for the use of Cialis as needed is up to 10 mg once daily, with the possibility of increasing the dosage to 20 mg or decreasing the dosage to 5 mg, depending on efficacy and tolerability. For once daily use, the FDA recommends a dosage of 2.5 mg, which may be increased to 5 mg depending on efficacy and tolerability. In this case, the patient has diagnoses of BPH and ED. Given that current medical literature supports the use of and requested dosage of tadalafil for the treatment of these conditions, the requested medication is medically indicated. Therefore, a dosing regimen for the medication, Cialis, 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 urology 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 wheelchair add-on items (procedure codes E1012 x 1, K0108 x 4, E2300 x 1, and E2311 x 1). The records provided for review document that this patient has a history of cerebral palsy, which is a nonprogressive condition due to a brain injury or lesion acquired in the antenatal, perinatal or early postnatal period (Graham, et al.). The patient uses a power mobility device as his primary means of mobility in his home and in the community. The provider noted that the patients current power wheelchair is in a state of disrepair. The patient has documented bilateral lower limb edema with impaired motor function. He spends prolonged periods of time in his power wheelchair. He requires elevation of his legs to help manage this edema (Trayes, et al.; Simon). While in the wheelchair, the patient requires power leg elevation functionality (E1012 x 1), which should be used with recline functionality to prevent a slouching posture due to posterior pelvic tilt promoted by the hamstrings, which are generally an issue in this patient population (Wu, et al.). The patient is obese and requires two width extensions (K0108 x 2) on his footplate to accommodate his body habitus. Power seat elevation can be an appropriate component for a power wheelchair in order to improve a patients independence with transfers (Koontz, et al.; Toro, et al.). However, this patient is unsafe in his transfers and he requires assistance. There is no documentation of an actual transfer trial demonstrating that he was able to independently transfer safely by using a power seat elevation feature. His environment can be adjusted as needed to optimize his independence in the home. Power seat elevation (E2300) is not medically necessary based on the available records, and as this seat function is not supported, the upgraded electronics (E2311) are also not required. All told, the requested wheelchair add-on items (procedure codes E1012 x 1 and K0108 x 2) are medically necessary for treatment of this patient, while the requested wheelchair add-on items (procedure codes E2300 x 1, K0108 x 2, and E2311 x 1) are not medically necessary for this patient. Final Result: The reviewer determined that a portion 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of an Inspire Hypoglossal Nerve Stimulator System.Findings: Two out of three physician reviewers found that the requested implantation of an Inspire Hypoglossal Nerve Stimulator System is likely to be more beneficial than any other available standard treatments for the patients medical condition.There is a plethora of sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. The STAR (Stimulation Treatment for Apnea Reduction) trial showed that upper airway stimulation (UAS) provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a 5-year follow-up. Studies 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. Studies showed that improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS with implantable hypoglossal nerve stimulation. Serious adverse events were uncommon. UAS was determined to be a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure. The American Academy of Otolaryngology-Head and Neck Surgery considers UAS via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in adult patients who are intolerant or unable to achieve benefit with positive pressure therapy. In this case, the patient has been diagnosed with obstructive sleep apnea (OSA) by polysomnogram on 2/11/17 with an apnea-hypopnea index (AHI) of 52.3 events per hour and a lowest oxygen saturation of 90%. Records indicate that the patient failed CPAP therapy because of claustrophobia which did not improve after trying several different masks and machines. Therefore, the requested implantation of an Inspire Hypoglossal Nerve Stimulator System is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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.