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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds with accessories. Findings: The records provided for review document that this patient has a history of paraplegia with at least good strength in the upper limbs. The patient has requested a power wheelchair. In the setting of neurologically-based mobility impairments, means of mobility should focus on more active means for the purposes of general health promotion. Moreover, manual wheelchairs provide greater maneuverability, particularly in indoor environments, due to their smaller size, smaller turning radii, and more direct control of the device. This patients records do not report any impairments of the upper limbs to preclude use of an optimally fitted manual wheelchair to accomplish mobility-related activities of daily living. The records do not indicate whether the manual wheelchair being propelled by staff is designed for efficient self-propulsion with design elements such as an optimally placed axle. All told, the requested power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds with accessories is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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

The patients parent has requested authorization and coverage for orthodontia/braces. In this clinical setting, the records note a submitted handicapping labio-lingual deviation (HLD) score of 27, which was recalculated by the Dental Plan as 19 and 16. The difference in scoring was in the area of measurement of anterior crowding, which is scored only if the crowding exceeds 3.5 mm in either arch. As the submitted documentation did not include intraoral photographs and only poor-quality model records, the presence or absence of anterior crowding cannot be affirmed. However, two scorers independently assessed an HLD score under the threshold of 26. Given the HLD score computed below the required threshold and a lack of orthodontic records supporting a severe malocclusion requiring intervention, the requested services are not medically indicated. Therefore, orthodontia/braces are not necessary to prevent disease and promote oral health or restore oral structures to health and function in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a PET scan (CPT 78815) and computerized tomography (CT) scan (CPT 74177 and CPT 71260) services with Beverly Hills Medical Imaging. Researchers note that spinal cord atrophy is prominent in chronic progressive neurologic diseases such as human T-cell lymphotropic virus type 1 (HTLV-1) associated myelopathy/tropical spastic paraparesis (HAM/TSP), using magnetic resonance imaging (MRI) to compare the spinal cord cross-sectional area in patients with HAM/TSP to that of healthy volunteers. In this case, the patient has a diagnosis of HAM syndrome and has undergone MRI studies and cerebrospinal fluid (CSF) analysis. In this clinical setting, given that MRIs have not shown any underlying lesion, and as current medical literature does not support the use of PET/CT in the evaluation and management of HAM syndrome, the services at issue were not medically indicated. Therefore, the PET scan (CPT 78815) and CT scan (CPT 74177 and CPT 71260) services with Beverly Hills Medical Imaging were not medically necessary for the 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 neurology with sub-specialty certification in vascular 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 hyperthermic intraperitoneal chemotherapy (HIPEC) surgery. This patient presented with metastatic disease at the time of initial diagnosis. The patient is noted to have poor prognostic features including a likely appendiceal origin and signet ring histopathology. The patients records indicate that he experienced at least partial response to the standard regimen of FOLFOX. The patients provider has recommended treatment with cytoreductive surgery and HIPEC. The use of HIPEC for appendiceal adenocarcinoma is supported by small studies that have shown a survival advantage in this particular clinical situation (Shaib, et al.). The National Comprehensive Cancer Network (NCCN) guidelines acknowledged that, patients with peritoneal carcinomatosis of appendiceal origin, [is] a group that has seen greater benefit with the cytoreductive surgery/HIPEC approach. Furthermore, the guidelines state that, complete cytoreductive surgery and/or intraperitoneal chemotherapy can be considered in experienced centers for selected patients with limited peritoneal metastases. This patient is being treated in a comprehensive cancer center with experience in HIPEC and is undergoing the proper evaluation for cytoreductive surgery with the inclusion of HIPEC. Given these findings, the requested HIPEC surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested HIPEC surgery 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Myrbetriq 50 mg tablets. Overactive bladder syndrome is defined by the International Continence Society (ICS) and International Urogynecological Association (IUGA) as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. The American Urological Association (AUA) guidelines recommend a stepwise approach to treatment, including behavioral modification and medical management (Gormley, et al.; Lightner, et al.). First-line medical management of overactive bladder includes anticholinergics, such as tolterodine or oxybutynin or the beta-3 agonist mirabegron (Myrbetriq). As noted in the medical literature, Myrbetriq has been shown in multiple prospective randomized trials with large numbers of patients to have equal efficacy to anticholinergic medications treating overactive bladder, but with fewer adverse events. This patient presents with a history of overactive bladder with symptoms including frequency and urgency. Per the medical records reviewed, the patient was previously treated with generic anticholinergic medications without relief of symptoms. The patients provider has recommended treatment with Myrbetriq, which is consistent with the U.S. Food and Drug Administration (FDA) approval and AUA guidelines for use of Myrbetriq. Therefore, the requested Myrbetriq 50 mg tablets 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 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

The patient has requested authorization and coverage for a Toujeo Max U-300 Solostar 300 units/mL insulin pen. Kumar and colleagues note that insulin therapy remains the cornerstone of effective diabetes management, and that timely intensification of insulin therapy reduces the progression of diabetes and the development of diabetes-related complications. Borgono and Zinman report that the continued development of improved injectable insulin formulations with superior pharmacokinetics and pharmacodynamics enhances glucose control and represents important clinical advances in the treatment of both type 1 and type 2 diabetes. Brown and colleagues report that Toujeo insulin glargine U-300 (Gla-300) is a new option for the treatment of diabetes mellitus that has been shown to be effective, with fewer episodes of hypoglycemia and slightly less weight gain than prior insulin therapies. In this case, the submitted records document that the patient is doing well on Toujeo insulin and that her glycemic control has gradually improved. In this clinical setting, the requested medication is medically indicated. Therefore, a Toujeo Max U-300 Solostar 300 units/mL insulin pen is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral facet joint injections. Findings:  The physician reviewer found that This patient presents with chronic low back pain from multiple etiologies including spinal stenosis and facet hypertrophy noted at L4-5 and L5-S1 on MRI. The provider reported increased pain with facet loading on physical examination. Facet arthropathy is likely a contributing etiology to the patients chronic pain. While other etiologies are likely causing his radicular symptoms, the patients facet hypertrophy is contributing to his axial back pain. In this clinical setting, the medical literature supports use of diagnostic medial branch blocks to assess facet hypertrophy as a contributing etiology for the patients chronic pain. Therefore, the requested lumbar/sacral facet joint injections are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 durable medical equipment (DME) RT300 functional electrical stimulation (FES) therapy system. Findings:  The physician reviewer found that records provided for review document that this patient sustained a traumatic injury to her cervical spinal cord. The patient has partial residual use of her upper limbs. She has declined to use a power wheelchair and she is using a manual wheelchair for her mobility. The mainstay of long-term management in this clinical setting focuses on surveillance and preventive clinical care related to the respiratory system, pressure injury, neurogenic bladder and bowel, tone issues, and monitoring for complications. The health and well-being in this patient population should be promoted through active exercise using volitionally intact muscles when possible and encouragement of participation in educational, social, recreational, avocational and vocational activities, i.e., at a wheelchair level. While standard rehabilitation measures may not resolve a patients neurological impairments due to their underlying spinal cord injury, the addition of an RT300 FES cycle ergometer is not expected to substantially improve health or functional outcomes beyond these standard measures. The FES cycle ergometer uses surface electrical stimulation leads to generate passive movement of the limbs to move the pedals of a stationary cycle. The intent of this passive movement of the limbs is to provide a measure of exercise and to provide various health benefits. However, the available peer-reviewed medical literature has not established that the RT300 FES provides improved health outcomes for patients with spinal cord injuries. The RT300 FES has not been shown to promote neurological recovery beyond natural recovery, or cardiovascular health, pulmonary health, bony health or other health parameters in a clinically significant manner. The FES device may help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but there is a lack of data demonstrating that use of the FES provides functional benefit in this clinical setting. Given these findings, the requested DME RT300 FES therapy system is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 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 computed tomography (CT) myelogram of the cervical, thoracic, and lumbar spine with contrast. Findings:  The physician reviewer found that patient presents with symptoms of both myelopathy and lumbar radiculopathy. The patient is status post multiple surgical interventions, and he has surgical hardware in his cervical, thoracic and lumbar spine. The patients symptoms of myelopathy could be due to canal stenosis with impingement of the cervical or thoracic spinal cord. In addition, his symptoms of low back pain with radiculopathy is concerning for lumbar nerve root impingement. Magnetic resonance imaging (MRI) will not be useful given the extensive metal artifacts including surgical hardware, which appears to be present at C3-4, C6-T1, and L1-S1. Plain CT alone will likely fail to show any central canal stenosis or spinal cord impingement. Given these findings, the requested CT myelogram of the cervical, thoracic, and lumbar spine with contrast is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurological 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

An enrollee has requested authorization and coverage for Humira 40 mg weekly Auto-Injector Pen Citrate-Free.Sandborn and colleagues state that anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohns disease in patients with moderate to severe disease. The use of Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. In a study by Sandborn and colleagues, the remission rate with weekly dosing was 46.9% versus 22.5% when dosing every other week. Ma and colleagues state that even higher doses have proven safe and effective when necessary. Additionally, American College of Gastroenterology guidelines for the treatment of Crohns disease state, Those with continued symptoms shouldhave their medication dose adjusted in order to attempt to optimize therapy. In this case, the patient had the disease previously controlled on Humira 40 mg every seven days, then active disease requiring emergency department presentation when decreased to Humira 40 mg every 14 days, and then recovery of remission when increased back to Humira 40 mg every 7 days. Therefore, a decrease to Humira 40 mg every 14 days, or discontinuation of Humira, could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or colonic dysplasia leading to colorectal cancer. Therefore, Humira 40 mg weekly Auto-Injector Pen Citrate-Free is medically necessary for the treatment of the patients 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 high-intensity focused ultrasound (HIFU) (CPT code 55880). The records reviewed document that this patient presents with Gleason 3+3 and Gleason 4+3 prostate cancer with 5 of 15 cores positive on transrectal ultrasound-guided biopsy. The patients provider has recommended treatment with HIFU. Many therapies have been investigated for the treatment of localized prostate cancer. HIFU has not been demonstrated to provide safe and effective long-term patient health outcomes in the treatment of prostate cancer for either whole gland or hemi-gland treatment. The American Urologic Association (AUA) noted that, if HIFU is offered as an alternative treatment modality for localized prostate cancer, it should be done within the context of a clinical trial. The AUA also noted that, Prospective randomized or comparative trials with other treatment modalities are lacking. Accordingly, the requested HIFU (CPT code 55880) is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested HIFU (CPT code 55880) is not likely to be more beneficial for treatment of the patient's 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 urology 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 authorization and coverage for Freestyle Libre continuous glucose monitor (CGM).A CGM system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, CGM systems have been demonstrated to be clinically valuable. A CGM system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose in clinical and public diabetes management settings, and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Henquin states that a CGM system has been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. Thus, the requested Freestyle Libre CGM is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for advanced lipoprotein testing services (CPT 83698, 83695, and 83704). Rosenson and colleagues noted that there may be a role for the measurement of low-density lipoprotein (LDL) cholesterol particle concentration, or the surrogate measure of apolipoprotein B, in patients with insulin resistance disorders who have not achieved their minimal acceptable LDL cholesterol targets. This patients records do not include documentation of an insulin-resistant disorder. Thus, the patient does not meet the criteria for lipoprotein B measurement as performed under CPT code 83704. With regard to CPT code 83695, the records supplied do not indicate any hepatomegaly or other reason to suspect hepatic steatosis to support an indication for this testing. CPT code 83698 can be performed to assess cardiovascular risk as associated with a variety of markers of inflammation, though to a lesser extent than C-reactive protein. Elevated levels of lipoprotein-associated phospholipase A2 have been reported as markers of increased cardiovascular disease risk. However, there is a lack of data in the peer-reviewed medical literature to support improved patient health outcomes with the use of this testing in this patients clinical setting. For these reasons, the advanced lipoprotein testing services (CPT 83698, 83695, and 83704) were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.