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 30 treatments of hyperbaric oxygen therapy in a hyperbaric oxygen therapy multi-chamber. In this case, the records did not document signs of ischemia, necrosis, or poor capillary refill that may indicate graft failure. While an edema of grafts was documented, this is not necessarily a sign of a failing graft and likely reflected normal postoperative appearance. There is a lack of consensus in current medical literature on the number of treatments to treat a failing graft, rather the number of treatments should be individualized based on response. In this clinical setting, hyperbaric oxygen therapy of any kind, whether monoplace or multi-place chamber, was not medically indicated. Therefore, 30 treatments of hyperbaric oxygen therapy in a hyperbaric oxygen therapy multi-chamber were not medically necessary for the treatment of this patientFinal 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 public health and general preventive medicine with sub-specialty certification in undersea and hyperbaric 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 patient has requested authorization and coverage for temazepam. The available documentation supports diagnoses of major depressive disorder (MDD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), sedative hypnotic use disorder, and insomnia. The patient has requested treatment with temazepam. However, each of the patients providers have recommended against ongoing treatment with temazepam. As recommended in the clinical guidelines and medical literature, the providers have weighed the risks of treatment with a sedative-hypnotic medication as outweighing the benefits to this patient. The patient has a history of escalating doses of their sleep medication on their own and has reportedly overused these medications to the point of potential overdose. Additionally increasing the patients risk is their regimen including opioids for pain management. Moreover, the patients records do not document that the patient has failed a course of cognitive behavior therapy (CBT) for insomnia or other first-line treatments that are not medication-based. Long-term use of temazepam is not clinically indicated for this patient. For these reasons, the requested temazepam is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 skilled nursing facility (SNF) level of care. Findings: As noted in the medical literature, SNF admission may be indicated for patients with more than one wound, including a stage 3 pressure ulcer, rehabilitation, gait training, and observation. One study noted that, Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces. Another study analyzed 477 patient records to determine the percentage of patients with pressure ulcers/injuries (PU/Is) who required admission to a SNF for wound care. The authors found that the majority of patients with a PU/I required admission from home to a SNF for appropriate care. In this case, the records document that the patients spouse has been unable to provide adequate care for the patient as demonstrated by her falls, weakness, and  cachexia. The provider has recommended SNF placement to observe and assess the patients changing condition as well as evaluate and provide modified or additional services as needed. Although the patient was previously not considered appropriate for skilled care, her declining status, persistent wounds, and falls support an indication for 24-hour skilled care. Currently, the patient requires 24-hour care for monitoring, falls, wound care, and adequate nutrition. For these reasons, the requested SNF level of care 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 family medicine, preventive medicine, and undersea and hyperbaric medicine, with expertise in wound care 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 reintegration/reunification therapy. There is a lack of adequate data in current medical literature to support the use of reintegration/reunification therapy to prevent or treat major depressive disorder and anxiety. DAndrade describes reunification therapy as a form of family therapy that is often court-ordered when a parent-child contact problem has culminated in the child refusing to spend time with one parent. The American Psychiatric Association (APA) clinical practice guideline for the treatment of depression reports that there is insufficient evidence to recommend family therapy for the treatment of adults with major depressive disorder. In this case, this patient has a history of major depressive disorder. She has not responded to multiple medication trials and declines further medication trials. The patients provider has also referred the patient for transcranial magnetic stimulation. While repetitive transcranial magnetic stimulation is recommended for patients with major depressive disorder who have not responded to medications, the requested service is not medically indicated. Therefore, reintegration/reunification therapy is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure at L5-S1. Current medical literature supports the use of the requested procedure in leading to statistically significant improvement over standard therapies including physical modalities and injections. Fischgrund and colleagues report that patients treated with radiofrequency ablation of the basivertebral nerve for the treatment of chronic back pain maintained benefits at two years following treatment in both Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). The  authors concluded that basivertebral nerve ablation is a durable, minimally invasive treatment for vertebrogenic chronic low back pain. Truumees and colleagues report that in patients with chronic low back pain and Modic type 1 or type 2 vertebral endplate changes, treatment with minimally invasive radiofrequency ablation of the basivertebral nerve resulted in significant improvement in pain and function. In this case, the patient has Modic endplate changes on MRI and axial low back pain. In this clinical setting, the requested procedure is likely to be superior to continued conservative care. Therefore, an Intracept procedure at L5-S1 is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure at L5-S1 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 service 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 myoelectric upper extremity prosthetic device with accessories. This patient is being treated for complete traumatic amputation of right shoulder and upper arm. He was evaluated for a prosthesis for his dominant right upper extremity. He is eager to regain function on his right side with an active grasp. this is reportedly so he can resume activities that bring enjoyment to his life, including returning to work. The recommended prosthetic is an interscapular thoracic level myoelectric prosthesis, with accessories. Carey and colleagues noted the choice of a myoelectric or body-powered upper-limb prosthesis can be determined using factors including control, function, feedback, cosmesis, and rejection. Vujaklija and colleagues commented that, surgical techniques in combination with modern, sophisticated hardware are enabling restoration of dexterous upper limb functionality. Resnik and colleagues concluded that patients who did not use a prosthesis or used a cosmetic prosthesis reported greater difficulty performing activities of daily living when compared to patients who use body-powered and myoelectric devices. Based on the records provided for review, a body-powered prosthesis is inadequate to meet this patients needs since he is unable to generate enough inches of excursion to fully operate the device. A body-powered prosthesis requires sufficient physical ability to produce large movements. This patient has an amputation at the interscapular-thoracic level that reduces his leverage and ability to create cable excursion to fully operate a body-powered prosthesis. For these reasons, the requested myoelectric upper extremity prosthetic device with accessories is medically necessary for treatment of this patient. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Medtronic InPen insulin pen system with Humalog 3 mL insulin cartridges. Findings:  The physician reviewer found that Beck and colleagues explain that devices used by people with type 1 diabetes include insulin pumps, continuous glucose monitors, and, most recently, systems that combine both a pump and a monitor for algorithm-driven automation of insulin delivery. Bailey and Stone report that the InPen system is a novel approach that uses a wireless pen that syncs to a mobile application featuring a bolus advisor, enabling convenient insulin dose tracking and more accurate bolus advice among other features. Klonoff and Kerr state that compared to syringes or vials for insulin administration, pens are more convenient, have better dosing accuracy, and are associated with improved adherence and persistence and less hypoglycemia risk. Given that current medical literature supports the use of insulin administration pens in this clinical setting, the requested device and supplies are medically indicated. Therefore, a Medtronic InPen insulin pen system with Humalog 3 mL insulin cartridges is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device and supplies 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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for (1) a referral to a skin laser specialist, (2) a 585-nm flashlamp pumped pulsed dye laser/CO2 laser specific for scars, and (3) a higher dosage of Kenalog 40 mg. Jin and colleagues report that the management of hypertrophic scars and keloids remains a therapeutic challenge, and that while laser therapy is an emerging minimally invasive treatment that has recently gained attention, the level of evidence for laser therapy as a keloid treatment is low. The authors conclude that further research is required to determine the mechanism of action for different laser systems and to examine the efficacy in quantifiable parameters, such as scar erythema, scar texture, degrees of symptom relief, recurrence rates, and adverse effects. De Las Alas and colleagues report that the efficacy of 585-nm pulsed dye laser in the treatment of hypertrophic and keloid scars may be superior to conventional modalities in improving overall scar appearance, but that results were comparable when scar parameters were evaluated separately. The authors concluded that more parallel comparison trials with standardized methods of treatment and outcome assessment are recommended to evaluate long-term treatment effects and recurrence rates. In this case, as the patient has only received two rounds of Kenalog, (1) a referral to a skin laser specialist is not medically necessary for the treatment of this patient. Given the lack of evidence in current medical literature supporting the benefit of laser therapies, either pulsed dye laser or ablative carbon dioxide lasers, in the treatment of keloids, (2) a 585-nm flashlamp pumped pulsed dye laser/CO2 laser specific for scars is not medically necessary for the treatment of this patient. In a systematic review of invasive and noninvasive treatment modalities for hypertrophic scars, Kafka and colleagues reported that intralesional injections of 5-Fluorouracil mixed with a low dose of triamcinolone were the most appropriate treatment modality. In this case, a stronger dose of triamcinolone injection may be medically indicated as long as the patient is aware of and understands the increased potential for atrophy. Therefore, (3) a higher dosage of Kenalog 40 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services and medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested reimbursement for inpatient hospital stay. Traisman explains that urinary tract infection (UTI) is a common pediatric infectious disease that occurs throughout all age groups and the age of onset, gender, history, and physical examination results determine treatment and long-term management. Pathogenesis is multifactorial, and may result from dysfunctional voiding, instrumentation, turbulent flow from voiding abnormalities, or hematogenous spread. The most common organism is Escherichia coli (E. coli), although viruses and other bacteria may also be responsible for UTI. Presentation of infection varies by age and degree of infection. In young infants, presentation may include fever, lethargy, irritability, poor feeding, vomiting and diarrhea. An examination may reveal ill appearance, costovertebral angle tenderness, and abdominal tenderness. Urinalysis may reveal pyuria, bacteriuria, nitrites, leukocyte esterase, and hematuria.  Additional laboratory studies should also be considered depending on clinical presentation. For neonates and young infants, hospitalization for treatment with parenteral antibiotics is necessary. Robinson and colleagues note that for infants and young children with first febrile UTI, a renal ultrasound is recommended to identify potential pathology, and a voiding cystourethrography is indicated in second febrile UTI to rule out reflux. In this case, the patient presented with prolonged persistent high fevers, vomiting, and toxic appearance. The patient was diagnosed with UTI with concerns for pyelonephritis and sepsis. Laboratory studies supported presence of severe infection, with significantly elevated white blood cell (WBC) count as well as elevated C-reactive protein (CRP). Following admission, it took several days for the fever curve to resolve to baseline. The patient remained on parenteral antibiotics during the hospital stay and was transitioned to an enteral antibiotic to complete the treatment course. In this case, given the potential for morbidity and complications, and the severity of the symptoms including the initial concerns for sepsis, the services at issue were medically indicated. Therefore, the inpatient hospital stay was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ofatumumab (Kesimpta) subcutaneous auto-injector 20 mg/0.4 mL every four weeks. The records provided for review document that this patient has a diagnosis of relapsing-remitting multiple sclerosis with active disease in the spinal cord. The patients provider has recommended treatment with Kesimpta, which is a disease-modifying therapy. The American Academy of Neurology (AAN) guidelines, as well as multiple studies, have shown the benefit of disease-modifying therapies to decrease relapses and reduce magnetic resonance imaging (MRI) activity in patients who have experienced relapses and/or MRI activity. The U.S. Food and Drug Administration (FDA) has approved Kesimpta for the treatment of patients with relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. Per the AAN recommendations for the treatment of patients with multiple sclerosis, this patient meets the criteria for treatment with disease-modifying therapy (Rae-Grant, et al.). In addition, the requested for treatment with Kesimpta is supported by the peer-reviewed medical literature. Olek and colleagues noted that monoclonal antibodies for the treatment of patients with multiple sclerosis may be preferred for patients with more active disease, as in this patients case. Hauser and colleagues concluded that Kesimpta was associated with lower annualized relapse rates that treatment with teriflunomide. Given these findings, the requested ofatumumab (Kesimpta) subcutaneous auto-injector 20 mg/0.4 mL every four weeks 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for evolocumab (Repatha) 140 mg/mL. The U.S. Food and Drug Administration (FDA) has approved proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for select patients with unresponsiveness to statins or statin intolerance. Orringer and colleagues noted that, A cardiovascular outcomes study has shown that these agents reduce incident atherosclerotic cardiovascular disease (ASCVD) events in patents with stable ASCVD and concomitant risk factors. However, this patients records do not include documentation to support treatment with a PCSK9 inhibitor. Currently, there is inadequate support in the peer-reviewed medical literature demonstrating a significant benefit of PCSK9 inhibitors such as Repatha in guiding optimal management of this patient. Therefore, the requested evolocumab (Repatha) 140 mg/mL is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.