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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical spine magnetic resonance imaging (MRI) (neck). The American College of Radiology (ACR) appropriateness criteria for the evaluation of new or increasing nontraumatic cervical radiculopathy note that MRI of the cervical spine is considered usually appropriate. An MRI is currently the preferred modality to evaluate the cervical spine in the setting of nerve root impingement. Kuijper and colleagues report that MRI findings in patients with cervical radiculopathy should be interpreted together with the clinical findings. In this case, the previous MRIs demonstrated multilevel degenerative changes. Given that the patient reports a recent increase in symptoms and radiculopathy, and as a repeat MRI of the cervical spine is necessary prior to intervention, the requested service is medically indicated. Therefore, cervical spine MRI (neck) is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for food allergy lab work (CPT codes 82784 x 1 unit, 82787 x 4 units, 83520 x 4 units, 86001 x 11 units, 86003 x 37 units, 86008 x 46 units, 88184 x 1 unit, 88185 x 2 units). The peer-reviewed medical literature supports the measurement of IgE levels to specific foods concerning for allergens as part of a food allergy evaluation for a patient. However, an extensive array of blood tests that examine aeroallergen component IgE as well as food IgG4 testing has not been demonstrated to provide benefit in the evaluation of food allergies. Sicherer and Sampson noted that, Current management relies heavily on avoidance and emergency preparedness, and recent studies, guidelines, and resources provide insight into improving the safety and well-being of patients and their families. The available data does not endorse the utility of the additional food allergy lab work studies requested in this patients evaluation and treatment. Therefore, the requested food allergy lab work (CPT codes 82784 x 1 unit, 82787 x 4 units, 83520 x 4 units, 86001 x 11 units, 86003 x 37 units, 86008 x 46 units, 88184 x 1 unit, 88185 x 2 units) is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certification in allergy and immunology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Medical literature reports that irritant contact dermatitis is often caused by cumulative exposure to weak irritants, accounting for 80% of all cases of contact dermatitis, and may co-exist with atopic dermatitis and allergic contact dermatitis, with pruritus classically reported by these patients. Researchers note that systemic contact dermatitis refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross reacting allergen via a different route. Per the authors, current treatment options include topical steroids and oral antihistamines for symptom relief and dietary avoidance to causative foods or metals. In this case, the patient presented with a pruritic rash. The patient was prescribed betamethasone and Zyrtec. Given that the patient had failed to respond to over-the-counter medication, the services rendered were urgent care services, defined as services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The patient presented again for evaluation for a vulvar mass that had been present for two months. Given that the patients symptoms were not sudden in onset and there was adequate opportunity for the patient to seek care on a non-urgent basis, the services provided were not urgent care services, defined as services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury.Final Result: The reviewer determined that a portion of the services at issue were 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 emergency 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 patients parent has requested authorization and coverage 20 hours a week of applied behavioral analysis (ABA) services. Based on the presented information, the Council of Autism Service Providers (CASP) and ABA Coding Coalition treatment guidelines, and the medical necessity criteria outlined by Papatola and Lustig, the requested ABA services are not medically necessary for treatment of this patient. The records provided for review do not include an updated assessment information regarding current levels of functioning, skill deficits, or challenging behaviors that are to be addressed during treatment. Per the  ABA Coding Coalition, without assessment and an individualized treatment plan, the focus of the ABA services remains unknown. Similarly, the focus of the requested ABA services, which is typically reserved for targeting specific challenging behaviors or a limited number of key functional skills, cannot be established based on the available documentation. Further, the requested 20 hours per week of ABA services does not meet the medical necessity criteria outlined by Papatola and Lustig. Per the authors, medical necessity criteria includes a) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) autism diagnosis supported by symptoms, b) symptoms of diagnosis causing impairment, c) motivation for change exemplified by family involvement, d) interventions are evidence-based and consistent for type, frequency, and duration of treatment, e) goals are constructed with patients family, f) outcomes are measurable, g) occurs in least restrictive environment, h) required for purposes other than convenience of patient or provider, i) measurable reduction in symptoms, j) symptoms are manageable, and k) day-to-day functioning has improved over baseline. The request fails to meet criteria e), f), h), i), j), and k). The patient should receive further assessment to inform a treatment plan that is individualized to their needs to better identify the level of support warranted. Moreover, the requested ABA services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Based on the available documentation, the requested 20 hours a week of ABA services 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 a licensed B.C.B.A, 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 patient has requested authorization and coverage for Orthovisc injections (CPT J7324) to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient did not respond to NSAIDs, corticosteroid injections, physical therapy, and ice. The presence of crepitus and negative McMurrays sign as well as absence of a history of trauma supports the presence of a degenerative process causing severe pain. In light of the patients presentation and age, he is a good candidate for treatment with viscosupplementation. Therefore, the requested Orthovisc injections (CPT J7324) to the right knee are 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 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 right knee hyaluronan or derivative (Hyalgan, Supartz or Visco-3) for intra-articular injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients records include documentation of excellent lasting relief from prior viscosupplementation. Furthermore, cortisone injections and other conservative measures have not been effective. Given these findings, the requested right knee hyaluronan or derivative (Hyalgan, Supartz or Visco-3) for intra-articular injections weekly for three doses are medically necessary for 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lupkynis (voclosporin) 7.9 mg capsules. The records provided for review document that this patient has a history of biopsy proven glomerular disease in SLE. The patient has reportedly failed treatment with numerous agents including prednisone, CellCept, Cytoxan, and Plaquenil. The patients provider has recommended treatment with Lupkynis, which is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with refractory nephritis. Since this patient has failed multiple standard first-line therapies, treatment with Lupkynis is appropriate for management of her lupus nephritis (Rovin, et al.; Clarke). Therefore, the requested Lupkynis (voclosporin) 7.9 mg capsules 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 certification in nephrology 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 proton beam therapy (radiation therapy, 30 Gy in 20 fractions). The National Comprehensive Cancer Network (NCCN) guidelines support the use of photon-based radiotherapy in this clinical setting.  In this case, a proton/photon plan comparison showed that a photon-based plan meets all nationally accepted objectives in terms of normal tissue exposure and target coverage. Proton radiation is not proven to yield superior clinical outcomes in this setting. This patient can be safely treated with photon radiation. Therefore, proton beam therapy (radiation therapy, 30 Gy in 20 fractions) 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 radiation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement surgery by anterior approach (CPT code 22857). The records document that this patient presents with chronic lower back pain that originates in the back, with radiation into the left buttock, posterior thigh, and posterior lateral lower extremity. Physical examination revealed antalgic gait with left lower extremity pain. The patients providers have recommended treatment with artificial disc replacement surgery by anterior approach. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The available documentation includes reports of conservative measures noted on the examination. There is a lack of updated documentation of recent conservative measures, which is essential since the patient is status post-surgery at bilateral L5-S1. In addition, formal imaging studies were not provided for review to corroborate the currently noted pathology. For these reasons, the requested artificial disc replacement surgery by anterior approach (CPT code 22857) is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a home setting for the patients already approved speech therapy services. Medical literature recommends early intervention for children with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists, even under three years of age. In a systematic review, researchers conclude that behavioral-based interventions are evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Researchers describe that treatment of individuals with autism spectrum disorder as involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Researchers report, Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder. While current medical literature thus supports the use of speech therapy for children with autism spectrum disorder, in this clinical setting, there is a lack of evidence regarding the medical necessity of home-based speech therapy. The records do not document that this patient has any medical conditions that prevent him from leaving the house. In this patients case, a home setting for speech therapy is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, a home setting for the patients already approved speech therapy services 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient admission. Reuner and colleagues note that urinary tract infections are a common cause of severe sepsis, and that patients with anatomic urinary obstruction have significantly higher mortality. Yamamoto and colleagues report that acute pyelonephritis (APN) is a common complication of ureteral obstruction caused by urolithiasis and can be lethal if it progresses to septic shock. Sepsis from urinary tract infections may carry significant morbidity and mortality. In this case, given that the patient was at high risk for substantial decline due the presence of fever, leukocytosis, and concern for sepsis, and required treatment with intravenous antibiotics, the service at issue was medically indicated. Therefore, inpatient admission 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.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in nephrology 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 extraction of 13 teeth with general anesthesia, or in the alternative deep anesthesia. Based on the provided documentation, the patient has asthma, is a smoker, has hepatitis C, and presents with elevated blood pressure during office visits. The planned number of extractions requires local anesthetic throughout the mouth, which creates a challenge. There is a great number of extractions, a full mouth of local anesthetic to be administered in a patient with a documented history of hypertension for non-surgical visits supports the need for sedation in order to reduce the need for re-administration of local anesthetic, keep the patients blood pressure within a manageable range, and prevent excessive peri-operative bleeding. The utilization of general anesthesia is appropriate for this patient and procedure. Therefore, the requested extraction of 13 teeth with general anesthesia is medically necessary for 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 a licensed D.M.D., board certified in periodontology, 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.