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 referral to an orthopedic specialist that provides tertiary level of care. Shoulder pain is common in the general population. Reports show the prevalence of one months history of persisting shoulder pain is between 7% and 26%. Furthermore, 40% of patients continue to complain of pain one year after primary care evaluation and treatment. When referred to an orthopedic shoulder specialist, the patient is likely to undergo treatment with a corticosteroid injection, exercise, or surgery with greater chance of success. In this case, there is evidence of a recent shoulder dislocation and a rotator cuff tear involving the supraspinatus tendon. Additionally, there is evidence of glenohumeral joint cartilaginous thinning. In light of these multiple problems, referral to an orthopedic shoulder specialist providing a tertiary level of care is appropriate for management of this patients worsening left shoulder pain. Therefore, the requested referral to an orthopedic specialist that provides tertiary 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 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 patients parent has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) infusions at 2 g/kg monthly for a duration of six months.Findings:  The physician reviewer found that Pediatric autoimmune neuropsychiatric disorders associated with streptococcal (PANDAS) has been described as the acute onset of obsessive-compulsive disorder (OCD) and/or motor tics in children following recent streptococcal infection. Symptoms frequently relapse and remit, and may respond poorly to psychotropic medications (Murphy, et al.). This patients rheumatologist, psychologist, psychiatrist, and pediatrician concur with the recommendation to continue monthly infusions of IVIG and Solu-Medrol. The records document that the patient has experienced an extremely severe form of OCD with tics, associated with severe, self-injuries, which have resulted in permanent scarring. She has been treated with multiple psychoactive medications with minimal improvement, required several prolonged inpatient hospitalizations, and she has required sedation in an intensive care unit on several occasions to prevent her from seriously injuring herself. Although there has been debate in the literature regarding its efficacy, in this particular patients case, there is a well-documented dramatic improvement in her symptoms after administration of IVIG, with subsequent devastating return of symptoms and regression when IVIG treatment has been delayed. The patient has undergone an appropriate diagnostic evaluation, including a spinal tap and MRI studies. In this specific clinical setting, the medical records support the efficacy of IVIG for this patients symptoms. Therefore, the requested Gammagard IVIG infusions at 2 g/kg monthly for a duration of six months 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 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 patients parent has requested authorization and coverage for additional speech therapy over a six-month period Speech therapy for a young patient with autism spectrum disorder should be provided on a consistent and frequent basis. Decreasing the frequency to is likely to result in regression, which will increase this patients disability. Weekly speech therapy is consistent with the American Academy of Pediatrics recommendations. Reporters conducted a meta-analysis of 25 studies on speech and language therapy interventions for children with primary speech and language delay or disorder. The reporters concluded that speech and language therapy interventions in young patients with expressive phonological and expressive vocabulary difficulties provide positive outcomes. Reporters noted that the ability to communicate effectively with others is central to childrens development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. For this patient with articulation/phonological disorder and mixed expressive and receptive language disorder, 60-minute speech therapy sessions once per week is appropriate to provide the patient with continued support and prevent regression. Therefore, the requested additional speech therapy over a six-month period are medically necessary to decrease disability and  correct or ameliorate the patients behavioral conditions.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 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 been diagnosed with bilateral knee osteoarthritis. On 2/24/20, the patient received bilateral knee Gelsyn injections. On 7/30/20, the provider noted prior viscosupplementation injections provided the patient with relief of symptoms for five to six months. The patient has also been treated with topical anti-inflammatory cream. The patient has requested authorization and coverage for a Gelsyn-3 injection series in both knees. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Gelsyn-3 injection series in both knees is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections in both knees. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties of both knees. The medical evidence supports the requested service in this clinical setting. Therefore, a Gelsyn-3 injection series in both knees is medically necessary for the treatment 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 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 patients parent has requested authorization and coverage for speech therapy services for one hour per week. Findings:  The physician reviewer found that the records provided for review document a diagnosis of autism. Given this diagnosis, the patient is at risk of impairment in social interaction with his peers. The treating speech therapist reported that the patient continues to make progress towards goals, and he should continue speech therapy sessions once a week. The provider charted that the patient has difficulty expressive language, as well as use of appropriate sequencing during play, familiar activities and narratives. The patients goals include generation of appropriate questions with moderate verbal and/or visual cues in order to maintain the conversation, when engaged in conversation with an adult on an unfamiliar topic, in three of five opportunities. In a meta-analysis of pragmatic language interventions for children with autism spectrum disorder, Parsons and colleagues reported that deficits in pragmatic language affect patients with autism throughout childhood necessitate effective, evidence-based interventions that can minimize the isolating, and long-term impacts of pragmatic language difficulties. All told, the requested speech therapy services for one hour per week 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 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 authorization and coverage for a Relizorb cartridge. Relizorb cartridges are comprised of lipase immobilized onto polymeric carrier beads, which when placed in a feeding tube, release small amounts of lipase in steady dosing. Freedman and colleagues found that use of Relizorb was safe, well tolerated, and resulted in significantly increased levels of plasma omega-3 fatty acid concentrations, suggesting overall increased fat absorption. Stevens and colleagues found that enteral nutrition using Relizorb improved fatty acid abnormalities in patients with cystic fibrosis, and that Relizorb could have important long-term therapeutic benefits in patients with cystic fibrosis. In this case, the patient has cystic fibrosis and has established the efficacy of Relizorb based on improved post-feeding symptoms and increased body weight after starting on Relizorb. Maintaining a BMI above 20 is of critical importance as the patient is scheduled to undergo a pre-lung transplant evaluation. Therefore, the requested Relizorb cartridge 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 internal medicine with sub-specialty certifications in pulmonary disease and critical care 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a transthoracic echocardiogram (CPT 93307). The American College of Cardiology Foundation Appropriate Use Criteria Task Force found that transthoracic echocardiograms were appropriate for re-evaluations of known aortic dilations. In this case, the patient had unequivocal and significant aortic dilation on one imaging study. As progressive aortic dilation is potentially life threatening due to an increased risk of aortic rupture, a repeat transthoracic echocardiogram to assess for any progressive aortic dilation is medically indicated. Therefore, a transthoracic echocardiogram (CPT 93307) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation imaging during a right total knee replacement surgery. Findings:  The physician reviewer found that this patient is planned to undergo right total knee replacement for primary osteoarthritis. X-rays demonstrated bone on bone articulation of the medial compartment, with sclerosis and marginal osteophyte formation. The patients provider has recommended computer-assisted navigation, which has been shown to improve alignment, lessen revision rates, and diminish cardiopulmonary compromise. However, current evidence-based medical literature do not support the routine use of computer-assisted navigation imaging for total knee replacement over conventional total knee replacement in this clinical setting. Lee and colleagues found a lack of significant difference in clinical or radiological outcomes between computer-assisted navigation for total knee arthroplasty and conventional total knee arthroplasty. Similarly, Young and colleagues reported no mid-term functional or radiographic differences between total knee arthroplasty with mechanical alignment or kinematic alignment. Therefore, the requested computer-assisted navigation imaging during a right total knee replacement surgery is not 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 computer-assisted navigation imaging during a right total knee replacement surgery is not 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 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Fasenra pen 30 mg/mL auto-injector.The submitted documentation does not support that the requested medication is medically necessary. Fasenra is FDA approved for the add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype. The Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention states that once good asthma control has been achieved and maintained for three months and lung function has reached a plateau, treatment can often be successfully reduced, without loss of asthma control.In this case, the patient carries a diagnosis of moderate-persistent asthma, and records indicate that the patient achieved adequate control of asthma after starting Fasenra in September 2018. Given the patients asthma stability over the past two years, standard practice would typically involve stepping down therapy by stopping biologic therapy, unless there is compelling evidence supporting its efficacy in controlling asthma. In this instance, there are no compelling data to support continued use of Fasenra in controlling the patients asthma. Under these circumstances, the requested Fasenra pen 30 mg/mL auto-injector is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication 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 internal medicine, with subspecialty certification in pulmonary 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for lumbar spinal fusion and vertebral body resection. Medical literature supported consideration of lumbar fusion for patients with degenerative disease of the lumbar spine, with disc herniations and radiculopathy, when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. Researchers found no added benefit from lumbar fusion for patients with degenerative disc disease and stenosis without spondylolisthesis and concluded that in the absence of deformity or instability, the inclusion of a fusion was not recommended. In assessing functional outcome following lumbar fusion, Researchers found that recent studies suggested a patients pretreatment psychological state was a major independent variable that affected the ability to detect change in functional outcome. In this case, the patient has worsening low back pain with intermittent radiation into the right lower extremity to the ankle and minimal radiation into the left lower extremity. Imaging shows degenerative disc disease with spondylosis from L3/4 to L5/S1 with mild to moderate central canal stenosis. There is no evidence of any focal neurologic deficit to support a diagnosis of lumbar radiculopathy. There is no imaging evidence of nerve root compromise or severe degenerative disc disease. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. There is a significant history of anxiety which has not been addressed with psychological clearance or by the neurosurgeon. The records show the provider did not recommend surgery prior to significant weight loss, and instead recommended a spinal cord stimulator prior to consideration of surgery. Therefore, lumbar spinal fusion and vertebral body resection are not 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 reimbursement and prospective authorization and coverage for Nuedexta 20/10 mg capsules. Pseudobulbar affect (PBA) is characterized by uncontrollable emotional episodes that are disconnected from or disproportionate to mood, and often occurs in adults with neurologic conditions. Hammond and colleagues noted that dextromethorphan/quinidine was shown to be an effective and well-tolerated treatment for PBA secondary to dementia, stroke, or traumatic brain injury. The U.S. Food and Drug Administration has approved the use of Nuedexta for the treatment of PBA. In this case, the patient presented with PBA and was prescribed Nuedexta. Given that treatment with Nuedexta is the standard of care for the patients diagnosis, the medication at issue was and is medically indicated. Therefore, Nuedexta 20/10 mg capsules were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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.