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 the medication Otezla. Otezla has been approved by the U.S. Food and Drug Administration (FDA) for treatment of patients with disseminated plaque psoriasis. This patient has disseminated plaque psoriasis that requires systemic treatment. Anti-tumor necrosis factor drugs can increase the risk for malignancy. Prior treatment with Otezla provided this patient with substantial relief of symptoms. The use of Otezla, which does not increase the patients risk of malignancy or infection, is warranted under these circumstances. Thus, Otezla is medically necessary for treatment of the patients medical condition.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 dermatology 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: At issue is whether the prostate lift procedure (UroLift) that was performed was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found that the Prostatic UroLift (PUL) system has been approved by the U.S. Food and Drug Administration (FDA) as an effective treatment of appropriately selected patients 50 years and over with BPH. The PUL system has shown to be successful and relatively safe in the short-term. A recent prospective, randomized, multinational study compared the outcome of the PUL procedure to the TURP procedure. The authors concluded that participants who underwent a PUL procedure responded significantly with regard to important aspects of quality of life. Further, the American Urological Association (AUA) affirms that the UroLift prostatic procedure should be considered an appropriate therapeutic tool used by urologists.Final Result: The reviewers determined that the requested procedure is likely to be more beneficial for evaluation 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 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: The patient is diagnosed with limb-girdle muscular dystrophy. The provider noted that the patient has increasing ventilatory insufficiency and inability to transfer and reposition herself due to complete immobility. Additional noted concerns included the patients risk for recurrence of sores. The patients neurological examination was consistent with severe weakness. A durable medical equipment (DME) evaluation revealed the patients active range of motion in the lower extremities is not functional, and only 25% in the upper extremities. In addition to limb-girdle muscular dystrophy, the patient has a medical history of fractures.Findings:  The physician reviewer found that limb-girdle muscular dystrophy is a progressive form of degenerative muscle disease. This patients records document that due to this condition, she is nonambulatory, with reduced strength in her arms and significant weakness in her legs. The patients physical weakness decreases her ability to change positions in bed and operate manual bed cranks.  The decreased mobility increases the propensity for pressure ulcers. The requested equipment is likely to decrease adverse medical events as well as improve the patients mobility and quality of life. The documentation supports that the total electric hospital bed with alternating pressure mattress and side rails is medically necessary. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a cold therapy unit. This patient underwent spinal surgery and was provided with post-operative use of a cold therapy unit. Although post-operative dynamic cold therapy units have been proposed as a method of reducing pain and the inflammatory response in the early post-operative period after orthopedic joint reconstruction surgery, there are limited data available showing patient outcomes are improved beyond results experienced with standard ice packs. Cooling devices to achieve relief of underlying back pain is limited at best. Nabiyev and colleagues concluded that when compared to treatment with narcotic pain medications alone, cold therapy units can provide accelerated improvement during early rehabilitation. However, the study did not compare cold therapy units against use of standard ice packs in this clinical setting. All told, the cold therapy unit (CPT code E0218) and related accessory (lumbar wrap, CPT code E1399) provided was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the cold therapy unit (CPT code E0218) and related accessory (lumbar wrap, CPT code E1399) provided was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the cold therapy unit (CPT code E0218) and related accessory (lumbar wrap, CPT code E1399) provided was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurological 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female has requested reimbursement for an occipital nerve block injection. The Health Plan has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. A review of the records indicates the patient has a history of meningioma surgery, rheumatoid arthritis, and reactive situational depression. Her primary care physician noted  that a magnetic resonance image had shown a pituitary microadenoma.  The patient reported a six-month history of migraines, with increased intensity for the past two weeks. The migraines were associated with nausea, dizziness, light and sound sensitivity, and neck pain. She had been taking Norco for pain relief. The records noted that an episode of loss of consciousness occurred in October 2018 after she had hit her head. She had been prescribed Keppra since a meningioma removal in 2016. One reviewer found that the requested occipital nerve block injection was likely to have been of greater benefit than other treatment options. Final Result: Two of the three reviewers determined that the requested injection was not likely to be more beneficial for evaluation 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for substance abuse rehabilitation services at a dual diagnosis facility that provides onsite IV fluids to assist with severe vomiting caused by cyclical vomiting syndrome. The progress notes indicate this patient was admitted with a history of substance use and mood disorder that included depression and anxiety. Applying the American Society of Addiction Medicine (ASAM) criteria for level of placement, the requested services are medically necessary. For dimension 1, the patient presents with acute intoxication and withdrawal potential. She has demonstrated significant withdrawal symptoms including delirium, abnormal lab values, and tachycardia. For dimension 2, the patient has biomedical conditions and complications. She has several medical problems as indicated by her cyclical vomiting, seizure disorder, and migraines. Further, for dimension 3, the patient continues to have emotional problems that contribute to her lack of sobriety. For dimension 4, the patient has exhibited minimal readiness to change considering her continued substance abuse. For dimension 5, the patient is at high risk for relapse as indicated by her history of numerous prior substance treatment trials and attempts, with inability to maintain sobriety. For dimension 6, recovery and living environment, the patient meets these criteria based on her lack of stable housing. All told, the requested substance abuse rehabilitation services at a dual diagnosis facility that provides onsite IV fluids to assist with severe vomiting caused by cyclical vomiting syndrome are supported as medically necessary for treatment of this patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral removal of gynecomastia. Findings:  The physician reviewer found that based on review of the medical records provided the procedure is not medically necessary. The patient complains of pain after his first surgery for gynecomastia. However, breast pain was not noted during the most recent providers examination. The primary complaint on that date was breast enlargement. In addition, the patient does not have any documented functional limitations related to the enlarged breasts or require treatment with conservative measures to relieve breast pain. All told, the requested bilateral removal of gynecomastia is not medically necessary for treatment of this patients medical condition. Further, the requested bilateral removal of gynecomastia is not supported as reconstructive in nature. The presence of enlarged breasts is an abnormal structure of the body. However, in this patient, the most likely etiology is obesity and lipomastia. While surgery can be considered for this patients condition to address a functional deficit, the surgery has not been recommended due to a functional limitation. Moreover, the requested surgery is not likely to make a more than minimal improvement in the patients appearance. The patient has already undergone one procedure to address this issue, and there is a lack of rationale to support a repeat procedure. Furthermore, weight loss is appropriate in this patient prior to consideration of surgery, as weight loss alone may resolve the breast enlargement. Thus, in this patient with a BMI over 39 kg/m2, weight loss prior to consideration for repeat surgery is advisable. Given these findings, the requested bilateral removal of gynecomastia is not medically necessary and is not reconstructive in nature for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested surgery is not medically necessary and is not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: An enrollees parent has requested reimbursement for inpatient psychiatric treatment program services and prospective authorization and coverage for future inpatient psychiatric treatment program services. This patient was admitted to the inpatient unit due to an episode of apparent psychosis. The psychiatric progress notes do not indicate suicidal ideation, homicidal ideation or adverse effects from medications. Findings:  The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. The patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, inpatient psychiatric treatment program services and future inpatient psychiatric treatment program services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There are many symptoms associated with postural tachycardia syndrome, including palpitations, syncope, paresthesias, lightheadedness, extreme fatigue and headache. Therapies include increased water/salt intake, elastic support hose, fludrocortisone, clonidine, propranolol, midodrine and pyridostigmine. Although there is some evidence to suggest that IVIG therapy can be effective in a select subset of patients with postural tachycardia syndrome, this is not considered standard therapy at this time. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested IVIG 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 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 presented with a history of nasal trauma and difficulty breathing for several months. On physical examination, there was no sinus tenderness and no boggy mucosa. She was referred to an otorhinolaryngologist (ENT). Nasal trauma is a common etiology for nasal obstruction, and functional rhinoplasty has been shown to be an effective method for treating nasal obstruction. Specific maneuvers can address deformities like septal deviation, nasal and septal fractures, valve collapse, and inferior turbinate hypertrophy. Each of these may contribute to nasal obstruction and require thorough evaluation for consideration by a specialist. This patient had nasal obstruction after nasal trauma. Thus, evaluation and treatment by an In-Network ENT is medically necessary.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 otolaryngology with subspecialty certification in plastic and reconstructive 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 is a 21-year-old female with a history of recurrent dislocation of the left patellofemoral joint. She had continued pain following a repeat reconstruction of the medial patellofemoral ligament using an Achilles tendon allograft previously. The operative report documented grade three and four chondromalacia of the left patellofemoral joint. Later the patella was stable, although the records noted pain due to arthritis. The physical examination later revealed tenderness on both the medial and lateral aspects of the left knee and a trace effusion. She has failed treatment with physical therapy. The patient has requested coverage for Synvisc-One injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc-One injections are medically necessary for the treatment of the patients medical condition. Focal chondral defects due to recurrent patellar dislocations are common in the patellofemoral joint and can significantly impair quality of life. This patient has failed treatment with medications and physical therapy. Due to her young age, additional treatment is likely to be necessary in the future for a long-term solution. Medical literature indicates that viscosupplementation may result in a moderate degree of pain relief in patients with mild osteoarthritis. Intra-articular hyaluronic acid offers one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis pain and quality of life. Medical evidence supports the requested services in this clinical setting. Therefore, the requested Synvisc-One injections are medically necessary for the 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Zembrace SymTouch 3 mg/0.5 mL pen injector. Sumatriptan is a triptan with a long-established history of use in the acute treatment of migraine headaches (Derry, et al). Sumatriptan is available in tablet, nasal spray, inhaled and injectable formulations. In this case, the patient has been prescribed Zembrace SymTouch, which is one of the injectable formulations of sumatriptan. While various formulations of injectable sumatriptan are available, there have been no comparison studies completed amongst the formulations. In this case, the Health Plan has authorized sumatriptan formulations Imitrex cartridge and syringe, and Alsuma pen injector. The records do not document an adequate trial of, or a contraindication to, treatment with these medications. Given these findings, the requested Zembrace SymTouch 3 mg/0.5 mL pen injector is not medically necessary for treatment of this patients migraine headaches. 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 neurology with subspecialty certification in sleep 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.