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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for foot orthotics. At a podiatry visit, the enrollee reported her problem started when she rolled her right ankle and broke her fifth metatarsal bone. The podiatry assessment indicates chronic right ankle instability secondary to malunion fracture of the fifth metatarsal, creating right foot varus, peroneal tendinopathy right, peroneal tubercle exostosis right calcaneus, pes cavus, and bilateral hammertoe deformity. The podiatrist indicated because of the varus position of her right foot, the enrollee will chronically have ankle instability; her lateral ankle ligaments are extremely dysfunctional and do not have the tension/ability to keep her ankle from rolling. This has caused her peroneal tendons to be overused and to develop cystic changes. The enrollee underwent surgical treatment for primary repair of a ruptured right peroneus brevis and longus, excision os peroneum right, ostectomy calcaneus right, and peroneus longus transfer to brevis right. A podiatry progress note indicates the enrollee was still complaining of pain on the outside of her right foot and ankle. She has difficulty walking and standing and did not believe she could return to her job. She also was in the intensive care unit three weeks prior for an infection, unrelated to this surgery. The podiatrist reminded her that her peroneal tendons will continue to be tender and strained until the next sequence of her reconstructive foot surgery can be finished. In the interim, her podiatrist prescribed an ankle foot orthosis as the only way to stabilize her ankle and prevent her peroneal tendons from rupturing until her surgical treatment is completed. The record indicates the enrollee also requested foot orthotics. Consistent with providers recommendation for ankle-foot orthosis (AFO), literature supports the AFO can be fixed or articulated to permit ankle range of motion, and stabilize the ankle instability. However, the foot orthotic is not medically indicated for ankle instability. As per a study in the medical literature, shoe inserts are recommended for foot pain caused by midfoot arthritis. However, this enrollee is at a high risk for rupturing her peroneal tendons if not stabilized by an appropriate orthosis. Since foot orthotics, such as shoe inserts, cannot stabilize the enrollees ankle instability, the foot orthotic was not medically necessary for the treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for consultation with an infectious disease specialist. The latest imaging shows a suspicion of ascariasis infestation in the common bile duct (CBD). Prior to this test, a computed tomography (CT) showed a dilated CBD, with endoscopic retrograde cholangiopancreatography (ERCP) recommended if the bilirubin is elevated. A gastroenterology consultation from indicates the physician suspects the enrollee has a delusional disorder and that he does not have a true continued infection. However, the physician further noted the enrollee may benefit from seeing an infectious disease (ID) specialist to confirm he truly does not have an infection. The records indicate the enrollee was referred to gastroenterology. Scheduling this procedure has been complicated by the enrollees psychosocial issues, including his belief that he has already proven he has worms. He is requesting evaluation by an infectious disease (ID) specialist. However, the ID specialist wants the enrollee to have additional testing by gastroenterology first. An evaluation by dermatology indicates the enrollee likely has delusions of parasitoids, but admitted this suspected diagnosis was out of the scope of their practice and recommended psychiatry evaluation and referral to an ID specialist. The review of documentation supports this enrollee has psychosocial co-morbidities. This enrollee may have a persistent worm infection. The MRI has raised the possibility of ascariasis in the CBD. In spite of the psychiatric disorder, there is still a possibility the enrollee has a persistent infection that is difficult to diagnose. The gastroenterologist has advised an ID evaluation. While it is unclear whether or not this weight loss is due to the suspected worm infection or other underlying cause, the enrollee reports a concerning clinical history that further supports this enrollee will benefit from a thorough infectious disease evaluation for infectious causes for enrollees weight loss and current suspicion for biliary ascariasis.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for home birth with a certified nurse midwife. According to the American College of Obstetricians and Gynecologists (ACOG), hospitals and accredited birth centers are the safest settings for birth. Although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with increased risk of perinatal demise, seizures, and serious neurologic dysfunction. There is a lack of adequate randomized clinical trials of planned home birth. In developed countries where home birth is more common than in the U.S., attempts to conduct such studies have been unsuccessful, largely because pregnant women have been reluctant to participate in clinical trials that involve randomization to home or hospital birth. Consequently, most information on planned home births comes from observational studies, which are limited by methodological problems. Some recent observational studies overcome many of these limitations, describing planned home births within tightly regulated and integrated health care systems, attended by highly trained licensed midwives with ready access to consultation and safe, timely transport to nearby hospitals. However, these data may not be generalizable to many birth settings in the U.S., where such integrated services are lacking. In this case, it is important to consider that the patient is also in a high-risk category. Typically, providers more carefully monitor women over the age of 35 to ensure the safety of the fetus and for delivery-associated complications in this higher risk population. All told, the requested home birth with a certified nurse midwife 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for cervical spine computed tomography (CT) scan with flexion/extension. The American College of Radiology (ACR) guidelines recommended cervical spine CT scan as the initial imaging for patients with prior cervical spine surgery, and new or increasing non-traumatic cervical or neck pain or radiculopathy. The ACR also noted that CT scan of the cervical spine as initial imaging for patients with cervicogenic headaches and new or increasing non-traumatic cervical or neck pain with no neurologic deficit and as the next imaging study for patients with chronic cervical or neck pain, no neurologic findings, and radiographs showing degenerative changes. This patient presents with complaints of severe right-sided neck pain with painful numbness from the right occipital area down into the right trapezius. She has also described a sensation in the right V3 distribution with the onset of neck pain, and a waxing and waning sensation of dizziness and aural tingling. A nuclear medicine bone scan has suggested some inflammatory uptake of the right occiput to C1 joint. In addition, she has an extensive amount of midline atrophy and scar tissue, which could be contributing to her pain at the craniocervical junction. A recent cervical MRI showed no significant spinal canal or foraminal stenosis, and evidence of a Chiari decompression. Current radiology guidelines support the requested imaging in this setting of prior surgery and increasing non-traumatic pain. Given the patients progressive symptoms, failed conservative treatment and potential for serious spinal instability, a CT scan is medically indicated. Therefore, the requested cervical spine CT scan with flexion/extension is medically necessary for evaluation of the 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 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 magnetic resonance imaging (MRI) of the lumbar spine, which includes neutral, flexion and extension. There is a lack of prospective, controlled, randomized studies that have shown the effectiveness and accuracy of upright MRI scanning versus the gold standard of MRI imaging. Small studies have reported promising findings to support the utility of upright MRI in limited circumstances. In this case, the patient presents with evidence of a 3 mm enhancing right-sided nerve root lesion at the level of L2 found on contrast enhanced MRI. This is an incidental finding that does not explain his symptoms and does not require further evaluation with the requested MRI. Given these findings, the requested MRI of the lumbar spine, which includes neutral, flexion and extension 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for referral to a vascular surgeon (CPT codes 99203 and 99213). This enrollee has an eight-year history of varicose veins in the left leg that started after her first pregnancy and worsened after her second pregnancy. At an office visit, examination of the left leg showed large saphenous vein prominence at the lower medial aspect and multiple smaller veins in the lower half leg, with no ulceration or skin discoloration. History indicates the enrollees varicose veins have progressed, and are currently symptomatic and painful during menstruation. Based on the history and physical exam, her provider prescribed a referral to a vascular surgeon.  The medical literature does not support delaying referral to vascular service for symptomatic varicose veins. Primary practitioners are encouraged to refer patients with symptomatic varicose vein disease, including symptoms such as pain, aching, discomfort, swelling, heaviness, and itching, to vascular services for early assessment and management. This enrollee reports pain with her varicose veins. Although the varicose veins currently do not show signs of ulceration and discoloration, her condition has been chronic and has progressed. Due to the progressive nature of varicose veins, literature supports early detection and early, effective intervention for varicose veins. Chronic venous insufficiency is one of the most common disorders of the vascular system, affecting approximately 50% of adults. If left untreated it can lead to a number of complications, including venous ulceration and venous thrombosis. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is licensed in surgery and vascular 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 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 referral for consultation with a bariatric surgeon. The American Association of Clinical Endocrinologists (AACE) and American Society for Metabolic and Bariatric Surgery (ASMBS) surgery state that bariatric surgery is currently indicated for patients with a body mass index (BMI) of 40, or a BMI of at least 35 kg/m2 with serious obesity co-morbid conditions. Thiss patients records do not document the presence of morbid obesity. Low BMI bariatric surgery is generally considered for patients with a BMI of at least 30 kg/m2 but less than 35 kg/m2 with type 2 diabetes mellitus requiring medication. This patient has a BMI of less than 35 kg/m2 and does not have documentation of medically treated type 2 diabetes mellitus. Therefore, the requested referral for consultation with a bariatric surgeon is not medically necessary for 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 surgery with expertise in bariatric 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 weekly play therapy. Play therapy is a form of psychodynamic psychotherapy for young patients, which is based from a belief that a childs play has symbolic unconscious meaning. Patients that can benefit from play therapy are interested in school and hobbies, communicates with others at an age appropriate level, is aware of his symptoms, and is ready for change. This patients records do not demonstrate that this patient meets these criteria. The documentation reports that this patient is experiencing problems adjusting to his parents divorce. The American Academy of Child and Adolescent Psychiatry (AACAP) recommend ongoing individual therapy and family therapy to help cope with this major life stressor. Cognitive behavior therapy (CBT) principles like emotion regulation and coping skills are also helpful for many patients in this clinical setting. However, the records provided for review do not support an indication for play therapy. All told, the requested weekly play therapy 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 psychiatry with subspecialty 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM). The Eversense real time CGM system consists of a subcutaneously inserted sensor, a wearable transmitter, and a smartphone application. The sensor longevity is achieved using multiple approaches, including the chemical structure of the glucose binding polymer, the platinum coating, the dexamethasone acetate eluting ring, and the subcutaneous position in comparison to transcutaneous real time CGM systems. The U.S. Food and Drug Administration (FDA) approved the Eversense CGM in 2018. There are multiple peer-reviewed studies and published literature attesting to the Eversense CGM accuracy, and its superiority to the Dexcom and the Freestyle Libre CGM devices. In a recent study that compared the three CGM systems, the point accuracy of the Eversense was significantly better than two other CGM systems. In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness. The Eversense CGM is implantable subcutaneously, which also supports superior accuracy when compared to Dexcom and Freestyle Libre CGM devices, and helps keep the sensor in place. All told, the requested Eversense CGM 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 internal medicine with subspecialty certification in diabetes, endocrinology 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

The patient has requested authorization and coverage for a neuropsychological evaluation. Patients with intractable epilepsy are likely to experience cognitive decline. In order to understand the nature and severity of a patients cognitive deficit, neuropsychological evaluation using a battery of tests is performed. A preoperative neuropsychological assessment should be comprised of standardized measures of cognitive function in addition to measures of behavioral and psychosocial function. The results from the presurgical assessment will establish a baseline against which change can be measured following surgery. The data will provide a collaborative contribution to seizure characterization, lateralization and localization, and provide evidence-based predictions of cognitive risk associated with the proposed surgery. This patient has a diagnosis of intractable epilepsy. As part of a presurgical work-up, her provider recommended neuropsychological testing to help identify the seizure focus in the brain. Given the support in the medical literature, the requested neuropsychological evaluation 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 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

The patient has requested authorization and coverage for paravertebral spine injection of the lumbar spine 1-3 dexamethasone sodium phosphate. Researchers concluded that the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. Researchers also concluded that based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. This patient presents with a history of chronic low back and left hip pain. She has been diagnosed with lumbar spondylosis without myelopathy or radiculopathy. A pain management report noted severe paraspinal spasms and tenderness from L2-S1 and no focal deficits. The provider reports that the patient has undergone multiple lumbar facet joint therapeutic injections. There are no pain management documenting a positive response to the lumbar facet joint therapeutic injections. In addition, there are no clinical findings consistent with facet joint mediated pain to support the requested therapy. There is a lack of details on the patients prior conservative treatment. Moreover, there are no clear clinical findings of facet joint mediated pain at three specific levels. The records do not include reports or discussions of imaging findings of facet pathology to support paravertebral facet joint injection of the lumbar spine. All told, the requested paravertebral spine injection of the lumbar spine 1-3 dexamethasone sodium phosphate is not medically necessary for treatment of the patients medical condition.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.