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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for blood glucose monitor and sensors. The records provided for review document that this patient presents with prediabetes. The U.S. Food and Drug Administration (FDA) approved the Freestyle Libre flash glucose monitoring system to monitor interstitial glucose concentration without obtaining a capillary blood sample from the fingertip for management of type 1 and type 2 diabetes in adult patients (Moser, et al.). While studies have aimed to assess the efficacy of the Freestyle Libre system for patients with prediabetes, this device is not recommended for this patient population (Whelan, et al.). Therefore, the requested blood glucose monitor and sensors are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammaked infusions. Hanewinckel and colleagues describe peripheral neuropathies as diseases of the peripheral nervous system that can be divided into mononeuropathies, multifocal neuropathies, and polyneuropathies. Damage to small nerves is known as small fiber neuropathy and may cause a wide range of symptoms due to the involvement of both somatic and autonomic processes. Morrison and Chaudhry note that a large number of medications and toxins can produce neuropathy. The U.S. Food and Drug Administration (FDA) approves the use of Gammaked for the treatment of primary humoral immunodeficiency, immune thrombocytopenic purpura, and chronic inflammatory demyelinating polyneuropathy. In this case, the patient has a diagnosis of small fiber neuropathy. Given that there is a lack of evidence in current medical literature supporting the use of  intravenous immunoglobulin (IVIG) for the treatment of small fiber neuropathy, the requested services are not medically indicated. Therefore, Gammaked infusions are 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 sub-specialty certification vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an office visit with a cancer specialist. The National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer recommend yearly prostate-specific antigen (PSA) screening for five years after undergoing definitive therapy. In this case, the patient is approximately five years out from having completed definitive therapy for treatment of prostate cancer. His PSA levels are under 0.1 ng/mL and checked regularly by the same provider following the patients thrombocytosis. In this clinical setting, given that the patient is receiving appropriate follow-up care under NCCN guidelines, the requested service is not medically indicated. Therefore, an office visit with a cancer specialist is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 sub-specialty certifications in medical oncology and hematology 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 isotretinoin.  Findings: Isotretinoin has been demonstrated to be the most effective treatment for acne vulgaris. Data suggests that treatment with isotretinoin has the potential to provide long-term improvement or remission. The American Academy of Dermatology (AAD) guidelines include isotretinoin for the treatment of acne vulgaris, especially moderate acne vulgaris that has been resistant to other treatments. This patients records document failure with at least two topical and one oral therapeutic option. They present with moderate severity of inflammatory papules as noted by the provider. Given these findings, the requested isotretinoin is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology with subspecialty certification in dermatopathology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest wearable cardioverter defibrillator. Current data from multiple trials have advocated the use of a LifeVest wearable cardioverter defibrillator after an initial diagnosis of severe left ventricle (LV) dysfunction with an ejection fraction (EF) of 35% or less, along with guideline directed optimal medical therapy. This patients EF was 19%. The recommended timing of placement of a LifeVest based on current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines is within 40 days of an acute myocardial infarction, or within 90 days of guideline directed medical therapy for an initial diagnosis of congestive heart failure with a severely reduced EF. There was a reasonable expectation that the patients EF would improve after revascularization given the myocardial viability study performed preoperatively, which would have avoided the need for permanent ICD placement. For these reasons, the Zoll LifeVest wearable cardioverter defibrillator was 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 Zoll LifeVest wearable cardioverter defibrillator was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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 reimbursement for  inpatient services. The records reviewed document that this patient sustained a moderate-to-severe traumatic brain injury on the basis of his presenting neurological examination and imaging findings. As a result of his injury, he required intensive care unit (ICU) monitoring, intravenous (IV) sedatives, and/or restraints in order to adequately observe and treat his condition and prevent him from causing harm to himself due to encephalopathy. The chart suggests that this level of care could only be de-escalated after three days of care when the patients mental status had sufficiently cleared. Moreover, the provider noted concern for diabetes insipidus due to high volumes of urine output, and this required careful work-up and evaluation. Based on the extent of the patients injuries, the services provided from the time of initial presentation for three days were medically necessary to evaluate and treat traumatic brain injury and any sequalae. However, by the fourth day of admission, the patient was allowed to be up and out of bed without bracing or spinal precautions, prior to obtaining upright x-rays. Although the provider noted that the patient was able to tolerate ambulating with moderate to minimal assistance, the provider indicated that the patient was unable to tolerate x-rays. The records suggest that the patient could have been assisted with being upright in order to obtain x-rays. All told, inpatient services for three days were medically necessary for treatment of this patient while the remainder of the inpatient services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a computed tomography (CT) angiography scan. Findings:  The physician reviewer found that the records did not reflect that the patient had clinical symptoms of coronary artery disease and noted that the patient was on lipid lowering therapy. In this clinical setting, the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend preventive interventions, including blood pressure and lipid management. Given that a coronary CT angiography would not provide additional clinical data to alter the appropriate management or to improve the outcomes in an asymptomatic patient, the service at issue was not medically indicated. Therefore, a CT angiography scan  was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for an 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. The U.S. Food and Drug Administration (FDA) describes Otezla (generic name apremilast) as a phosphodiesterase 4 inhibitor and approves its use for patients with moderate to severe plaque psoriasis. A review of studies suggests that this medication is effective for the treatment of moderate to severe psoriasis. Papp and colleagues note that apremilast is efficacious, safe, and tolerable for patients with moderate to severe plaque psoriasis. In this case, the patient has chronic plaque psoriasis covering 15% of her body surface area. There is sufficient support for the requested medication in this clinical setting. Therefore, Otezla 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 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: 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 an Optune device and transducer arrays. Findings:  The physician reviewer found that (FDA) has approved the use of Optune, a portable medical device that produces alternating electrical fields called tumor treatment fields (TTFields), to treat recurrent glioblastoma. Stupp and colleagues found in an analysis of 315 patients with glioblastoma who had completed standard chemoradiation therapy, that adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. The authors also found that TTFields therapy was associated with lower toxicity and improved quality of life. In this case, the patient is clinically stable and shows no clinical signs of tumor progression. The records note that the patient is tolerating and doing well on Optune tumor treatment field therapy. In this clinical setting, continued treatment with electric field therapy for the treatment of glioblastoma is medically indicated. Therefore, the Optune device and transducer arrayS were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device 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 internal medicine with sub-specialty certification in medical oncology and hematology 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 Octagam infusions. This patient presents with complaints of ataxia, dizziness, weakness, dysarthria, and dysphagia. Her provider has recommended treatment with Octagam intravenous immunoglobulin (IVIG). Eftimov and colleagues noted that, Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) causes progressive or relapsing weakness and numbness of the limbs, developing over at least two months. IVIG is a U.S. Food and Drug Administration (FDA) approved medication that has been demonstrated to be safe for the management of several neurological diseases. Although this patient is experiencing severe symptoms, there is a lack of documentation in the records provided for review to support an indication for IVIG Octagam infusions. Therefore, the requested Octagam infusions are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in vascular 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 brand name Copaxone 40 mg/mL injected subcutaneously three times per week. Findings:  The physician reviewer found that Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Multiple sclerosis is characterized by multifocal inflammation of the central nervous system, which causes impaired nerve conduction. Current medical literature directing treatment for multiple sclerosis supports treatment with Copaxone as used in this patients management and care. The provider noted that the patient has experienced stable disease while treated with Copaxone. The generic version of Copaxone reportedly resulted in side effects, which supports treatment with brand name Copaxone. Considering the patients stability on brand name Copaxone, and clinical adverse effects experienced with a generic substitute, continuation of brand name Copaxone is appropriate. Therefore, the requested brand name Copaxone 40 mg/mL injected subcutaneously three times per week is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested brand name 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 subspecialty certification in vascular 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 magnetic resonance imaging (MRI) of the right foot. The American College of Radiology (ACR) appropriateness criteria for acute trauma to the foot indicate that, following normal or equivocal radiographs, MRI of the foot is usually appropriate for patients with suspected Lisfranc injury, tendon injury, occult fracture or dislocation. While MRI and ultrasound are similarly sensitive in detecting ligamentous and tendinous disruptions of the foot and ankle, MRI is superior in detecting occult fractures and acute bone stress related changes. The ACR appropriateness criteria for stress fractures, including both fatigue and insufficiency types, note that radiographs of the area of concern should be the initial imaging study, and if the findings are conclusive for insufficiency fracture, no further imaging is needed. The authors note that MRI is usually not appropriate in suspected lower extremity stress (insufficiency) fractures. In this case, the patient has right foot pain with ongoing pain localized to two to four of his toes. On examination, there was moderate tenderness to palpation along the second through fourth digits and metatarsal heads. The records noted mild pain with range of motion of the second to fourth metatarsal phalangeal joints. Previous x-rays did not show fracture or dislocation and were non-diagnostic for the symptoms noted. The patient reports persistent pain despite appropriate conservative measures. In this clinical setting, the requested service is medically indicated. Therefore, MRI of the right foot 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for hospitalization services from 4/4/21 forward. The records document that this patient has glioblastoma multiforme. By 4/6/21, the patient has been medically stable, and she has not required advanced interventions or monitoring. She experienced chronic lactic acidosis and tachycardia that has been managed with a beta blocker. She also has a seizure disorder that has been treated with Keppra without any reported breakout seizures. Per the Society for Neuro-Oncology (SNO) and European Society of Neuro-Oncology (EANO) consensus review and the National Comprehensive Cancer Network (NCCN) guidelines, the patient requires palliative care services (Wen, et al.). Based on the available documentation, the patient does not meet the requirements for continued hospitalization services. Therefore, hospitalization services from 4/4/21 forward were not and are not medically necessary for 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 internal 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.