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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultralight aluminum frame wheelchair with smart drive power assist. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Pushrim-activated power-assisted wheels reduce the forces required to propel manual wheelchairs, particularly on inclines and over high friction surfaces.  Primarily, the benefits are the reduction of load on the arms and decrease on cardiopulmonary demand.  It is not proven that there are reduced forces or moments exerted at the rim, or that there are benefits with respect to repetitive use injuries at any point in the kinetic chain. In the present case, the patient is reported to have instability at the wrists and carpal tunnel syndrome.  Gripping and grasping are reported to be challenging.  Ongoing use of a manual wheelchair in this clinical setting, with or without power assist wheels, would not be expected to be tolerated. Therefore, the requested ultralight aluminum frame wheelchair with smart drive power assist is 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 physical medicine and rehabilitation 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 parent of an enrollee has requested authorization and coverage for Nutropin AQ. Findings:  The physician reviewer found that This patients predicted adult height is within normal limits for his genetic target. The medical evidence does not support growth hormone therapy in this clinical setting. The records do not represent idiopathic short stature, given the height standard deviation score. The observation of slightly decreased height velocity is also consistent with that most often observed in children with an acquired constitutional delay of growth. The ongoing height velocity is consistent with short stature on the basis of constitutional delay. The available laboratory data does not support a diagnosis of growth deficiency. All told, Nutropin AQ is not medically necessary for the 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 reimbursement for partial hospitalization program services. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services assists providers in determining the appropriate level of care. With regards to risk of harm, the records support a score. During the dates in question, the patient had passive suicidal ideation with no intent or plan. In terms of functional status, the records support a score. The patient had ongoing severe deficits in her interpersonal relationships. With regards to medical/addictive/psychiatric comorbidity, the records support a score. The patient had diagnoses of bulimia nervosa, moderate, major depressive disorder, and posttraumatic stress disorder. In terms of recovery environment, the records support a score. The patient had discord with her family. With regards to level of support, the records support a score. The patient reported a history of abuse. However, the patients boyfriend offered support. In terms of treatment history, the records support a score. The patient was cooperative with treatment. She continued to struggle with chronic depression and body image problems. With regards to engagement and recovery status, the records support a score. The patient was engaged with treatment. She was able to form a positive relationship with staff and clinicians. Thus, the records support a composite score. Based on these criteria, the patient met criteria for intensive outpatient program level of care. Thus, the patient could have been treated in a less restrictive environment. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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:  An enrollee has requested reimbursement for residential treatment. The submitted documentation supports the medical necessity of a portion of the services at issue. This patient was struggling with identity formation. The patient had poor self-esteem and self-defeating coping strategies in context of anxiety, depression, alcohol abuse and poor motivation. As such, a conservative treatment course was to be expected. On 2/07/18, there was no discharge plan in place. The patient felt self-hatred and was engaged in all-or-none thinking while struggling with urges to drink alcohol. On 2/09/18, the patient had visions of drinking and starving upon discharge. The patient needed staff support during lunch. The provider increased the patients anti-craving medication, naltrexone, discontinued the prazosin, and changed the dose and timing of the trazodone. On 2/10/18, the patient was eating meals, but doing so slowly. On 2/12/18, the patient completed an outing and was looking forward to continuing treatment in a less restrictive setting.  In this patients case, discharge on 2/07/18 would have resulted in an unnecessary risk for prompt relapse and possible need for readmission. The patient was still having mood symptoms, anxiety and craving. The patient feared social situations and relapsing. The patient had not embraced a discharge plan. The patient was not fully motivated for recovery. Based on the records, residential treatment center services were safe, appropriate and consistent with good medical practice through 2/11/18, but not thereafter. By 2/12/18, there was no evidence to suggest that residential programming would further improve the patients condition or prevent a more serious episode of illness superiorly to well-coordinated services delivered in a less restrictive setting. Therefore, residential treatment provided from 2/07/18 through 2/11/18 was medically necessary for the 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for subcutaneous implantable cardioverter defibrillator. Based upon current guidelines from the American College of Cardiology, implantable cardioverter defibrillator therapy is appropriate for patients with hypertrophic cardiomyopathy who have significant risk factors for sudden cardiac death. The patient has a history of unexplained syncope and hypotension with exercise as well as a family history of sudden cardiac death and hypertrophic cardiomyopathy. The subcutaneous implantable cardioverter defibrillator device has now been evaluated extensively and showed excellent efficacy in the EFFORTLESS registry with three years of follow-up. The clinical experience to date suggests that the subcutaneous implantable cardioverter defibrillator is appropriate for younger patients under the age of 40 years to avoid the need for intravascular access with its potential for long-term complications. Therefore, the subcutaneous implantable cardioverter defibrillator is likely to be more beneficial for treatment of the patients medical condition than available standard therapy.One reviewer found that subcutaneous implantable cardioverter defibrillator is not likely to be more beneficial for treatment of the patients medical condition than available standard therapy.Final Result: Two of the three reviewers determined that the requested device 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  All three 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: An enrollee has requested reimbursement for the remote heart monitor. The use of different types of ambulatory cardiac monitoring for arrhythmias has evolved over the past 10-15 years. Researchers reported that current guidelines suggest that short duration monitors (24 or 48 hour Holter) or symptom-activated external loop recorders are available. Newer systems with mobile outpatient telemetry for longer periods of time have developed more recently and are recommended for infrequent symptoms or when there is investigation of the cause of cryptogenic stroke and suspected atrial fibrillation. Researchers also reported that the Heart Rhythm Society describes that the choice of monitor needs to be matched to the individual patients symptom frequency. Use of the MCOT is usually reserved for cases of infrequent symptoms or when the shorter duration monitors are negative or inconclusive. For these reasons, the remote heart monitor provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the remote heart monitor provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the remote heart monitor provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the radiofrequency neurolysis. The records provided for review do not indicate physical examination findings consistent with facet mediated pain. In addition, the records do not document findings of positive diagnostic facet blocks with anesthetic producing 70% or better pain relief for duration of anesthetic. The current guidelines support radiofrequency neurolysis when there is facet mediated pain and documented series of two diagnostic facet blocks with anesthetic. Researchers reported that radiofrequency neurolysis of the facet joints shows improved pain control for facet mediated pain in patients with low back without radiculopathy. A study found no benefit for radiofrequency neurolysis in patients with low back pain without radiculopathy or facet mediated pain. There was benefit for patients with facet mediated pain. As this patients records do not document facet mediated pain with positive response from diagnostic blocks, the radiofrequency neurolysis was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the radiofrequency neurolysis was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue 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:  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  All three 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: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy every two weeks. The records provided for review document that this patient has a history of chronic inflammatory demyelinating polyneuropathy (CIDP). The patient has been stable on IVIG without side effects. Previous attempts to stop IVIG resulted in relapses requiring hospitalizations. Given these findings and the current medical literature, the requested IVIG therapy every two weeks is supported as medically necessary for treatment of this patients CIDP. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: A female enrollee has requested authorization and coverage for intraoperative neurophysiologic monitoring. Peripheral nerve injury is a serious complication of hip surgery that can adversely affect a patients health outcome. Several studies have described the use of electromyography and intraoperative sensory evoked potentials for early warning of nerve injury. In the medical literature, analyzed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intraoperative monitoring. The authors reported that in 35% of the procedures, the provider was alerted to a possible lesion to the sciatic or femoral nerve. The authors concluded that intraoperative neurophysiological monitoring is effective for alerting the surgeon to the possibility of nerve injury. A study found that neuromonitoring during hip arthroscopic labral repair and debridement procedures might be useful to prevent temporary and permanent neural tissue injuries. Given these findings, the requested intraoperative neurophysiological monitoring is 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 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: An enrollee has requested authorization and coverage for Soma and Tylenol #3 or dantrolene and tramadol. There is support for a portion of the requested medications. For patients with chronic low back pain who have had an inadequate response to non-drug therapy, the American College of Physicians recommends treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. The guidelines note clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks. Therefore, tramadol is medically necessary for the treatment of this patient. However, Tylenol #3, which contains an opiate, is not recommended for chronic use in non-malignant pain unless the provider assesses the benefit as outweighing the harm. A formal risk assessment would need to be documented along with baseline urine toxicology. Therefore, Tylenol #3 is not medically necessary based upon the records provided. Soma is a muscle relaxant which is prone to abuse, and this medication has been studied for acute use. Chronic use of Soma would be off-label. Therefore, Soma is not medically necessary for the treatment of this patient. Oral dantrolene is used for spasticity from spinal cord injury, cerebral palsy and multiple sclerosis. This patient does not have any of these indications. Therefore, dantrolene is not medically necessary for the treatment of this patient. All told, tramadol is medically necessary in this patients case. However, the records fail to demonstrate the medical necessity of Soma, Tylenol #3 or dantrolene.Final Result: The reviewer determined that a portion of the requested medications is 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 anesthesiology with sub-specialty certification in pain 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 parent of an enrollee has requested authorization and coverage for Nutropin pen injector. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patients pre-treatment growth velocity was poor, and her adult predicted height was more than 2.25 standard deviations below the mean for her genetic target height and for adult population mean. Although they passed provocative GH testing and is not known to have a morphological abnormality of the pituitary gland, they meets U.S. Food and Drug Administration criteria for treatment of idiopathic short stature with poor adult height prediction that is below 59 inches. Therefore, Nutropin pen injector is medically necessary for treatment of this patient. Fnal 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: An enrollee has requested authorization and coverage for Synvisc One (hyaluronan) injections. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A systematic review was conducted of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, Synvisc One (hyaluronan) injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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.