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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) level of care. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm, due to recent use of alcohol and marijuana prior to IOP admission, and self-harm and disordered eating even after months of IOP treatment. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment, due to disordered eating, interpersonal conflict with parents, and struggles with interpersonal connections and relationships. The patients sobriety while enrolled in IOP demonstrated gains and/or stabilization in functioning while participating in a structured, protected, and/or enriched service.With regard to comorbidity, the records support a score of 3. The patient had significant co-morbidity, due to the presence of substance abuse, disordered eating, depressed mood, and anxiety. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a stressful environment due to role expectations that exceeded the patients given age, status, and developmental level, as demonstrated by patients feeling overwhelmed by academic expectations. With regard to level of support of the recovery environment, the records support a score of 2 due to parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient had significant resiliency and/or response to treatment but required formal supports or ongoing care in alternative supportive relationships, as demonstrated by the patients ability to maintain sobriety within the structure and support of the IOP program. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated somewhat passively in treatment. Thus, the patient has a total score of 18. In this case, the recommended level of care is high-intensity community-based services. This is consistent with the IOP level of care the patient received. Therefore, IOP level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve neurostimulator.Multiple studies have demonstrated hypoglossal nerve stimulation can improve health outcomes for patients with obstructive sleep apnea (OSA). Researchers reported on the ADHERE Registry, which is a multicenter prospective observational study to establish long-term outcomes in patients treated with upper airway stimulation. The researchers reported that across their multi-institutional study, upper airway stimulation therapy continues to show significant improvement in subjective and objective OSA symptoms. A meta-analysis by researchers demonstrated clinically significant decreases in observed mean apnea/hypopnea index (AHI) and Epworth Sleepiness Scale combined with improvements in quality of life scales. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy. This patient with OSA has an AHI of 56.5 and body mass index (BMI) of 29.6 kg/m2. The provider documented that the patient failed treatment with continuous positive airway pressure (CPAP). There was no evidence of complete concentric collapse at the nasopharynx, velopharynx, or soft palate on drug induced sleep endoscopy (DISE). All told, the requested implantation of a hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested implantation of a hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 otolaryngology 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 Otezla 30 mg tablets. Based on the guidelines from the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF), patients who have 3-10% BSA involvement have moderate disease, while patients with 10% or more BSA involvement have severe psoriasis. Patients with severe psoriasis are candidates for phototherapy and systemic medical therapy. However, there are no step therapy guidelines, and the choice of therapy should be made at the discretion of the treating provider with attention paid to the patients comorbidities. Otezla is U.S. Food and Administration (FDA) approved for the treatment of moderate to severe psoriasis and has Level A evidence to support its efficacy. Given that this patient has documented evidence of severe disease with a BSA of 15%, the requested medication is consistent with the AAD and NPF guidelines. Given this support, the requested Otezla 30 mg tablets are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 cardiac computed tomography (CPT 75571). Based on standard risk factor calculations, this patients 10-year cardiovascular risk is low. However, her low-density lipoprotein is close to recommended statin treatment levels and she has a diagnosis of Crohns disease, which significantly raises her risk of developing cardiovascular disease. Findings:  The physician reviewer found that in addition, she has been unsuccessful with diet and exercise in lowering her body mass index and improving her overall cardiovascular risk and lipid profile. Given these additional clinical factors, statin therapy should be considered. Further risk stratification with computed tomography calcium scoring has been shown to be useful in determining the need for lifelong statin therapy in this type of indeterminate clinical situation. Given this support, the cardiac computed tomography (CPT 75571) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the cardiac computed tomography (CPT 75571) was likely to be more beneficial for evaluation 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 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 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 patients parent has requested reimbursement and prospective authorization and coverage for Norditropin FlexPro. U.S. Food and Drug Administration (FDA) approved indications for the use of Norditropin (somatropin) in pediatric patients include, but are not limited to, growth hormone deficiency. Deodati and Cianfarani note that growth hormone therapy in children with ISS seems to be effective in partially reducing the deficit in height as adults. In this case, the patient has been diagnosed with ISS and began treatment with growth hormone therapy at age five. He met FDA approved indications for the initiation of somatropin therapy due to suspected growth hormone deficiency. The records show the patient has nearly attained a normal adult height. The provider recommends continuing Norditropin for the next six to twelve months as his growth plates close. Therefore, Norditropin FlexPro was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Orthovisc injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior Orthovisc injections received four years ago. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections for both knees 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral custom foot orthotics. The submitted documentation supports the medical necessity of the requested equipment. The records document foot pain, metatarsalgia, a painful tailors bunion, and flat feet/pes planovalgus. The patients provider has recommended a pair of custom foot orthotics. Custom foot orthotics are utilized to support certain areas of the foot during gait, and reduce the range of motion of painful joints. In this patients case, custom orthotics would support this patients flat feet, alleviate strain of the longitudinal arch, and reduce pain to the forefoot, including below her metatarsal heads as well as the painful tailors bunion. Therefore, the requested bilateral custom foot orthotics are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The 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 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 Tysabri infusions. Multiple sclerosis is a progressive condition which leads to worsening neurological disability. Researcher describes natalizumab as the first humanized monoclonal antibody indicated in the treatment of relapsing-remitting multiple sclerosis (RRMS). The researcher noted natalizumab was indicated in active RRMS based on its remarkable efficacy in reducing disease activity and reducing the risk of disability progression. Medical literature noted that the choice of using natalizumab was currently based on the professional experience of the neurologist, and on patients clinical features and preferences. In this case, the patient has multiple sclerosis and has recurrent symptoms. Given the current medical literature and the providers recommendation that the patient continue on Tysabri, the requested treatment is medically indicated. Therefore, Tysabri infusions are 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 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: An enrollee has requested authorization and coverage for electrical bone growth stimulator (HCPCS E0747). Clinical studies show variable safety and efficacy of electrical bone growth stimulation under different conditions and patient scenarios. Khalifeh and colleagues concluded that electrical bone growth stimulation presents a unique approach to accelerate healing and promote fusion success rates. Cook and colleagues found that the use of electromagnetic fields in bone healing have been studied, with most results showing improvement in healing of both bone and cartilage. Most supportive data are found in relation to the spine, femur, and tibia, but there is increasing evidence for its use in the foot and ankle for treatment of non-unions and as an adjunctive device in arthrodesis, particularly in high-risk populations. This patient presents status post left tibia and fibular fractures, as well as severe left foot skin traumatization and fractures. As of 6/17/20, the provider indicated that the patient had tenderness to palpation along the mid-shaft of the tibia along the fracture site. X-rays revealed some callus formation to the tibia and minimal callus formation noted at the fibula. Additional physical therapy was planned. The provider recommended a bone growth stimulator. However, there is no discussion of follow-up x-rays to confirm a diagnosis of fracture nonunion and document no signs of progressive healing. Moreover, there are no risk factors documented to support an indication for an electrical bone growth stimulator or detailed evidence of failed standard care. Therefore, the requested electrical bone growth stimulator (HCPCS E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested electrical bone growth stimulator (HCPCS E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for acupuncture. In investigating the efficacy of acupuncture for acute migraine attacks, the researchers found the results suggested acupuncture was effective in relieving pain and reducing the usage of acute medication. Researcher noted, Acupuncture seems to be at least as effective as conventional drug preventative therapy for migraine and is safe, long lasting, and cost-effective. It is a complex intervention that may prompt lifestyle changes that could be valuable in patients recovery. In this case, the patient continues to be symptomatic, with migraines episodes on a weekly basis, and is non-responsive to medication. Given that current medical literature suggests acupuncture is safe and effective for migraine prevention and for pain management, the requested services are medically indicated for this patient. Therefore, acupuncture is 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Medtronic 670G insulin pump with continuous glucose monitoring system. A continuous glucose monitoring system (CGMS) is one of several devices approved by the U.S. Food and Drug Administration that records blood sugar levels at repeated intervals continually.  CGMS may identify fluctuations and trends that would otherwise go unnoticed, preventing hyperglycemia and hypoglycemia. Lane and colleagues found that CGMS may be used to tighten glycemic control, and may promote safer and more effective glycemic control than self-monitoring of blood glucose. CGMS can lead to even greater improvement when used in conjunction with insulin pump therapy. In this case, the patient is an insulin-dependent diabetic currently using a MiniMed 630G pump with less than adequate control. Her hemoglobin A1C on 7/21/20 was 10.9, with a history of elevated blood glucose. Notably, on 4/1/20, her blood glucose was greater than 500, and she has a history of diabetic ketoacidosis. In this case, tighter control of 24-hour blood glucose would be beneficial. In this regard, the MiniMed 670G pump, a hybrid closed-loop insulin delivery system that uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor, would help the patient optimize her glycemic control, thereby reducing the likelihood of long-term diabetic complications. Therefore, the Medtronic 670G insulin pump with continuous glucose monitoring system is medically necessary for the 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 sub-specialty certification in endocrinology, diabetes 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for transthoracic echocardiogram (CPT 93303). The submitted documentation supports the medical necessity of the services at issue. This patient previously had an echocardiogram in 2015 that showed a small perimembranous VSD. She reportedly had been asymptomatic. Perimembranous VSDs are followed even if hemodynamically insignificant because patients may develop RVOT or LVOT obstruction from overgrowth of aneurysm tissue, aortic insufficiency and double-chambered right ventricle even with no change in the murmur. This is more likely to happen during periods of rapid growth. The published guidelines for children and adults recommend follow-up echocardiogram every three to five years. Therefore, transthoracic echocardiogram (CPT 93303) was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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 cardiology 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.