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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Norditropin FlexPro 10 mg. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the records document recent height below 2.7 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. In this clinical setting, given that the patient meets the diagnostic criteria for ISS, the requested medication is medically indicated. Therefore, Norditropin FlexPro 10 mg 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 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: The patient has requested authorization and coverage for chiropractic services. Researchers compared the short-term effects of manipulative treatment to those from a therapeutic home exercise protocol for chronic cervical pain and found that both interventions improved function and pain after one week, with only marginal differences between the groups in favor of manipulative therapy. While the article referenced cervical pain, the findings may be applied to chronic back pain. In this case, while the patient has been referred for chiropractic care, the documented symptoms included midback pain, stiffness, and soreness, described as debilitating for one week, and did not note physical examination findings of limitations caused by pain. In this clinical setting, the requested services are not medically indicated. Therefore, chiropractic services 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 licensed D.C., board certified in chiropractic 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 patients parent has requested authorization and coverage for Vyvanse. The records document that this patient has symptoms of impaired processing speed, working memory, and learning. The records document that the patient has difficulty following instructions. Although the diagnosis of attention deficit hyperactivity disorder (ADHD) is not listed in the records, the patient demonstrated improvement in his school performance while treated with Vyvanse, and his symptoms are suggestive of ADHD, which frequently coexists with autism spectrum disorder. Previous treatment with Adderall XR and Concerta were ineffective, and Focalin caused insomnia. In the medical literature, Najib and colleagues describe that Vyvanse is a stimulant agent with low abuse and diversion potential that can be beneficial in the treatment of ADHD in children and adults. Cortese and colleagues conducted a meta-analysis of the available medical literature on the comparative efficacy and tolerability of oral medications for ADHD in children and adults. The authors concluded that Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. This patient underwent a stepwise trial of other stimulant medications, which have either been ineffective or have caused insomnia. Concerta and Adderall XR did not improve his symptoms, while Focalin caused insomnia. Vyvanse was effective in improving the patients school performance and was well tolerated. All told, the requested Vyvanse 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 neurology with special qualification in child 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 reimbursement for Xifaxan 200 mg tablets. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan for the treatment of travelers diarrhea, reduction of risk of overt hepatic encephalopathy recurrence, and irritable bowel syndrome with diarrhea. Current medical literature and guidelines on the treatment of chronic obstructive pulmonary disease (COPD) do not support the use of Xifaxan in the treatment of COPD. In this clinical setting, the medication at issue was not medically indicated. Therefore, Xifaxan 200 mg tablets were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 sub-specialty certifications in pulmonary disease and in critical care 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 reimbursement for air and associated ground ambulance transportation services. The current practice guidelines emphasize that providers must consider the fragile nature of malnourished patients when determining an appropriate treatment course. The records document that this patient with anorexia nervosa failed to make progress at California facility, and she was referred to the program in Arizona. Although the patients vital signs were stable on transport, she had significant sinus bradycardia and she remained an elevated fall risk during transport. The provider noted that two days prior to transport, the patient had hyponatremia on routine labs. Thus, the patients intake restriction continued to be profound, and she was at risk for a seizure. During transport, the patient required Ativan for anxiety, and she was emotionally distressed throughout most of the trip. Given the patients medical instability, the additional medical monitoring provided via air ambulance transport was medically necessary. For these reasons, the air and associated ground ambulance transportation services were medically necessary for 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections in the jaw. The American Academy of Neurology (AAN) recently updated its guidelines on using Botox in the treatment of brain disorders (Simpson, et al.). Botox is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Botox has been demonstrated to be safe and effective to increase headache-free days and improve health-related quality of life in chronic migraine. Frampton and Silberstein reviewed the current evidence on Botox in the prevention of chronic migraine. The authors found that the data suggests that Botox is an effective and generally well tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of oral prophylactics (Frampton and Silberstein). Moreover, Kocaman and colleagues suggested that Botox may also be effective in the treatment of temporomandibular disorder (TMD). The authors found that the patients with a diagnosis of chronic migraine and concomitant TMD reported a decrease in temporomandibular junction pain as well as a decrease in myalgia and headache after Botox treatment. In this case, the patient has a history of chronic migraines that has not responded to oral preventative medications and TMD. Based on the current medical literature, TMD can be a risk factor in migraine progression. Treatment with Botox is an effective prophylactic treatment for treatment of this patients chronic migraines and TMD. Therefore, the requested Botox injections in the jaw are medically necessary for 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 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:  An enrollee has requested authorization and coverage for Tandem insulin pump. Findings:  The physician reviewer found that According to Edem and colleagues, insulin pump therapy is an effective method for achieving glycemic control that provides flexibility both in basal infusion rates and the timing and frequency of prandial and correctional bolus dosing. The U.S. Food and Drug Administration have approved at least seven insulin pumps, all of which have slightly different approaches in providing a solution for those with insulin-requiring diabetes. Pinsker and colleagues state that the Tandem insulin pump allows for updatable software, which enables access to new technology as soon as it is commercialized. The remote software update process allows for minimal interruption in therapy compared to purchasing a new pump. Recent data from Pinsker and colleagues suggests that this process results in sustained reductions in hypoglycemia, thereby improving overall glycemic control. Therefore, Tandem insulin pump is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested device 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 patient has requested authorization and coverage for Bystolic 5 mg daily. While beta blockers are not regarded as the optimal first-line therapy for the management of hypertension, they may be indicated in certain clinical situation, especially in conjunction with an angiotensin II receptor blocker (ARB) as in this case, including for patients with rhythm disturbances, angina and prior myocardial infarction. In this case, the patient has a history of frequent premature ventricular contractions (PVC). Medical literature notes that potential PVC triggers include uncontrolled hypertension, and that the most common treatment medical therapy for patients with significant or persistent PVC related symptoms includes beta blockers. The patient has reported side effects with other trialed beta blockers, including other B-1 selective medications, and good response to Bystolic over a prolonged period. In this clinical setting, given the patients history of frequent PVC and as the records reflect that he is also on an ARB, the requested medication is indicated for the treatment of hypertension. Therefore, Bystolic 5 mg daily 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for segmental pneumatic compressor, trunk (E0656). This patient presents with chronic inflammation and edema in the legs and abdomen status post oophorectomy. The patient has been treated with manual lymphatic drainage, elevation, exercise, and compression without substantial improvement. Her provider has recommended a segmental pneumatic compressor for the trunk. Intermittent pneumatic compression using a pump with leg garment can potentially be a useful complement for maintenance edema management, with the foundation of care being compression garments. However, intermittent pneumatic compression is not a substitute for appropriate conservative care, particularly given that intermittent pneumatic compression may cause complications and may not be well tolerated (Chang and Cormier). Moreover, there is a lack of data demonstrating a clinical benefit with an intermittent pneumatic compression device that includes a truncal garment extension. The truncal garment extension has not been shown to improve patient health outcomes in the treatment of lymphedema or lipedema in the lower body. Given these findings, the requested segmental pneumatic compressor, trunk (E0656) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 patient has requested authorization and coverage for urine tests [albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)]. Benarroch-Gampel and colleagues note that routine preoperative laboratory testing for ambulatory surgery is not recommended as neither testing nor abnormal results are necessarily associated with postoperative outcomes. In this case, the patients history does not indicate a need for further evaluation of renal function, such as a known bleeding diathesis or abnormal hemoglobin and hematocrit levels. In this clinical setting, given that the documentation fails to indicate a concern regarding renal function, the requested services are not medically indicated. Therefore, urine tests [albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)] are not medically necessary for the evaluation of 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 urology with sub-specialty certification in pediatric urology 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 consultation with a nephrologist and/or kidney function test/renal function test (KFT/RFT test). The records provided for review document that this patient has normal baseline renal function and no history of renal disease. In this clinical setting, a nephrology consultation is not indicated. However, for urologic surgery the medical literature and guidelines recommend performance of baseline preoperative kidney function blood tests which typically include, sodium, potassium, chloride, CO2, blood urea nitrogen (BUN), and creatinine. Common complications from surgery include acute renal failure. These baseline preoperative kidney function tests will thoroughly assess the patient prior to considering surgery. Therefore, the requested KFT/RFT test is medically necessary for evaluation of this patient, while the requested consultation with a nephrologist is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partial overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) a consultation with a cardiac electrophysiologist, (2) heart magnetic resonance imaging (MRI), (3) electrocardiogram, and (4) blood tests (TSH T3, T4, TSH - thyroid stimulating immunoglobulin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin T, and plasma ceramides). Researchers note that while second opinions in general internal medicine may lead to the establishment of a new diagnosis in a small proportion of patients, second opinions have value as new treatments are often initiated and patients may report improved symptomology. In this case, the patient has a history of two syncopal episodes, chest pain, and resolved atrial septal defect (ASD). The records document an extensive cardiac evaluation by an electrophysiologist and pediatric cardiologist, including an electrocardiogram, cardiopulmonary stress testing, Zio patch monitoring, echocardiogram, laboratory testing and cardiac MRI, which did not show evidence of cardiac pathology, long QT syndrome or arrhythmia. In this clinical setting, although it appears unlikely based on this evaluation that the patient has significant cardiac pathology, a second opinion to review the performed studies and to conduct a clinical evaluation is reasonable and medically indicated. However, in the absence of specific recommendations and clinical indications, repeat testing of, or  other studies in addition to, already extensive normal cardiac studies are not medically indicated. Therefore, (1) a consultation with a cardiac electrophysiologist is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are 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 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:  An enrollee has requested authorization and coverage for a consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphate, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).According to Kwo and colleagues, work-up for underlying liver disease is appropriate given the risk of eventual cirrhosis and subsequent complications of decompensated cirrhosis, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested tests (lipoprotein, anion gap, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase, and prothrombin time) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. In this case, the patient has elevated liver enzymes. However, the patient does not have an indication for consideration of liver transplantation and has been evaluated by a transplant hepatologist on 3/09/21, with lack of evidence of chronic liver disease on extensive laboratory testing. For these reasons, the blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphate, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are medically necessary for the evaluation of the patients medical condition. However, a consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are partially 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 internal medicine with sub-specialty certification 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 a similar medical condition.