Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zephyr Endobrachial Valve replacement procedure (CPT 31647 x 2 and CPT 31651 x 2 with a four-day inpatient stay). Based on a review of the chart and peer-reviewed medical literature on bronchoscopic lung volume reduction, the requested procedure is appropriate for this patient and likely to be more beneficial than standard alternatives. The patient does not have any collateral ventilation and his pulmonary function testing results are within the parameters recommended by the FDA for treatment with the Zephyr device. Further, the patient has completed pulmonary rehabilitation. Current studies reported data that the Zephyr device provides modest improvement in symptoms and lung function. Based on these findings, the requested Zephyr Endobrachial Valve replacement procedure (CPT 31647 x 2 and CPT 31651 x 2 with a four-day inpatient stay) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Zephyr Endobrachial Valve replacement procedure (CPT 31647 x 2 and CPT 31651 x 2 with a four-day inpatient stay) 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 3 is board certified in board certified in internal medicine with subspecialty certification in pulmonary disease and is 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

The patient has requested reimbursement for a mandibular reposition. The patient is diagnosed with mild obstructive sleep apnea. The provider noted that the patient was not able to tolerate continuous positive airway pressure (CPAP) in the past. Researchers notes that the mandibular advancement appliance (MAA) is the most common type of a dental device in use today. The device makes the mandible protrude forward, preventing or minimizing the upper airway collapse during sleep. A significant variability in the patients response to treatment has been observed, which can be explained by the severity of sleep apnea at baseline and duration of treatment. In some trials, patients with mild OSA show a similar treatment effect after the use of CPAP or MAA. It is worthwhile to give it a try with an oral appliance of MAA type in snoring, mild-to-moderate sleep apnea, and in individuals who are intolerant to CPAP treatment. In this case, the patient has been diagnosed with OSA and was intolerant of CPAP. The medical evidence supports the device at issue in this clinical setting. Therefore, a mandibular reposition device was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.D.S., certified in oral facial and maxillary 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 has been diagnosed with a posterior glottic cyst and subglottic stenosis. The patient was noted to have been born premature at 26 weeks, with a history of posterior glottic cyst excision . The patient had silent aspiration noted on a dysphagia study, which was noted to have resolved , but impaired oral skills continued. A gastric tube was placed to provide most of her nutritional requirements. The patient has been treated with occupational therapy. The patients parent has requested authorization and coverage for Real Food Blends enteral formula. The Health Plan denied the request and reported the requested enteral formula is not medically necessary for the treatment of this patient. At issue in this case is whether Real Food Blends enteral formula is medically necessary for the treatment of the patients medical condition. A researcher reported, A blenderized tube feeding (BTF) is a mixture of food and liquid that is pureed and administered through a feeding tube. The author also reported, However, concerns also exist, such as contamination of the blend with microorganisms and increased viscosity causing feeding tube occlusion. A study reported, Blenderized diets are associated with decreased healthcare use, improved symptom scores, and increased patient satisfaction compared with conventional formulas. However, the study by the researchers does not distinguish among patients receiving home-blended diets versus commercially available blended formula, such as Real Food Blends. In this case, the clinical notes do not document that the patient experienced gastrointestinal distress associated with the standard formula. The medical evidence does not support the requested enteral formula in this clinical setting. Therefore, Real Food Blends enteral formula is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested enteral formula 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.1 criteria for IOP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. 30 sessions in an IOP over a period of three months was reasonable to promote continued sobriety. With the structure provided in the IOP, the patient was building coping skills to improve his ability to maintain sobriety. All told, the IOP services were medically necessary for 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 with expertise in addiction 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For documented reasons, the RTC level of care services were medically necessary for 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 with expertise in addiction 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: Upheld Decision of Health Plan

The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with medically monitored community based services. Given these findings, the RTC level of care services were not medically necessary for 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a standing power wheelchair with attendant control (CPT E2331), power seat elevation (CPT E2300), and powered standing feature (CPT E2301). Use of custom powered mobility and standing devices in patients with permanent mobility impairment allows increased function, independence, and participation in activities in and outside of the home. Current evidence shows that standing wheelchairs allow for frequent position changes without physical transfer and facilitate autonomous and meaningful participation in age appropriate physical, social and educational activities. For this patient, use of the powered standing and wheelchair device will enable him to reach his rehabilitation goals. In addition, standing with use of a power wheelchair is an essential component in the medical and rehabilitative care of this patient. The powered standing feature will allow the patient ongoing weight bearing without the need for two-person maximum assistance. Moreover, the standing power wheelchair with requested features will enable to patient to independently access tools and materials in the classroom. The standing wheelchair will permit the patient to function to his maximum capacity. Given these findings, the requested standing power wheelchair with attendant control (CPT E2331), power seat elevation (CPT E2300), and powered standing feature (CPT E2301) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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 enrollee is requesting authorization and coverage for the medication, Budesonide (9mg daily). The enrollee has a history of inflammatory bowel disease, a perianal fistula, and concern for Crohns disease. A progress note reports the plan from the prior visit was to start prednisone, Uceris and Stelara, but the enrollee did not follow this regimen. The progress note indicates the enrollee had tapered off the prednisone; however, his symptoms returned and prednisone, 15 milligrams was restarted. The enrollees physician reports the enrollee has tried Remicade, Entyvio, methotrexate and Imuran without relief. The note reports the enrollee has shown improvement in rectal bleeding since starting budenoside; however, his symptoms of diarrhea and frequent bowel movements, though improved, continue to be demonstrated. Treatment for four months with budesonide is reasonable and would be considered induction rather than maintenance.  Maintenance would be chronic and lifelong treatment.  This is a request for four months and is appropriate in the professional society guidelines.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  According to the patients medical record, this is a patient with systemic lupus erythematosus (SLE, an autoimmune disease).  The patient has a low positive ANA (a screening test to detect autoimmune diseases) , malar rash and joint pains. The provider prescribed Benlysta (belimumab) 200 milligrams weekly and stated the patient has tried and failed prednisone, methyl prednisone, gabapentin and Plaquenil. The patient experiences pain, chills and nausea when unable to take Plaquenil. The patient has taken Plaquenil for 10 years but recently developed a rash due to Plaquenil use. The Federal Drug Administration has approved Benlysta for autoantibody positive SLE, excluding renal and central nervous system disease (neither is present in this case). It is most useful in joint and skin disease, which is what the patient has. Benlysta is added to standard medication such as Plaquenil or steroids. ANA titers can vary with time, and after ten years, the current presence of a borderline titer of 1:40 does not preclude the diagnosis of SLE. The same can be true for more specific antibodies such as anti-Sm and anti-DNA. The patient has symptoms in the skin and joints without Plaquenil due to a reaction to that medication, so the patients options are Benlysta or medications that have toxicities at least equal to and more likely more severe than Benlysta. Steroids have not provided the patient with good relief, and one would not want to rely on them for chronic management. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology        and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the  medication, Xifaxan 200 mg (6 tablets daily for 14 days). The enrollee has diagnoses of small intestinal bacterial overgrowth, dyspepsia, gastritis, and gastroesophageal reflux disease. A progress note reported enrollee symptoms of abdominal pain, but no distention or rectal bleeding. A breath test showed bacterial overgrowth; hydrogen dominant. A progress note reported the enrollee continued to have symptoms of acid reflux and of stomach tenderness after eating. The physician ordered Xifaxan (rifaximin) and for the enrollee to start on Biocidin five days after completing treatment with Xifaxan. Literature reports small bowel intestinal overgrowth is improved with rifaximin. The authors report that 1200 or 1600 milligrams per day rifaximin dosages lead to significant improvement. This enrollee has small bowel intestinal overgrowth and rifaximin has been shown to be beneficial at the 1200 milligrams per day dosage. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient reported fatigue, headaches, postnasal drip, and nasal congestion. The provider noted computed tomography (CT) of the sinuses revealed no mass, no acute fracture or dislocation, and no aggressive osseous lesions. The provider noted the patient has mild septal deviation and concha bullosa that does not obstruct her airway. The patient has requested authorization and coverage for concha bullosa reduction surgery. The Health Plan denied the request and reported the requested surgery is not medically necessary for the treatment of this patient. At issue in this case is whether concha bullosa reduction surgery is medically necessary for the treatment of the patients medical condition. Studies reported, A concha bullosa (CB) represents the presence of air cell in the turbinates, and the middle turbinate concha bullosa is a common nasal cavity anatomical variation. The authors also noted, Our findings show that the CB does not appear to give rise to chronic sinusitis, but the extensive type was more symptomatic than the bulbous or lamellar types. In this case, the patient has a history of headaches, fatigue, and postnasal drip. CT imaging showed a concha bullosa with no sinus disease. There was no documentation the patient had sinusitis or nasal obstruction. The medical evidence does not support the requested surgery in this clinical setting. Therefore, concha bullosa reduction surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 otolaryngology 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:  The enrollee requested authorization and coverage for Shingrix, 50mcg/0.5ml. The enrollee has a rash to her back. The progress note reports the symptoms occur randomly. The enrollee has a history of recurrent shingles. The progress note indicates the enrollee will accept topical therapy, but that systemic therapy has resulted in a 30 percent hair loss. She returned to her provider due to another outbreak, which began one week prior. The provider ordered Valtrex, 1000 milligrams per day, and ordered a shingles vaccine for the enrollee. The physicians diagnosis at that visit was herpes zoster with complications. She reports having experienced 13 episodes of shingles since over the last year and a half. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to support this service as likely to be more beneficial than any other standard treatment. A thorough search of the literature did not yield any robust studies for which shingles vaccine was effective in this age group and diagnosis. Shingrix is not approved for those younger than age 50.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology and are 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.