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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for botulinum toxin (Botox) series injections every three months. Findings:  The physician reviewer found that preventive treatment when migraine attacks significantly interfere with a patients daily routines despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. In 2016, the American Academy of Neurology (AAN) updated its guidelines to include Botox 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 is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with chronic migraine (Simpson, et al.). In addition, Botox has been established as safe and effective to increase headache-free days and improve health-related quality of life in patients with chronic migraine. In this case, the patient has a history of chronic migraines that has not responded to multiple oral preventative medications. The patient experienced clinical improvement with Botox therapy. Her provider has recommended continued treatment with Botox injections every three months. Based on the AHS statement and AAN guideline, this patient is a candidate for prophylactic treatment with Botox therapy every three months for the treatment of chronic migraine. For these reasons, the requested Botox series injections every three months 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a L4-L5 artificial disc replacement surgical procedure (CPT 22857). The U.S. Food and Drug Administration (FDA) approves for the ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or two consecutive levels from L3 to S1. The FDA further notes that the patient should have no more than grade 1 spondylolisthesis at the involved level(s) and have failed at least six months of conservative treatment. The FDA notes that contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, Zigler and colleagues noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for low back pain. Diagnostic imaging demonstrates moderate degenerative hypertrophic facet arthropathy at the requested surgical level, with a normal intervertebral disc. There is no documented evidence of significant DDD, which is typically the primary indication for artificial disc replacement. Given that current medical literature does not support artificial disc replacement in the lumbar spine in this clinical setting, the requested service is not medically indicated. Therefore, a L4-L5 artificial disc replacement surgical procedure (CPT 22857) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 reimbursement and prospective authorization and coverage for (1) Gammagard (immune globulin) infusion administered on 2/12/21 and (2) Gammagard (immune globulin) infusions every 4 weeks. In this case, the patient has a history of recent sinopulmonary infections in the setting of low IgG levels and pneumococcal antibody levels. In this clinical setting, given the patients history of infections in the setting of abnormal laboratory values and diagnosis of specific antibody deficiency, the services at issue were and are medically indicated. Therefore, (1) Gammagard (immune globulin) infusion administered on 2/12/21 and (2) Gammagard (immune globulin) infusions every 4 weeks were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 internal medicine and in allergy and immunology 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 an implantable ambulatory event monitor. The records provided for review document that this patient experienced episodes of dizziness prior to the syncopal episodes. Evaluation with a Holter monitor several months before was unrevealing. He presented with chest pain followed by recurrent acute syncopal episodes and he was noted to be in atrial fibrillation, which responded to chemical cardioversion. He was evaluated for underlying causes of syncope including coronary artery disease (CAD). An echocardiogram demonstrated normal left ventricle (LV) function. The recurrent episodes of syncope, prior negative Holter results, and history of known paroxysmal atrial fibrillation supported concern for an arrhythmic cause of his syncope. As noted in the medical literature, implantable loop recorders have a specific clinical role in this patients scenario. The likelihood of a rhythm disturbance was high given the known prior atrial fibrillation and recurrent witnessed syncope along with infrequent events, and other explanations including CAD and LV dysfunction were ruled out. Earlier use in these situations has been shown to result in higher diagnostic yield with earlier diagnosis of the rhythm disturbances that inform subsequent treatment decisions. In this case, following several months of monitoring, sick sinus syndrome was confirmed, and a pacemaker implanted. All told, the implantable ambulatory event monitor was medically necessary for 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 internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240). Stroke is caused by one of several pathophysiologic processes involving the blood vessels of the brain. The process may be intrinsic to the vessel, as in thrombosis seen in a hypercoagulable state. Stroke evaluation involves brain imaging, cardiac testing, and laboratory studies. The records provided for review document that this patient underwent a comprehensive neurological evaluation and patent foramen ovale closure. Despite the exhaustive work-up and medical evaluations, the patient sustained a subsequent stroke and etiology remained cryptogenic. Coinciding with the patients brain ischemia there was diagnosis of unprovoked pulmonary embolism. Ischemic strokes in a patient under 50-years of age and coinciding pulmonary embolism supports suspicion for an underlying hypercoagulability as the etiology of the ischemic events. This patient has undergone comprehensive evaluation and continues to have ischemic events with coinciding evidence of hypercoagulability. Obtaining laboratory studies to evaluate the presence of hypercoagulable etiologies, specifically testing for Prothrombin (Factor II) G20210A gene mutation, is supported by the medical literature. Given these findings, the requested Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240) is likely to be more beneficial for evaluation 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 evaluation 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 neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Magnetic resonance imaging (MRI) of the head and magnetic resonance angiography (MRA) of the head. Findings: The patient has a history of facial and upper extremity numbness or tingling. As noted in the medical literature, this patients symptoms are concerning for transient ischemic attack (TIA). Per a study, patients with TIA or stroke are at increased risk of recurrent stroke. Treatment protocols include thorough evaluation and therapies focused on reducing the patients risk of recurrent stroke. Brain imaging with MRI is indicated for all patients with suspected TIA. It is critical to establish whether there is an obstructive lesion in an artery supplying the affected territory. Noninvasive options for evaluation of large vessel occlusive disease include MRA. In this patients clinical setting, the MRI and MRA were indicated for diagnostic purposes and to help guide treatment. All told, the MRI of the head and MRA of the head were medically necessary for 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 neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Durolane (Hyaluronan) injectionsAn exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of lasting benefit from prior Durolane injections. Furthermore, the options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Therefore, bilateral Durolane (Hyaluronan) injections 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Xyosted 75 mg/0.5 ml auto injector. Testosterone replacement therapy for hypogonadism may be indicated based on laboratory results, when two values show a deficiency in free testosterone when measured against normal values by 11 a.m. on each draw. Ongoing treatment of hypogonadism would be indicated by low or low-normal values prior to routine supplementation. In this case, given that the submitted laboratory testing showed normal testosterone values of free testosterone within 35-155 pg/mL and total testosterone within 250-1,100 ng/dL, the medication at issue was not and is not medically indicated. Therefore, Xyosted 75 mg/0.5 ml auto injector was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for use of a power scooter. The records provided for review do not support an indication for use of a power scooter. Per the patients physical therapy evaluation, the patient was capable of self-propelling a manual wheelchair and he was planned to undergo evaluation for a leg prosthesis. The medical records do not establish that the patient has musculoskeletal, cardiovascular, respiratory or other impairments that preclude effective propulsion of an optimally configured manual wheelchair using his upper limbs and right lower limb to accomplish his mobility-related activities of daily living (MRADLs). Many patients self-propel appropriately fitted manual wheelchair using one or both feet, in addition to the upper limb or limbs (Heinrichs, et al.). The patient can use a manual wheelchair until he is able to effectively use a transtibial leg prosthesis, which can be a highly effective means of community mobility, particularly with good prosthetic suspension and a dynamic response foot (Askew, et al.) Overall, there is no indication that the patient requires a power scooter to meet his MRADLs needs in or out of the home. Therefore, the requested use of a power scooter is not medically necessary for this patient to perform one or more MRADLs in or out of the home, including access to the community.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 patients parent has requested authorization and coverage for a psychoeducational assessment test. Wolraich and colleagues note, The use of neuropsychological testing has not been found to improve diagnostic accuracy in most cases, although it may have benefit in clarifying the child or adolescents learning strengths and weaknesses. The American Psychological Association notes that psychological and neuropsychological testing is not medically indicated when administered for educational or vocational purposes that do not inform medical or health management such that the purpose of testing is not to alter or direct medical or health management, or when repeat testing is not required for medical decision-making; for example, because the repeat testing is because of a patient preference or request. In this case, the patient underwent previous psychological testing and was diagnosed with attention deficit hyperactivity disorder (ADHD). The request for updated testing is from an academic support specialist at the patients school and not from a clinician. The documentation does not show that the testing is for a reevaluation of the patients diagnosis or clinical treatment plan. In this patients case, a psychoeducational assessment test is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, a psychoeducational assessment test is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Brand name Herceptin. Per the National Comprehensive Cancer Network (NCCN) guidelines, biosimilar agents for trastuzumab (Herceptin) are endorsed as standard substitutions. In addition, U.S. Food and Drug Administration (FDA) approved biosimilar agents, such as Kanjinti, are appropriate substitutes for brand name Herceptin. Oftentimes, patients with HER2 positive metastatic breast cancer can develop progression of disease and need to be changed to different medications. Based on current recommendations, brand name Herceptin is not supported for treatment of this patient when biosimilar agents are available to provide control over this patients disease. Therefore, the requested brand name Herceptin is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.