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 an implantable ambulatory event monitor. Findings:  The physician reviewer found that Forleo and colleagues report that continuous rhythm monitoring over long periods of time is superior to intermittent recording using external monitors to detect the presence of atrial fibrillation episodes and to quantify the atrial fibrillation burden. The authors further note that implantable devices for continuous atrial fibrillation keep detailed information about arrhythmia recurrences. In this case, the patient has undergone two radiofrequency ablation procedures and continues to experience palpitations that may be related to recurrent atrial fibrillation. A two-week event monitor did not reveal recurrent atrial defibrillation. The patient has easy bruising on Xarelto. In this case, given that an assessment of the safety of discontinuing Xarelto would depend on the patients atrial fibrillation burden based on long-term monitoring, the requested device is medically indicated. Therefore, an implantable ambulatory event monitor is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested device 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 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: The patient has requested authorization and coverage for Monovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of excellent results from Monovisc injections one year ago. The medical literature supports the requested repeated Monovisc injections of both knees as reasonable, appropriate, and medically necessary for treatment of this patients primary osteoarthritis of both knees, right worse than left. Given this support, the requested Monovisc injections in both knees 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 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 three-day electroencephalography (EEG) neurological testing in a hospital setting. This patients documentation indicates that the patient presents with complaints of spastic spells. The patient reports experiencing unprovoked recurring spontaneous episodes of altered consciousness and sensorium, which are concerning for a seizure diagnosis. As noted in the medical literature, EEG is an important tool in the diagnoses and management of patients with epilepsy. EEG monitoring is often used to help distinguish epileptic seizures from nonepileptic events. A routine EEG is typically less than an hour but can be enhanced with prolonged monitoring to obtain an extended EEG recording. EEG should be utilized for patients when seizure or epilepsy is a concern by the patients history and/or physical examination findings. Mikhaeil-Demo and colleagues noted that recordings taken over several days have been shown to increase sensitivity of seizure activity. This patient underwent evaluation with EEG in the outpatient setting that was inconclusive. In this clinical setting, the requested EEG is appropriate for further evaluation and potential diagnosis of this patients symptoms. Therefore, the requested three-day EEG neurological testing in a hospital setting is medically necessary for evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Forteo. Khosla and Hofbauer state, Osteoporosis is an enormous and growing public health problem. Once considered an inevitable consequence of ageing, it is now eminently preventable and treatable.  While anti-resorptive drugs, especially bisphosphonates, are considered standard therapy, Li and colleagues report that pro-formative anabolic drugs, such as Forteo, have attracted wide attention in recent years. The authors further note that randomized controlled trials show a higher efficacy with the use of teriparatide (brand name Forteo) in the treatment of osteoporosis than bisphosphonates such as risedronate. Laura and colleagues report that anabolic therapy is associated with a higher fracture risk reduction than oral bisphosphonates. Therefore, Forteo 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Salicylic acid 20% ointment twice weekly. Findings:  The physician reviewer found that The records document that this patient has a long history of ichthyosis vulgaris. The provider noted that the patient has been treated with Amlactin and tretinoin, which were ineffective. The provider noted that the patient has experienced adequate relief with 20% salicylic acid ointment. Fenner and Silverberg reported that, Atopic dermatitis is a common chronic pruritic inflammatory skin disorder, characterized by an abnormal skin barrier, immune dysfunction, and an altered skin microbiome. The authors noted that, Skin disorders associated with atopic dermatitis include diseases sharing similar genetic origins like ichthyosis vulgaris. There are several topical treatment options available for the treatment of patients with various ichthyoses of the skin. The mainstay of treatments are keratolytics, including ammonium lactate, urea, salicylic acid, and moisturizers. This patients records do not document adequate treatment and failure of salicylic acid 6% lotion, foam, or shampoo, which have been approved by the Health Plan and do not require compounding. The records do not support that the patients condition is unlikely to respond to treatment with 6% salicylic acid preparations to support an indication for treatment with salicylic acid 20% formulation. For these reasons, the requested salicylic acid 20% ointment twice weekly 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 dermatology 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart. In this case, the patient has significantly increased coronary risk. The American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, coronary CT scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. While the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data from controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable with treatment based on standard risk factor profiling and basic lipid analysis. Therefore, CT scan of the heart is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested CT scan of the heart 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 service 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for a Zoll LifeVest. In this case, notes report that the patient underwent a dual chamber implantable cardioverter defibrillator (ICD) for secondary prevention of sudden cardiac death. A systemic bacterial infection required redo of aortic valve replacement (AVR) and device explantation of ICD leads and pulse generator. Procedure notes reported that the patient underwent subcutaneous ICD implantation. In this clinical setting, a Zoll LifeVest was appropriate during the patients treatment and recovery from the severe systemic infection that required a redo of heart valve surgery while the device was explanted until he was cleared by infectious disease to undergo a new ICD implant procedure. Therefore, a Zoll LifeVest was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Zoll LifeVest at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
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 PR510 Zero Gravity infinite position MaxiComfort lift chair.Findings:  The physician reviewer found that Chu and colleagues report that despite continued research efforts into this group of genetic neuromuscular disease, patients with limb-girdle muscular dystrophy (LGMD) continue to be treated symptomatically with the aim of prevention or addressing complications. Pousada Garcia and colleagues state, There is a need for a more comprehensive investigation into the role of different kinds of support that can improve the quality of life of persons with neuromuscular disease. In a study on the effects of different assistive seats, Lou and colleagues report that further studies are needed to examine the biomechanical effects of assisted seats on individuals with disabilities.  While the records note that the patient has a neuromuscular disorder and difficulty standing up from a chair, he is able to ambulate once standing. In this case, the requested equipment includes zero gravity, Trendelenburg, and recline positions and settings that exceed the patients medical needs. Given that there is insufficient evidence in current medical literature indicating a medical need for a recliner lift chair for this patients neuromuscular disease, the requested equipment is not medically indicated. Therefore, the requested PR510 Zero Gravity infinite position MaxiComfort lift chair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue 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 with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immunoglobulin (IVIG) home infusions. There is a lack of clinical trial data reported to establish effective treatments for the management of patients with statin-triggered autoimmune myopathy. The consensus during the 224th European Neuromuscular Centre (ENMC) International Workshop defined anti-HMGCR myopathy in patients with (a) elevated serum creatinine kinase (CK) levels, (b) proximal muscle weakness, and (c) anti-HMGCR autoantibodies (Allenbach, et al.). The ENMC group reached consensus regarding treatment recommendations for patients with anti-HMGCR myopathy and noted that IVIG should always be added within six months when other treatment strategies are ineffective. In this case, the patient has clinical and laboratory findings consistent with anti-HMGCR myopathy and a history of diabetes. Per the ENMC consensus group, IVIG should be considered as monotherapy in anti-HMGCR myopathy patients with contraindications to or intolerance of high dose steroids as in this patients clinical setting due to comorbid diabetes. In addition, the published clinical studies have demonstrated that IVIG is an effective and a well-tolerated alternative to steroids in diabetic patients with statin-induced autoimmune myopathy. Mammen and Tiniakou reported that three patients with diabetes who declined treatment with glucocorticoids were treated with IVIG. The authors concluded that, our experience suggests that monotherapy with IVIG may be considered as a first-line treatment for statin-triggered autoimmune myopathy. Gungor and Wieshmann described a case report of a diabetic patient who had severe statin-induced autoimmune myopathy. The authors reported that the patient made a full recovery with regular IVIG infusions, his symptoms relapsed when the IVIG infusions were discontinued for 28 weeks, then his symptoms remitted again following recommencement of IVIG infusions. The data suggest that IVIG infusions are an effective and well tolerated alternative to steroids and immunosuppressants. Given this support, the requested Gamunex-C IVIG home infusions 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 reimbursement and prospective authorization and coverage for skilled nursing facility services. Findings:  The physician reviewer found that Solvang and colleagues note that people experiencing multitrauma will often live with problems in functioning for a profound period in life. In this case, the patient sustained severe trauma due to a motorcycle accident resulting in major injuries to multiple body regions, including the urinary bladder and the pelvis. He underwent multiple procedures and surgeries. The patient continued to have a suprapubic catheter. He remained non-weight bearing in the bilateral lower limbs. While the patient has undergone inpatient rehabilitation, he has largely plateaued with respect to functionality on account of ongoing bilateral lower limb non-weight bearing restrictions, which were necessitated by the severity of his original injuries and the time required for proper healing of the injured/repaired tissues. The records also note an endurance deficit and motivation issues, as the patient has elected to truncate therapy in order to attend to a visitor and has also refused therapy.  The patient continues to require extensive physical assistance for his lower body self-care activities. The records do not state when the patient may undergo an orthopedic reevaluation, or when his weight bearing status might be upgraded. In this case, the patients rehabilitation goals revolve around optimizing his compensatory skills at a wheelchair level while he waits for his bones to heal sufficiently enough for significant weight bearing activities such as stand pivot transfers, standing, ambulation, and climbing stairs. Given that there is no indication that the patients functional status is improving, and as the submitted records do not document a need of inpatient level of care for rehabilitation, medical, or nursing care, the services at issue were not and are not medically indicated. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent Solution Pen-Injector 300 mg/2 mL. Findings:  The physician reviewer found that the medical literature, Hailey-Hailey disease (HHD) is a genetic condition that results in blistering of the skin. Currently, there is a lack of specific approved treatments for the condition, and the literature has mainly case reports of treatments that have worked for certain patients. The records provided for review document that this patient has experienced severe symptoms for many years as have many of her relatives. The patients provider reports that the HHD condition causes the patient severe pain and discomfort. The patient has tried and failed several topical and systemic treatments including Botox, naltrexone, systemic and topical steroids, antibiotics, antifungals, cyclosporine, and tacrolimus. One case series described successful use of Dupixent in three patients with severe HHD with control of the disease for at least 17 months, no flares, and no side effects (Alzahrani, et al.). In addition, the patients daughter has HHD and is being treated with Dupixent with good results, per the providers letter. Given the findings in the medical literature and successful treatment of the patients daughter with Dupixent considering the genetic nature of the condition, treatment with Dupixent is appropriate for this patient. Therefore, requested Dupixent Solution Pen-Injector 300 mg/2 mL 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 dermatology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). The U.S. Food and Drug Administration (FDA) approves HIFU as a minimally invasive treatment approach to ablate prostate tissue. Maestroni and colleagues report that a systematic review of literature revealed that HIFU is effective in the treatment of clinically localized prostate cancer. Given that current medical literature supports the efficacy of HIFU in this clinical setting, the requested service is medically indicated. Therefore, HIFU 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.