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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for sub-acute rehabilitative services.Nas and colleagues noted, The treatment and rehabilitation period is long, expensive and exhausting in spinal cord injury (SCI). Whether complete or incomplete, SCI rehabilitation is a long process that requires patience and motivation of the patient and relatives. Per Hagen and colleagues, Knowledge of cardiovascular sequelae after spinal cord injuries and assessment of these is important for correct diagnostics, planning of preventive measures and optimal treatment. Rosin and colleagues noted, Skin breakdown, including burns and pressure injuries (PrIs), is a devastating complication of spinal cord injury (SCI).In this case, the patient has a complicated rehabilitative history related to his spinal cord injury. The patient was appropriately transferred to acute rehabilitation for acute care for his spinal cord injury following cervical stabilization surgery. Unfortunately, the patients rehabilitation was complicated by atrial fibrillation with rapid ventricular response. Spinal cord injury patients, particularly tetraplegics, typically have newly developed cardiac complications. This complication required that the patient receive acute care for about 10 days. As a result, the patient did not receive the rehabilitation that he would have received in an acute or sub-acute rehabilitation facility. This likely set the patient back in his rehabilitation. When the patient was transferred to a skilled nursing facility, he ended up developing a stage 3 pressure sore. The notes indicate that the patient needed at least moderate assistance to perform pressure reliefs. Such wounds will not heal without consistent pressure reliefs, which would have to be performed at least every hour. Vocational nurse notes indicate that the patient needed maximum assistance for activities of daily living. The pressure sore that was developed in the skilled nursing facility will not heal without consistent pressure reliefs and wound care. The patient is at risk for further injury and complications without wound care, consistent pressure reliefs and further rehabilitation to help him better independently perform activities of daily living. Under these circumstances, the sub-acute rehabilitative services were and are medically necessary to treat the patient's medical condition.Final Result: The reviewer determined that the services at issue were and are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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 Synvisc injections to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments including arthroscopic surgery, NSAIDs, and cortisone injections, with the alternative being a total knee replacement. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc injections to the right knee are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent. Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of patients aged six years and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Boguniewicz and colleagues note that moderate-to-severe atopic dermatitis is defined as involving over 10% of BSA and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and is not recommended for younger children. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has moderate-severe atopic dermatitis with almost 60% BSA involvement. The patient had tried and failed topical steroids including triamcinolone, mometasone, Clobetasol, and tacrolimus, and was noted has having seen improvement on a trial of Dupixent. Light treatment, which is generally given up to three times weekly, is not an option in this case due to the patients age, as it would require that the patient to miss school, and as the patient does not live near a provider. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent 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 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for FoundationOne CDx testing. All patients with metastatic colorectal cancer should undergo tumor genotyping for RAS (KRAS and NRAS) and BRAF gene mutations individually or as part of a next-generation sequencing panel. Parsons and colleagues note that colorectal cancer that demonstrates microsatellite instability (MSI) may be caused by germline mismatch repair (MMR) gene mutations. Universal MSI and/or MMR testing is recommended for all patients newly diagnosed with colon cancer, along with HER2 testing. As the results from these tests help determine both standard treatment recommendations and clinical trial recommendations, the service at issue was likely to have been more beneficial than any standard therapy. Therefore, FoundationOne CDx testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the FoundationOne CDx testing 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 services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Volara System. The Volara System is more likely than other modalities to be beneficial in this clinical setting because it provides both improved lung expansion through positive end expiratory pressure as well as a high frequency oscillatory airflow, which complement  each other. The available current medical literature suggests a benefit from the equipment and supplies at issue. Therefore, the Volara System was and is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Volara System at issue was and 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 equipment was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certifications in pulmonary disease and in critical care medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for spinal magnetic resonance imaging (MRI). Findings: The AIM criteria for spine imaging states that one of the requirements is conservative management, which is documented in this patients records. An additional AIM requirement is evidence of objective weakness or sensory abnormality corresponding to a dermatome, reflex abnormalities, or spasticity. The patients strength, sensation, and reflexes were reportedly normal on the most recent physical examination before the MRI. The patients reported pain was in the gluteal region and behind the thigh, which is where the S1 and S2 nerves innervate. Both nerves continue to innervate the back of the lower extremity below the level of the knee, which was not present in this patients clinical setting. Therefore, the patients nerve pain was not likely due to S1 or S2 nerve compression. The American College of Radiology (ACR) requirements for low back pain imaging state that for patients with subacute or chronic pain, MRI of the lumbar spine may be appropriate. However, this patients pain was in the gluteal region rather than lower back and not in a dermatomal distribution, which did not support an indication for MRI. Therefore, the spinal MRI was not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 neuroradiology with subspecialty certification in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief lasting six months with prior Synvisc-One injections. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc-One injection in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 20 hours of physical therapy utilizing the Wurn Technique. The treatment of intraabdominal adhesions in persons with a history of abdominal surgeries starts with conservative care such as bowel rest and decompression, but there is risk of recurrence because the underlying etiology, the adhesion, is not addressed. There is a lack of evidence supporting the benefit from any type of manual therapy for this condition and a lack of objective evidence derived from disinterested sources supporting the Wurn Technique, which is a proprietary, commercial technique. Researchers note that chronic pelvic pain and symptoms may result from various intra- and extra-pelvic etiologies. Researchers note that often no specific etiology can be identified for chronic pelvic pain in women, and that while pharmacotherapy, physical therapy modalities, and mental health interventions are often employed for treatment of these pains and/or symptoms, evidence-based therapies are limited. In this clinical setting, there is a dearth of high-grade evidence supporting the efficacy of physical therapy interventions. Therefore, 20 hours of physical therapy utilizing were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the 20 hours of physical therapy utilizing the Wurn Technique at issue was not 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 services at issue were not 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 upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for image-guided bilateral sacroiliac joint injection including arthrography. Findings: One study noted that, various studies have reported that three or more than three provocation tests might provide a more sensitive and specific identification of the stress from the sacroiliac joint. The authors concluded that, A diagnostic sacroiliac joint block helps to establish a more accurate diagnosis of intra-articular sacroiliac joint pain. Another study stated that diagnosis of sacroiliac joint dysfunction was made with three or more positive provocation tests, with the highest sensitivity being Faber (91.4%) and lowest probability was Gaenslen test. The authors also stated that the proposed criteria for diagnosis of sacroiliac joint dysfunction, which includes pain in the area of the sacroiliac joint, reproducible with provocative maneuvers, and must be relieved with local anesthetic injection into the sacroiliac joint or the lateral branch nerves. In this case, the patient has chronic low back pain with mixed examination findings of positive findings on two sacroiliac joint provocation maneuvers along with positive back pain reproduced with lumbar facet joint loading. Based on the most recent evidence-based guidelines regarding the clinical diagnosis of sacroiliac joint related back pain, at least three provocative maneuvers are required to establish strong suspicion for sacroiliac joint back pain. Furthermore, the providers impression was an L5 facet issue, which supports a pain generator above the L5 vertebral body, or the facet joint. There is a lack of evidence in the literature to support performing an SI joint injection on a patient with suspected facet joint related back pain. Given these findings, the requested image-guided bilateral sacroiliac joint injection including arthrography is not medically necessary for 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 board certified in anesthesiology with subspecialty certification in pain 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy. Chronic headaches are debilitating and can significantly decrease a patients quality of life. Findings:  The physician reviewer found that this patient with chronic headaches, alternating treatment with Botox and occipital nerve blocks have decreased her headaches by greater than 75%. On review of the records, occipital nerve block therapy was supported in the medical literature for use in this patients clinical setting. Ebied and colleagues found that, Occipital nerve block as adjunctive therapy has shown safety and efficacy in treating patients with migraines, measured by the reduction in pain. In addition, Juskys and Sustickas noted that, Occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. Given these findings, the occipital nerve block therapy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the occipital nerve block therapy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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 and prospective authorization and coverage for Estrogel (estradiol gel). The records provided for review document that this patient presented with postmenopausal symptoms including hot flashes and night sweats, problems with sleep and libido, and vaginal dryness. The provider recommended treatment with Estrogel. As noted by Monteleone and colleagues, the signs and symptoms of menopause include central nervous system-related disorders, metabolic, weight, cardiovascular and musculoskeletal changes, urogenital and skin atrophy, and sexual dysfunction. Pinkerton noted that menopausal hormone therapy can provide relief for patients with hot flashes and night sweats, reduce bone loss and risk of fractures, and address genitourinary syndrome of menopause. Paciuc concluded that estrogen remains the most effective treatment for vasomotor symptoms and genitourinary symptoms, for osteoporosis prevention, symptom relief, and chronic disease prevention in female patients. Given this support, the Estrogel (estradiol gel) was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.