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 Acthar Gel 80 units subcutaneously twice a week. The U.S. Food and Drug Administration (FDA) approves the use of Acthar Gel for the indication of nephrotic syndrome. Medical literatures report that Acthar Gel may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. In this clinical setting, the requested medication is medically indicated. Therefore, Acthar Gel 80 units subcutaneously twice a week is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in nephrology 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 resumption of skilled nursing facility (SNF) services including physical therapy and occupational therapy. The records document that this patient has a history of oropharyngeal dysphagia likely related to history of recent prolonged and complicated medical course related to COVID-19 infection, resulting intubation and tracheostomy. Per the providers notes, the patient presented to the emergency department following hospital discharge. The patient was transferred to a long-term care facility. The patient has an indwelling nasogastric tube, and the patient has reported slightly worsening shortness of breath compared to baseline. The patient recently failed bedside swallow screens and continues to require nasogastric feedings. On review of the records from the emergency department reassessment, the patient was in borderline status. Based on the patients persistent symptoms related to COVID-19 infection including tachycardia, oxygen desaturation, and weakness, the patient requires intensive rehabilitation services including skilled nursing care and the physical and occupational therapy services provided in a SNF treatment setting (Udina, et al.; Agostini, et al.). Given these findings, the requested resumption of SNF services including physical therapy and occupational therapy is 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 internal medicine with subspecialty certification in infectious diseases 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 custom oral sleep device Vivos Airway Device. This patients records document a history of OSA. The provider reports that treatment with two CPAP machines has not provided the patient with substantial improvement in her symptoms of OSA including excessive daytime sleepiness. The patient has requested a Vivos custom oral sleep device. Per the American Academy of Sleep Medicine (AASM), there is a paucity of data reported in the medical literature demonstrating the efficacy and safety of the Vivos oral sleep device in the treatment of patients with OSA (Patil, et al.). The AASM and American Academy of Dental Sleep Medicine (AADSM) guidelines recommend that a qualified dentist use a custom, titratable appliance over non-custom oral devices (Ramar, et al.). The current medical literature and guidelines report the benefit of treatment with mandibular advancement devices and CPAP therapy for treatment of patients with OSA. This patients records document intolerance to a replacement CPAP device after her previous CPAP device was recalled. Thus, the next logical treatment option is a mandibular advancement device. However, because of a lack of literature support for the Vivos system, the requested custom oral sleep device Vivos Airway Device (CPT 21089, E0486, and 21299) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary diseases, critical care medicine, and sleep 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 authorization and coverage for RT300 SLSA functional electrical stimulator (FES). In this case, the patient has a diagnosis of locked-in state. Emphasizing the need for significant multidisciplinary rehabilitation, Researchers report that multimodal treatments that are frequent and sensory can provide significant improvement for patients with locked-in syndrome. The authors further note that FES has been found to be particularly beneficial. Researchers explain that locked-in syndrome is a rare condition that results in tetraplegia and that although acute management is much like that of any severe stroke, rehabilitation and recovery of these patients have not been previously described.  Because locked-in syndrome is so rare, there is a lack of high quality studies that examine the efficacy of various treatments. In this case, the provider reported that the patient had some motor function and was improving functionally with the upper and lower extremities with use of the RT300 FES. As FES has been demonstrated to increase muscle mass in patients with spinal cord injured patients, it is reasonable that FES would increase the muscle mass in patients with tetraplegia from other etiologies, like locked-in syndrome. Without treatment, the patient will continue to lose muscle mass and function, and there are no obvious viable treatments other than FES that can maintain, or increase, muscle mass for a patient with locked-in syndrome. Therefore, the RT300 SLSA FES 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 requested RT300 SLSA FES 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 device 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 reviewer 1 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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 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 magnetic resonance imaging (MRI)  of the thoracic spine. The American College of Radiology appropriateness criteria for the evaluation of back pain reports that in a patient with subacute or chronic back pain who is a surgical candidate with persistent symptoms after four to six weeks of conservative management, MRI is considered usually appropriate. Imaging after conservative treatment could affect patient management if intervention is pursued, and may demonstrate disc disease and central canal stenosis among other findings, which may be the cause of the patients symptoms and may prompt intervention. First-line conservative treatment of back pain may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, or activity modification. If the patient is a candidate for intervention, and the pain persists despite four to six weeks of conservative measures, then MRI imaging may be appropriate. In this case, the submitted records do not document trial and failure of conservative management, specifically the physical therapy for at least four to six weeks. A previous MRI of the thoracic spine demonstrated minimal degenerative changes. There is no indication of trauma since the prior MRI or significant symptoms to suggest a substantial change would be detected on imaging. While the provider has requested an MRI for evaluation of possible arteriovenous malformation (AVM), there is no indication from the prior MRI report of an AVM. Given the lack of documentation regarding the trial and failure of physical therapy, the requested service is not medically indicated. Therefore, MRI of the thoracic spine 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 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for labiaplasty surgery. Hayes and Temple-Smith stated that, The most popular of the female genital cosmetic surgeries is labiaplasty, which involves cutting back the labia minora so that they sit flush with, or are entirely hidden by, the labia majora. Ozer and colleagues commented that, Most women applying for labiaplasty have labia minora that would be considered a natural size by a medical professional, emphasizing the importance of having a validated definition of the natural variation in labia size. The Franco classification divides labia minora width into four groups: less than 2 cm; 2-4 cm; 4-6 cm; and greater than 6 cm. In a study of 200 premenopausal women not seeking labiaplasty, Widschwendter and colleagues reported that, The median width of the labia minora was 19.0 mm, and the median length was 35.5 mm. The objective size of the labia was significantly associated with womens subjective perception of the labial size, but not with self-reported complaints. This patient presents with complaints of pain, discomfort, and irritation from the labia minora since puberty. Photographs show that the patients labia minora is within the wide documented range of normal without evidence of irritation or deformity. Based on the medical information received for review, the requested labiaplasty surgery is not medically necessary for treatment of this patient. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Based on the medical information received for review, the patients labia are within normal limits of size and are not abnormal structures. The patients labial size does not represent a congenital defect, a developmental abnormality, or a result of trauma, infection, tumors, or disease. Moreover, a labiaplasty would not be performed to improve function or provide a more than minimal improvement in the patients appearance. Therefore, the requested labiaplasty surgery is not reconstructive in nature for treatment of this patient. All told, the requested labiaplasty surgery is not medically necessary and not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested labiaplasty is not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Krystexxa (pegloticase) 8 mg intravenous (IV) every two weeks x 12 months. The American College of Rheumatology (ACR) guidelines recommend treatment with Krystexxa over continuation of uric acid lowering therapy for patients with two or more gout flares per year who are not candidates for treatment with xanthine oxidase inhibitors such as allopurinol or uricosurics, and other interventions have failed to achieve target uric acid levels (FitzGerald, et al.). However, the ACR guideline indicates that an optimal trial of oral therapy with allopurinol should be performed prior to treatment with Krystexxa use due to the potential adverse effects of Krystexxa. The ACR states that allopurinol is the preferred first-line agent to treat gout given its efficacy when dosed appropriately. As noted in the U.S. Food and Drug Administration (FDA) approval, treatment with allopurinol often requires doses more than 300 mg per day up to the maximum FDA-approved dose of 800 mg per day. This patients records document a diagnosis of gout. The provider noted that the patient has been treated with up to 300 mg daily of allopurinol, but not up to 800 mg per day. Per the ACR guidelines, the patients allopurinol dosing should be optimized prior to switching to Krystexxa. Moreover, there is a lack of report that the patient has been treated with, or has a contraindication to, other agents such as probenecid prior to consideration for treatment with Krystexxa. For these reasons, the requested authorization and coverage for Krystexxa (pegloticase) 8 mg IV every two weeks x 12 months 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 certification 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 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 a Rifton Hi/Lo activity chair. Stewart and colleagues report that modifiable risks for scald injury in children under five years of age include keeping hot objects in the kitchen out of reach of children. Jain and colleagues report that children with autism spectrum disorder (ASD) have more injuries than children without ASD, noting that the injury risk among children with ASD may be driven by co-occurring conditions, including visual impairment, and recommend injury prevention interventions. Choking in individuals with intellectual disability is common and a significant cause of death, with Landes and colleagues reporting in a review of death certificates of adults with intellectual disability in the United States that up to 4.8% of deaths were due to choking and aspiration. Guthrie and Stansfield note that caregivers involved in choking incidents report significant distress and anxiety. In this case, the patient has diagnoses of intellectual disability, ASD, and Cohen syndrome. The patient has visual impairment due to retinitis pigmentosa. The patient has frequent stereotypic behaviors, with violent backwards and forwards rocking when placed in a highchair for feeding. The patient is at high risk for injury, having already sustained bruising to the back and abdomen, and is also at risk of choking during these rocking stereotypies. The patient can propel the current highchair across the kitchen floor and is at risk of scald injury if a pan is knocked off the stove. Given that the requested equipment will adequately restrain the patient during feeding and ensure safety by protecting the patient from injury due to falls, choking, and scalding, the requested equipment is medically indicated. Therefore, a Rifton Hi/Lo activity chair is medically necessary for the 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.
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 continued acute care services. In this case, the records noted that the patient reported ongoing chronic abdominal pain.  She was previously noted to have opiate dependence. Her vital signs were stable, and she was afebrile. An abdominal examination was benign with a functioning gastrostomy-jejunostomy tube. She was at her baseline mental status. The records did not document active infection, acutely abnormal laboratory values, or significant electrolyte disturbances. The plan of care included podiatry follow-up for toe pain, continuation of anti-seizure medications, as she was medically stable on the current dosage, and continued enteral nutrition using the gastrostomy-jejunostomy tube. She was receiving physical therapy, able to perform bed mobility, transfers, and gait training up to 200 feet with auxiliary crutches. In this clinical setting, given that the patient was and is medically stable and able to receive continued care at a lower level of intensity, the services at issue were not and are not medically indicated. Therefore, continued acute care 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 internal 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen intravenous immunoglobulin (IVIG) infusions (1 gm/kg monthly for three months). The records provided for review document that this patient presents with symptoms concerning for long COVID-19. The patients provider has recommended treatment with Privigen IVIG. However, there is a lack of data in the peer-reviewed medical literature to support treatment with IVIG for this patient. Vinkenoog and colleagues reported on a retrospective observational study in which IgG antibody was evaluated as a correlate to COVID-19 symptoms. The authors did not directly assess the safety and efficacy of IVIG for the treatment of patients with neurologic symptoms as a result of COVID-19 infection and their findings do not include a recommendation for treatment with IVIG. Toscano and colleagues found that IVIG provided some clinical improvement in patients presenting with Guillain-Barre syndrome after COVID-19 infection. However, there is a lack of support for treatment of IVIG for this patients long COVID-related neurologic symptoms such as anxiety, palpitations, and joint pain post infection. For these reasons, the requested Privigen IVIG infusions (1 gm/kg monthly for three months) are 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 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 authorization and coverage for Orthovisc 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 reportedly benefitted from viscosupplementation with Orthovisc injections of both knees every six months for six years. Thus, the patient is a good candidate for additional viscosupplementation of both knees with Orthovisc. Therefore, the requested Orthovisc 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.