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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute rehabilitation services. Findings:  The physician reviewer found that Breshears and colleagues note that dexamethasone is a standard treatment for cerebral edema after brain tumor surgery, however, side effects including diabetes, hypertension, and insomnia can negatively impact the quality and safety of care provided to patients. Jessurun and colleagues note that dexamethasone has long been a staple of neurosurgical treatment used to control peritumoral edema and focal neurological symptoms. The authors note that the use of dexamethasone is associated with a variety of adverse events including muscular weakness, hyperglycemia, cushingoid symptoms, mental disorders, and gastrointestinal ulceration. These adverse effects are known to be related to cumulative dose and duration of therapy. In this case, the patient is status post meningioma resection, and reported stopping steroid use due to insomnia and other putative adverse effects. She was admitted to the emergency department with an altered mental state that was attributed to the cessation of steroids. The records noted an improvement in mental health and functional status after her steroids were restarted with a tapering schedule. While the patient required contact guard assistance for transfers and some cues, the records noted medical stability and functional improvement. In this clinical setting, given that the patients rehabilitation needs can be met at a less intensive setting of care, the requested services are not medically indicated. Therefore, acute rehabilitation services are not medically necessary for the treatment of 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 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 laparoscopic or laparoscopically-assisted vaginal hysterectomy, removal of uterus. Findings:  The physician reviewer found that Tu and As-Sanie note that in the evaluation and management of pelvic pain, gynecologists still lack precise methods to determine when the uterus is the primary problem. The authors further note that hysterectomy in many cases provides a durable solution. Chronic pelvic pain may represent pathology in a specific organ system and/or as a chronic pain syndrome. As chronic pelvic pain may be due to more than one etiology, the goal of evaluation is to identify treatable causes of pain and differentiate specific peripheral causes from those overlapping with centralized pain syndromes. In this case, the patient has a history of pelvic pain. The records document a thorough work-up with history, imaging, and physical examination notable for worsening pain with uterine palpation along with concerns of adhesions and polycystic ovary syndrome (PCOS). The records note that medical management with Depo-Vera failed to control the patients symptoms and led to concerns of low bone density. Given the extent of the patients history, work-up, multi-disciplinary evaluation, and failed medical treatment, the requested service is medically indicated. Therefore, laparoscopic or laparoscopically-assisted vaginal hysterectomy, removal of uterus 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 obstetrics and gynecology 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 referral to an allergist who specializes in diagnosing and treating mast cell disorders. Valent notes that the various symptoms of mast cell activation syndrome are probably one of the more frequently recorded and frequently treated symptoms in daily practice in internal medicine. In this case, the patient underwent a workup for mast cell activation syndrome by a specialist in allergy/immunology, which was negative. Given that the patient has recently been evaluated by a specialist, whose field includes training in the diagnosis and treatment of mast cell activation syndrome, that did not indicate a diagnosis of mast cell activation syndrome, the requested service is not medically indicated. Therefore, a referral to an allergist who specializes in diagnosing and treating mast cell disorders is not medically necessary for the evaluation 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for treatment from an inpatient chronic pain program.Chopra and colleagues evaluated current options for pain management of Ehlers-Danlos syndrome. Chopra and colleagues advocated a multidisciplinary approach, including physiotherapy for core stabilizing and joint stabilizing and proprioception enhancing exercises along with general fitness programs. They also recommended cognitive behavioral therapy and medication management with various classes of agents, including nonsteroidal anti-inflammatory drug (NSAIDs), neuromodulators, acetaminophen, and topical lidocaine. A study by Van Meulenbroek and colleagues assessed changes in disability, physical functioning, and other pain-related outcomes for hypermobile adolescents (age 12-21 years) with chronic musculoskeletal pain after following an outpatient multidisciplinary rehabilitation treatment. The treatment consisted of physical training and cognitive behavioral therapy, with the goal to improve physical parameters, such as aerobic capacity, muscle strength and proprioception. Cognitive behavioral therapy aimed to restore a normal pattern of daily functioning by decreasing pain-related fear. After treatment, the adolescents had lower levels of disability, decreased pain-related fear, a reduction in pain intensity and increased levels of physical functioning. Additionally, the medical literatures consensus is that a multidisciplinary approach is the main factor for best outcomes and not a clinical setting. No rationale has been provided identifying why multidisciplinary treatment would be unable to be provided in an outpatient setting. Therefore, treatment from an inpatient chronic pain program is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an extra wide hospital bed (E0303). Hagen reports that along with motor and sensory deficits, instabilities of the cardiovascular, thermoregulatory and broncho-pulmonary system are common after a spinal cord injury. Sezer and colleagues report that the goals of rehabilitation and other treatment approaches in spinal cord injury are to improve functional level, decrease secondary morbidity and enhance health-related quality of life. This may include the use of durable medical equipment such as wheelchairs or hospital beds to enhance mobility that has been lost due to the spinal cord injury. In this case, the patient has a documented height of 64 inches, and a weight of 180 pounds. Given that the submitted records did not document reasons why the patient could not stretch in a regular sized bed, or an evaluation from physical or occupational therapy with findings that an extra wide hospital bed is recommended for this patient, the requested equipment is not medically indicated. Therefore, the requested extra wide hospital bed (E0303) is not medically necessary for the treatment of this patient.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall immediate release (IR) 20 mg twice a day, Adderall IR 20 mg three times a day, or in the alternative, Adderall extended release (XR) 30 mg every morning. As noted in the medical literature, attention-deficit/hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders among adults. For most patients with ADHD, first-line therapy includes medication management with amphetamines. While substance abuse or concurrent use of cannabis can create challenges in the setting of treatment of patients with ADHD with amphetamines, this alone is not a contraindication. This patient presents with multiple medical conditions including traumatic brain injury (TBI), seizures, and ADHD. The continuation of the patients medication regimen with Adderall is supported as consistent with current recommendations. Adderall XR dosed once per day will help enable the patient to be compliant with his regimen. Given these findings, the requested Adderall XR 30 mg every morning 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 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

The patient has requested authorization and coverage for chiropractic services. The records provided for review document that this patient has low back pain with radiation to the right lower leg. The patient has been treated with medications, topical gel, and physical therapy without substantial improvement. Treatment with epidural steroid injections provided some relief of pain and related symptoms. The patients provider has recommended treatment with chiropractic services. Ghasabmahaleh and colleagues reported that in patients with subacute or chronic lumbar radiculopathy, spinal manipulation can improve the results of physiotherapy when performed over a period of three months. Overall, the current medical literature supports the safety and efficacy of chiropractic care for low back pain. Given this support, the requested chiropractic services are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for air ambulance transportation. Current medical literature supports spinal cord rehabilitation following traumatic spinal cord injury (SCI). Herzer and colleagues report that earlier rehabilitation after traumatic SCI may improve a patients functional status at discharge. Labruyere and colleagues likewise report that early rehabilitation, defined as within 30 days of injury, improves outcome and recovery for spinal cord trauma patients. The authors further note that in a dedicated SCI rehabilitation setting, effective treatment and proper monitoring of spontaneous and rehabilitation-based motor function improvements is performed with appropriate, valid, reliable, and internationally accepted clinical assessment tools. In this case, the patient suffered a complete spinal cord injury and was an appropriate candidate for spinal cord injury rehabilitation following medical and surgical stabilization. Despite being requested, the submitted records did not include information on whether there was a similarly credentialed spinal cord rehabilitation facility in closer in proximity to Renown Regional Medical Center in Reno, Nev. than the Santa Clara Valley Medical Center in San Jose, Calif. In this clinical setting, given that specialized rehabilitative care for patients with SCI results in better outcomes with fewer complications and as air ambulance was the only reasonable method to transport the patient to Santa Clara Valley Medical Center, the service at issue was medically indicated. Therefore, air ambulance transportation was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lidocaine patch 5%. Findings:  The physician reviewer found that a review conducted by Moisset and colleagues evaluated the available pharmacological and non-pharmacological treatments for neuropathic pain. The authors concluded that, The recommendation for the use of topical lidocaine in peripheral neuropathic pain is weak (moderate quality of evidence but excellent safety profile). Per the U.S. Food and Drug Administration (FDA), the lidocaine patch has been approved for patients with a diagnosis of post-herpetic neuralgia. In this case, the patient has chronic thoracic spine pain after sustaining a spinal cord infarct during a procedure to repair a ventral dural tear of the thoracic spine that was causing cerebral spinal fluid leaks. The patient has undergone a multimodal treatment plan that has included neuromodulating agents such as pregabalin, tizanidine, and Cymbalta. The patient reports that lidocaine patches applied locally to the thoracic spine have been effective at alleviating his pain. However, the current medical literature does not support the use of the lidocaine patch for musculoskeletal pain. The records do not support a diagnosis of post-herpetic neuralgia. Moreover, there is a paucity of evidence regarding the efficacy of the lidocaine patches for the treatment of this patients pain emanating from the spinal cord due to myelomalacia. All told, the requested Lidocaine patch 5% is not 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 upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for MRI of the left foot. Latt and colleagues note that MRI may be used to confirm the presence of plantar fasciitis but is most useful in excluding the presence of other causes of heel pain such as calcaneus stress fracture, Baxter neuritis, tarsal tunnel syndrome, and insertional Achilles tendinopathy. In this case, the records document that the patient has reported ongoing pain in the left heel for several months despite conservative treatments, including activity modification, controlled ankle movement (CAM) boot immobilization, nonsteroid anti-inflammatory medications, icing, and stretching. In this clinical setting, given the patients ongoing pain despite a lengthy conservative treatment plan, the requested service is medically indicated. Therefore, an MRI of the left foot is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Humira 80 mg per week.According to Alikhan and colleagues, treatment with biologics is currently one of the mainstays of therapy in the United States. Humira is currently the only U.S. Food and Drug Administration (FDA) approved medication for this disease. Humira is currently approved at 40 mg weekly. However, there is a study by Zouboulis and colleagues that shows that dose escalation to 80 mg weekly is more efficacious. Moreover, it has been proposed that obese patients may need higher dosing. In this case, the patient has done well on Humira 40 mg weekly but still has flaring symptoms, which may indicate that she needs alternative treatment. This can be initially accomplished by escalating her dosing of the Humira to 80 mg weekly. Given this patients BMI, since this patient is still flaring at the standard dose of Humira, it would be appropriate for this patient to have a trial of dose escalation to 80 mg weekly to see if this can control this chronic disease. Thus, Humira 80 mg per week is medically necessary for the treatment of the patients medical condition. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax, 2 mg, twice a day. The submitted documentation does not support the medical necessity of the requested medication. Alprazolam (brand name Xanax) is a medication in the benzodiazepine family. Kennedy and ORiordan note that while benzodiazepines have effective anti-anxiety properties, best practice guidelines generally recommend short-term use, for two to four weeks, at the lowest possible dose due to issues of tolerance and dependence. The authors further note that benzodiazepines should only be prescribed in the lowest effective dose for the short-term relief of severe anxiety or panic disorder, usually in an acute crisis situation. The U.S. Food and Drug Administration (FDA) notes that the maximum daily dose of alprazolam recommended for the treatment of anxiety is 4 mg in three to four divided doses, which is equivalent to a maximum single dose of 1.25 mg. In this case, the patients psychiatrist prescribed 1 mg of alprazolam three times daily as needed for anxiety. The patient has subsequently requested that his dose be increased to 2 mg twice daily, possibly suggesting that the patient has developed tolerance to alprazolam, requiring a higher dose to maintain the same effect as the original lower dose, which was denied by his psychiatrist. In this case, given the high potential for tolerance and dependence on benzodiazepines, the requested medication is not medically indicated. Therefore, Xanax, 2 mg, twice a day, is not medically necessary for the 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Saxenda or Wegovey. Mancini and De Melo describe liraglutide as a glucagon-like peptide 1 (GLP-1) receptor agonist that has emerged as an effective therapy for type 2 diabetes and obesity. The authors further note that as an adjunct to a reduced-calorie diet and increased physical activity, treatment with liraglutide 3.0 mg may provide statistically significant and clinically meaningful weight loss. Nuffer and Trujillo note that obesity treatment guidelines recommend the use of pharmacologic therapy in adults who have a BMI of 30 or higher. Given this patients history of obesity and as obesity may lead to the development of comorbidities such as diabetes and hypertension, the requested medication Saxenda is medically indicated. Therefore, Saxenda is medically necessary for the treatment of this patient.