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 a magnetic resonance imaging (MRI) of the thoracic spine (CPT 72146). In this case, the patient has tried multiple types of pain management, however the documentation does not reflect information about current treatment. While the patient has attempted conservative treatment in the past, given the recurrent nature of back pain, the same type of conservative management, including non-steroidal medications and physical therapy, are indicated for each recurrence. The American College of Radiology (ACR) appropriateness criteria for chronic neck and low back pain note that MRI is usually not appropriate in the absence of red flags raising suspicion for an underlying condition. The in case, the patient presents with pain but without symptoms that would raise red flags such as radiculopathy, prior tumor, recent trauma, or infection. Given that intensive conservative management is recommended first for every episode of pain, the requested service is not currently medically indicated. Therefore, magnetic resonance imaging (MRI) of the thoracic spine (CPT 72146) 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 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: An enrollee has requested authorization and coverage for an MRI of the cervical spine.The American College of Radiology (ACR) Appropriateness Criteria indicates that an MRI of the cervical spine is usually appropriate for patients with chronic cervical or neck pain. The addition of radiculopathy is a further justifiable indication of the cervical spine MRI. In the ACR recommendations, a distinction is made between patients with relatively acute or even chronic pain depending on whether there are any red flags. Red flags include such issues as infection, prior tumor, and unexplained weight loss. In this case, the patient had objective signs of degenerative change for many years, and now has evidence of radiculopathy (numbness and tingling). In this setting, it is medically appropriate to obtain an MRI of the cervical spine. The Health Plans denial noted six weeks of conservative therapy is necessary prior to the MRI of the cervical spine. The argument for delaying imaging studies for six weeks may be appropriate when one is only dealing with pain. While six weeks of conservative therapy is generally warranted, in this particular patient, considering the chronicity and well-documented degenerative change, the best and most efficacious means to evaluate the patient for a spinal stenosis, foraminal encroachment, or disc herniation is to obtain an MRI of the cervical spine. Thus, the MRI of the cervical spine is medically necessary for the evaluation of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for requested authorization and coverage for Nutropin AQ Nuspin.In this case, the patients height, growth velocity, bone age, and pre-pubertal findings were normal. MRI of the pituitary was also normal. His family history does not contribute to diagnosis of a disorder involving growth or pubertal progression. Based on the submitted documentation, the patients predicted adult height is close to 67 inches, and his mid-parental height is 68.6 inches. His predicted adult height is within the normal range for his family and within the normal range for North American males. He does not meet generally accepted U.S. Food and Drug Administration (FDA) approved diagnostic criteria for idiopathic short stature, since his height is above -2.25 standard deviations. Growth hormone provocative tests should not be used as the sole diagnostic criterion for diagnosis of growth hormone deficiency, because such tests are prone to false results for multiple reasons. Thus, Nutropin AQ Nuspin is not medically necessary for the treatment of the patients medical condition.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 pediatrics with sub-specialty certification in pediatric endocrinology 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 computed tomography (CT) of the heart. Findings:  The physician reviewer found that records provided for review support that this patient has a borderline 10-year arteriosclerosis cardiovascular disease risk. Based on current published guidelines, moderate intensity statin therapy may be considered for this level of low density lipoprotein (LDL) cholesterol with a borderline risk profile. The CT of the heart was indicated to assess the patients coronary calcium score, which is a risk-enhancing factor that would reclassify the patient to a higher risk score and support treatment with cholesterol lowering statin therapy. Given the patients coronary calcification score of zero was helpful to determine whether the patient required long-term treatment with statin therapy. Therefore, the CT of the heart 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 CT of the heart 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 evaluation 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 subspecialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 3 Enhanced External Counterpulsation Treatments, and authorization and coverage for 35 additional Enhanced External Counterpulsation Treatments.Findings:  The physician reviewer found that the 3 Enhanced External Counterpulsation Treatments (CPT G0166) at issue were not likely to be more beneficial than any other available standard treatments for the patients medical condition, and the requested 35 Enhanced External Counterpulsation Treatments (CPT G0166) are not likely to be more beneficial than any other available standard treatments for the patients medical condition.The use of enhanced external counter pulsation (EECP) in chronic stable ischemic heart disease has been addressed in American College of Cardiology (ACC) Guidelines from 2012, updated in 2014. These guidelines recommend that EECP may be considered in patients with angina pectoris that is refractory to standard therapies that include surgical or percutaneous revascularization, or optimal guideline directed medical therapy. In this case, the submitted documentation reflects that enrollee is being treated medically with a beta blocker but not other standard anti-ischemic medications, so therefore his medical therapy would not be considered optimized. Under these circumstances, the 3 Enhanced External Counterpulsation Treatments at issue were not likely to be more beneficial than any other available standard treatments for the patients medical condition, and the requested 35 Enhanced External Counterpulsation Treatments are not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue and requested services were not, and are not, likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine, with subspecialty certification in cardiology, and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine, with subspecialty certification in cardiovascular disease, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 skilled nursing facility (SNF) services. Findings:  The physician reviewer found that acute respiratory syndrome coronavirus-2 (COVID-19) is a novel ribonucleic acid (RNA) coronavirus that is the etiologic agent responsible for the current pandemic. This virus typically causes flu-like symptoms, and can progress to severe acute respiratory failure, and multiorgan failure. There is currently no pharmacotherapeutic agent that is proven to be effective treatment for COVID-19 infection. Treatment is largely supportive, including managing symptoms, trying to prevent ventilatory failure, and preventing complications, as well as avoiding transmission to others. Early rehabilitation is important, particularly in the setting of severe respiratory infection, severe functional impairments, and prolonged hospital stays. Rehabilitation should be tailored to an individual patients needs, accounting for comorbidities, impairments, strengths, and resources (Barker-Davies, et al.). In the present case, the patient has multiple chronic medical conditions, but she was independent at baseline. She developed septic shock due to COVID-19 infection and she required critical care. She was ultimately stabilized and transferred to a SNF where she has been progressing functionally slowly. However, this slow progress is commensurate with the severity of her disease and comorbidities. As of February 2021, the patient started making more significant functional progress with improvements in her self-care and ability to self-propel a wheelchair. Further rehabilitation has been essential for the patient to continue to work on her self-care and mobility in order to maximize independence and to decrease burden of care until she functionally plateaus. All told, the SNF services were and are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for a hysteroscopy dilation and curettage polypectomy procedure.An UpToDate review on hysteroscopy notes that the procedure is performed for the evaluation or treatment of the endometrial cavity, tubal ostia, or endocervical canal in women with (among other indications) abnormal premenopausal or postmenopausal uterine bleeding and endometrial thickening or polyps. An UpToDate review on how to approach abnormal uterine bleeding states that hysteroscopy provides direct visualization of the endometrial cavity. The review notes that in an operative setting, hysteroscopy allows targeted biopsy or excision of lesions identified during the procedure. UpToDate notes that guidelines regarding heavy menstrual bleeding suggest that for patients with abnormal uterine bleeding and suspected submucosal fibroids, polyps or endometrial pathology, outpatient hysteroscopy may be performed as initial evaluation.In this case, the patient has persistent abnormal uterine bleeding and imaging that suggests a polyp or other structure inside the uterine cavity as a cause. Under these circumstances, treatment via hysteroscopy with dilation and curettage would permit removal of the probable polyp, if found, through the scope under direct visualization. Therefore, the requested hysteroscopy dilation and curettage polypectomy procedure is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser hair removal of the face, chest, stomach, genital area, buttocks, back, and thighs. The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that for some patients, certain interventions can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. The WPATH includes hair removal to help alleviate gender dysphoria by electrolysis, laser treatment, or waxing. This patient presents with gender dysphoria. Her providers have recommended laser hair removal to help her achieve an appearance more consistent with her gender identity. Given this support, the requested laser hair removal of the face, chest, stomach, genital area, buttocks, back, and thighs 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 psychiatry with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all prescription medication of C-Cefazolin 50 mg/mL. In this case, the patient had a significant infection of her left lacrimal duct with associated stone formation consistent with actinomyces. Given that this patient required an ophthalmic formulation of an antibiotic to treat actinomyces, the medication at issue was medically indicated. Therefore, the prescription medication of C-Cefazolin 50 mg/mL was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 infectious 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear implant procedure on the left side (CPT 95927, 95940, 69930, 69990 and HCPCS L8614).Cochlear implantation for single-sided deafness has been approved by the U.S. Food and Drug Administration (FDA). The FDA criteria requires profound hearing loss in the ear to be implanted and 5% or less word discrimination with monosyllabic words. The patient has a history of Menieres disease with poor hearing on the left side. She had a BAHA, but was unable to use it due to poor benefit, and it was removed. Profound hearing loss is defined as having a pure tone average (PTA) of 90 dB HL or greater at 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz. In this patients case, evaluation on 2/04/21 revealed a PTA of 80 dB HL in the left ear. Thus, this patient does not have the profound hearing loss required to fulfill the FDA criteria currently for the cochlear implantation for single-sided deafness. Thus, the requested cochlear implant procedure on the left side (CPT 95927, 95940, 69930, 69990 and HCPCS L8614) is not medically necessary for treatment of the patients medical condition.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 otolaryngology 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 Orencia (abatacept) subcutaneous injection 125 mg/mL. The American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis recommend, If disease activity remains moderate or high despite disease-modifying antirheumatic drugs (DMARD) monotherapy, use combination traditional DMARDs, or add a TNF inhibitor or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone. In this case, the patient has undergone DMARD monotherapy without improvement, and is using Cimzia, a TNFi. Given that treatment options for the patients persistent disease activity include non-TNF biologics, such as Orenica, the requested medication is medically indicated. Therefore, Orencia (abatacept) subcutaneous injection 125 mg/mL 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 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

Gender: FNature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an MRI. The American College of Radiology (ACR) Appropriateness Criteria state that magnetic resonance imaging (MRI) is considered the gold standard in the evaluation of the shoulder for entities involving the glenoid labrum and rotator cuff, given its excellent depiction of soft tissue structures. In addition to evaluating the rotator cuff, MRI can aid in detecting extra-articular abnormalities, including osseous and soft-tissue findings that may predispose to or be the result of shoulder impingement. (ACR 2018). A study concluded rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. History and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. Treatment options include nonsteroidal anti-inflammatory agents, subacromial corticosteroid injections, and exercise therapy. Surgical intervention is generally reserved for those failing nonoperative measures and/or healthy, young, and middle-aged adults with full-thickness rotator cuff tears. In this case, the patient has been diagnosed with impingement syndrome and tear of supraspinatus tendon of the right shoulder. Progress notes indicate the patient had right shoulder pain that was worsening since onset three weeks prior. The pain was worse with repetitive and overhead activities of daily living. The patient received appropriate conservative treatment, including NSAIDs, physical therapy, and injection. X-rays found the acromioclavicular joint space and glenohumeral joint space were maintained. Per the submitted documentation, the patient underwent surgical repair after the MRI was performed. There is sufficient support for the services at issue in this clinical setting. Thus, the MRI performed was medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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.