Persius/hicric huggingface dataset:
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 genetic testing including whole genome/exome sequencing for congenital anomalies (CPT 81415 and 81416).Findings:  The physician reviewer found that patients medical history involves a number of different body systems including ophthalmologic, audiologic, skeletal, and neurologic. Her brother is reported to have nearly identical symptoms, which suggest the presence of an underlying genetic etiology. She has undergone genetic testing with a chromosomal microarray and testing of a panel of genes associated with ophthalmologic conditions. However, this testing has largely been non-diagnostic. Since an underlying genetic etiology is likely and a confirmed genetic syndrome would provide critical information for this patient, whole exome sequencing is an appropriate next step (Dragojlovic, et al.; Kernohan, et al.). Therefore, the requested genetic testing including whole genome/exome sequencing for congenital anomalies (CPT 81415 and 81416) is medically necessary to decrease disability and correct or ameliorate the patients physical conditions.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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 Fasenra subcutaneous injections. Findings: Based on the available information, treatment of this patients eosinophilic-type asthma with anti-interleukin 5 (IL-5) immunotherapy is medically necessary based on his prior history of poorly controlled asthma. Moreover, the patient has demonstrated excellent response to Fasenra therapy that blocks the IL-5 eosinophilic pathway. However, the records do not document that the patient has failed to respond or has experienced intolerable side effects with the formulary alternative mepolizumab, which also blocks the IL-5 eosinophilic pathway in a similar manner as Fasenra. Overall, there are inadequate information to support treatment with Fasenra in lieu of standard therapy with mepolizumab. Therefore, the requested Fasenra subcutaneous injections are not medically necessary for 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 in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for injection therapy, immune globulin (Gammagard liquid), nonlyophilized, 500 mg. Moriguchi and colleagues noted that a study of four patients with neuralgic amyotrophy treated intravenous immunoglobulin infusion (IVIg) therapy showed good response. Naito and colleagues reported that nine out of then patients with neuralgic amyotrophy who received IVIg therapy with methylprednisolone pulse therapy (MPPT)  showed clinical improvement of motor impairment. In this case, the patient has tried and failed steroid therapy. Given the providers recommendation and current medical literature, the requested service is medically indicated. Therefore, injection therapy, immune globulin (Gammagard liquid), nonlyophilized, 500 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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 tertiary level care for intraocular lens exchange. Davis and Pineda note that the most frequent indication for intraocular lens exchange surgery was dislocated intraocular lenses, and that the second most frequent indication was patient dissatisfaction after multifocal intraocular lens implantation. Kim and colleagues note that multifocal intraocular lens exchange can be performed safely with good visual outcomes using different types of intraocular lenses. In this case, the patient has blurry vision, possibly attributed to intraocular lenses. Given that this patients condition could be treated surgically by an ophthalmologist, and that the documentation does not reflect emergent conditions or that special services are required, the requested service is not medically indicated. Therefore, tertiary level care for intraocular lens exchange is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a knee scooter. Ciufo and colleagues note that the knee scooter is a commonly used mobility device in the setting of unilateral below-knee immobilization to manage lower extremity injuries and elective surgery. The authors continue that the knee scooter assists patients in maintaining independence, performing daily activities, and returning to work, concluding that there was a statistically significant decrease in volumetric flow rate in subjects using a knee scooter device with a flexed knee. In a comparative study of patients using a wheeled walker verses patients using axillary crutches, Kocher and colleagues concluded that wheeled knee walkers provided increased assisted ambulation and had a lower rating of perceived exertion than axillary crutches on level surfaces in healthy participants. In this case, the patient is post-surgical right ankle repair of bone cysts and arthrotomy. Given current medical literature supporting the use of a knee scooter as safe and effective, the patients comorbidities and the providers recommendation, the requested equipment is medically indicated. Therefore, a knee scooter 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.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly in-person mental health therapy services. There is a lack of evidence of disparity in effectiveness of telehealth versus in-person therapy. Per Shore and colleagues, Telemental health in the form of interactive videoconferencing has become a critical tool in the delivery of mental health care. It has demonstrated its ability to increase access and quality of care, and in some settings to do so more effectively than treatment delivered in-person. Moreover, the authors noted that there are no absolute contraindications to patients being assessed or treated using telemental health. In this case, the Health Plan has provided the patient with adequate time to transition to an in-network provider with telehealth services. Based on the current medical literature, use of telehealth mental services is appropriate for this patient to address her symptoms of depression. Therefore, the requested weekly in-person mental health therapy services are not medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to alcohol and substance use resulting in potentially harmful behaviors, including a recent overdose requiring emergency treatment. The records noted the patient had difficulty recognizing barriers to his recovery. In terms of functional status, the records support a score of 3. The documentation noted serious functional impairment due to the patients substance use.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of major depressive disorder, generalized anxiety disorder, cannabis use disorder, hallucinogenic dependence, and alcohol dependence. In terms of level of stress of the recovery environment, the records support a score of 4. The patient has a stressful environment due to his parents divorce, and access to drugs and alcohol in the community. With regard to level of support of the recovery environment, the records support a score of 3 due to his parents limited ability to provide the structure the patient requires.  In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged with a history of poor response to outpatient therapy. Thus, the patient has a total score of 24. The records support a 3 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the RTC level of care. Therefore, RTC services were and are medically necessary for the 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 psychiatry with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a comprehensive outpatient rehabilitation program that includes speech, occupational, physical and cognitive therapy for four (4) hours per day, three (3) to five (5) times per week for three months. Giustini and colleagues note that one of the main considerations when dealing with traumatic or nontraumatic brain injury is the complexity of the rehabilitation process. Smania and colleagues report that while functional and cognitive impairments in patients with severe traumatic, cerebrovascular, or anoxic acquired brain injury (ABI) may improve with time and rehabilitation, patients with cerebrovascular and anoxic ABI may have a more challenging clinical course. Skilled therapy services following an acute injury may promote recovery, maximize function given impairments, and transition patients to an independent program when feasible, or train caregivers for supervising a brain injury survivor's convalescence in the community. In the setting of severe brain injuries, deficits may remain severe despite intensive rehabilitation measures. In this case, the patient suffered acute brain in July 2019. She made substantive gains sufficient to reintegrate to the community in October 2019. The documentation shows that the patient has been undergoing intensive outpatient therapies since, but has been making mostly modest functional progress, and her overall status is largely unchanged. In this clinical setting, ongoing intensive outpatient multidisciplinary rehabilitation is not expected to marginally and positively impact the patients clinical or functional course or outcomes beyond any further recovery she may potentially experience with a program overseen by her caregivers, to include physical and mental exercises, and the passage of time. Therefore, comprehensive outpatient rehabilitation program that includes speech, occupational, physical and cognitive therapy for four (4) hours per day, three (3) to five (5) times per week for three months is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance guided focused ultrasound (MRgFUS) ablation of uterine leiomyomata (CPT code 0071T). There are multiple treatment options for the management of a multi-fibroid symptomatic uterus. If a patient opts for uterine-sparing interventions, then surgical options include laparoscopic, hysteroscopic, or abdominal myomectomy procedures versus less invasive options including MRgFUS. As noted in the medical literature, MRgFUS utilizes high-intensity ultrasound energy to induce coagulative necrosis of fibroids. MRgFUS results have been reported to reduce myoma volume by approximately 37-40% (Gorny, et al.). The MRI provides real-time visualization and thermal monitoring to optimize tissue destruction with optimization of safety. There are a number of factors that may impact effectiveness of treatment including size, vascularity, and heterogeneity of the fibroids. Ideal treatment candidates have three or fewer fibroids measuring less than 10 cm in maximal dimension, homogenous and dark on T2-weighted images, and well-vascularized without calcification (Gorny, et al.). Based on this guideline, this patient met the criteria for MRgFUS. She presented with multiple fibroids, with the largest measuring about 5 cm. MRgFUS is an accepted treatment option in this clinical setting. Accordingly, the MRgFUS ablation of uterine leiomyomata (CPT code 0071T) was 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 MRgFUS ablation of uterine leiomyomata (CPT code 0071T) was likely to be more beneficial for treatment of the patients 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 authorization and coverage for esketamine (Spravato). Findings:  The physician reviewer found that Spravato is U.S. Food and Drug Administration (FDA) approved for use in conjunction with an oral antidepressant in patients with treatment refractory depression who have failed at least two antidepressant medications. Per the FDA, Spravato is effective for the treatment of depressive symptoms in adults with unipolar major depression that include acute suicidal ideation or behavior. Although the parent molecule ketamine has proven efficacy for alleviating suicidal ideation, the evidence supporting use of Spravato is mixed, with one trial yielding some positive results for suicidal ideation and two larger trials finding no benefit (Sancora, et al.; Bozymski, et al.). This patients records lack support or recommendation from the patients provider that he receive Spravato for treatment of his depression. Spravato is recommended for use in conjunction with an oral antidepressant and this patient has failed medication trials with other oral antidepressants. Recent notes suggest that the patient was interested in discontinuing treatment with Wellbutrin. Moreover, the records do not include a providers recommendation for treatment with Spravato, which requires administration in a monitored environment to monitor for side effects. All told, the requested esketamine (Spravato) is not medically necessary for 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Monovisc injections, (2) PRP injections, or (3) if (2) is determined to not be medically necessary, PRP injections for each knee. Findings: 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 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 a systematic review and meta-analysis of the effects and safety of the combination of PRP and hyaluronic acid (HA) in the treatment of knee osteoarthritis, a study found that the combined use of intra-articular viscosupplementation and PRP can heal degenerated cartilage and delay the progression of knee osteoarthritis. Another study noted that in the treatment of  patients with symptomatic knee osteoarthritis, PRP injections resulted in 12 months of improvement in knee pain and function. In this case, the patient has mild osteoarthritis of both knees. They have tried and failed other conservative treatments, including physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs), with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated for the treatment of this patient. Therefore, (1) Monovisc injections, and (2) PRP injections 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.