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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with pancreatic insufficiency, cystic fibrosis (CF) and severe obstructive airway disease. The patient is managed with maximal medical therapy, which includes Pulmozyme, hypertonic nebulized saline, azithromycin, and an airway clearance device. She is currently using a Hill-ROM vest, which provides high-frequency chest wall oscillation. The patients pulmonary tests have been stable per the records provided.  The patient has requested authorization and coverage for a high frequency chest compression device (Monarch Vest System). The Health Plan has denied this request, indicating that the requested device is not medically necessary for the treatment of this patient. The patient has requested an upgraded device for airway clearance. Current literature does not indicate differences in efficacy between devices for airway clearance. Although high-frequency chest wall oscillation may be useful in adult patients, there is a lack of data indicating that it is superior to positive expiratory pressure therapy or other clearance techniques.  This patient already has a high-frequency chest wall oscillation system that she uses regularly. Her adherence is good. The records do not document a medical reason for changing devices. A review of the specifications from the U.S. Food and Drug Administration (FDA) shows a lack of significant difference between the models. Thus, the requested high frequency chest compression device (Monarch Vest System) 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 certified in internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein blood testing. This patients baseline basic lipid profile is within good range. In addition, the patient does not present with any risk factors or symptoms to suggest that she is at risk for early onset cardiovascular disease. For this patient, no current medical treatment of lipids is indicated aside from lifestyle modification. In the medical literature, measurement of advanced lipoproteins has not been shown to provide any information that would alter the treatment strategy in this low risk patient. Based on current recommendations, initial and repeat testing of advanced lipoprotein markers is not considered within the standard of care. In addition, measurement of methylenetetrahydrofolate reductase (MTHFR) polymorphisms has not been shown to be clinically useful in assessing cardiovascular risk. All told, the advanced lipoprotein blood testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein blood testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the advanced lipoprotein blood testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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: A patient requested authorization and coverage of Xtampza, Percocet, and Soma. At issue in this case is whether the aforementioned medications are medically necessary for treatment of this patients medical condition. Findings:  The physician reviewer found that in this case, the patient does not meet the criteria for treatment with Xtampza, Percocet and Soma. The provider reports that the patient has failed multiple conservative measures. However, there is no documentation that the patient has failed other medications. Further, the records do not include a signed opioid contract or evidence of random urine testing to ensure compliance with this medication regimen. In addition, the use of Soma is not supported by current medical guidelines. Moreover, there is no evidence of analgesia or functional improvement with use of these medications. Given these findings, Xtampza, Percocet and Soma are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with a neuropsychiatrist who specializes in traumatic brain injury and long-term care at an inpatient rehabilitation facility that specializes in traumatic brain injury. Findings:  The physician reviewer found that The submitted documentation supports the requested services in this clinical setting. This patient sustained severe traumatic brain injury. The records document attention deficit/hyperactivity disorder and behavioral issues involving agitation. A neuropsychiatrist who specializes in traumatic brain injury is medically appropriate in this patients case. A neuropsychiatrist who specializes in traumatic brain injury will be able perform a complete neurocognitive assessment and provide therapies which may be beneficial for the rehabilitation of this patient. An inpatient rehabilitation facility that specializes in traumatic brain injury is medically appropriate in this case. This treatment setting will allow the patient to improve concentration skills and assist him with difficulties in completing daily tasks. Traumatic brain rehabilitation often involves neuropsychiatrists, psychologists, occupational therapists and physical therapists. Therefore, treatment with a neuropsychiatrist who specializes in traumatic brain injury and long-term care at an inpatient rehabilitation facility that specializes in traumatic brain injury 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hepatology consultation In this patients case, physical examination and lab testing revealed hepatomegaly, elevated bilirubin, and potential liver changes due to cardiac function. These findings may be benign, but could be a sign of primary or secondary hepatic disease with long-term consequences. Further testing, including blood tests and liver biopsy, could help determine the underlying etiology for these findings, or rule out serious disease. Since these tests are associated with potential adverse effects, they should be performed only when required after an appropriate serologic work-up. For these reasons, this patients medical condition is best evaluated by a hepatologist, who is trained to evaluate for common and uncommon diseases of the liver in patients with findings suggestive of possible hepatic or biliary disease. For these reasons, the request for hepatology consultation is supported as medically necessary for the evaluation of this patients medical condition.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 internal medicine with sub-specialty certification in gastroenterology 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: The patient has requested authorization and coverage for an implanted hypoglossal nerve stimulator. Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and safety for treatment of OSA. In patients who do not tolerate CPAP, or fail to improve with an oral appliance, surgical intervention may be required. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. As reported in the published medical literature, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. The studies reported the hypoglossal nerve stimulator is safe and effective in patients with OSA who have nonconcentric airway collapse, an apnea/hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. This patient meets the criteria for the requested procedure with nonconcentric airway collapse, an AHI of 33, and BMI of 24. She has failed CPAP and due to the severity of her condition, the patient is not a candidate for oral appliance therapy. For these reasons, an implanted hypoglossal nerve stimulator is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.One reviewer found that an implanted hypoglossal nerve stimulator is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology with subspecialty certification in plastic and reconstrutive surgery and is actively practicing.  One Reviewer is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing.  All three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Dupixent. The records provided for review document that this patient presented with moderate-to-severe atopic dermatitis. The patient has tried and failed therapy with topical steroids and Eucrisa. The medical records document the presence of side effects with topical steroid therapy. Dupixent is U.S. Food and Drug Administration (FDA) approved for the treatment of asthma in patients 12 years of age and older and adults with moderate-to-severe atopic dermatitis. The medical documentation reports that this patient has moderate-to-severe psoriasis and adverse effects from topical steroid use. As the FDA approval for Dupixent in patients aged 12 years and older is in place for asthma, the medication is deemed safe in this age group. Moreover, there are ongoing trials examining the use of Dupixent in the adolescent age group with positive results reported in the literature. For these reasons, Dupixent is more likely to be more effective for treatment of this patients moderate-to-severe atopic dermatitis than other alternative therapies.Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is actively practicing.  All three 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

Findings:  The physician reviewer found that the patient has history of right knee osteoarthritis who is requesting reimbursement for Orthovisc injections. In the medical literature, researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. All treatments except acetaminophen showed clinically significant improvement from baseline pain. In addition, another research reported that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was efficacious during a 54-month follow-up period. This patient presented with a history of recurrent right knee pain with associated swelling and a diagnosis of right knee osteoarthritis. She was status post Orthovisc injections and a corticosteroid injection, with reported significant pain relief. She had minimal relief reported with Naprosyn. She subsequently underwent Orthovisc injections and steroids to the right knee. There is a lack of evidence that this patient achieved objective improvement with the Orthovisc injections for at least six months, or had failed to respond to corticosteroid injections to support the medical necessity of repeat injections. Although the patient reported pain relief, there were no improvements in right knee range of motion. The combination of the steroid injection and Orthovisc injection given on the same date makes it difficult to determine which injection provided pain relief. All told, the Orthovisc injections they received were not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested service was 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: An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the left and right breast. The submitted documentation supports that the requested services are medically necessary. Contrast enhanced breast MRI is a highly sensitive (greater than 90%) examination which has clear indications and can identify abnormalities that are occult on mammography and ultrasound. The indications for breast MRI include high risk screening, new diagnosis of breast cancer to evaluate for additional sites of disease, patients with positive margins after lumpectomy, evaluation of response to chemotherapy prior to surgery, evaluation for breast cancer recurrence, and evaluation of metastatic cancer of an unknown primary source. According to the American College of Radiology, MRI may be used when mammographic/sonographic findings are inconclusive or in the setting of complex breast augmentation cases in which mammography is difficult.In this case, due to the patient's history of multiple, extensive post-operative complications, as well as in the setting of silicone implants, breast MRI is recommended for screening due to the inability to adequately asse with extensive sc ss the breast tissue mammographically. Because the patient has had multiple prior surgeries ar tissue, the breast tissue would not be well visualized due to the inability to compress the breast tissue. Under these circumstances, magnetic resonance imaging (MRI) of the left and right breast is medically necessary for the patients medical condition.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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of her knee. Findings:  The physician reviewer found that MRI of the knee has become the preferred method for imaging the knee to visualize pathology and assist in patient management and treatment. The knee is one of the most frequently injured joints, and knee pain can affect all age groups. Due to the diverse pathology, complex anatomy, and various possible injury mechanisms, the MRI knee protocol and sequences permit detection of both soft tissue and bony injuries in accurate detail. MRI is also sensitive for detecting early cartilage degeneration progressing to osteoarthritis, and can evaluate other joint structures which can be sources of pain following acute injury. Furthermore, the MRI scan can determine the type of meniscal tear, whether degenerative or traumatic, and can be useful in prescribing appropriate treatment. For these reasons, an MRI to evaluate this patients knee for a suspected lateral meniscal tear is essential to make a definitive diagnosis from the viewpoint of proper management. As such, the requested MRI scan of the knee is medically necessary for evaluation of this patients medical condition. 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 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 Xifaxan 550mg. Findings:  The physician reviewer found that the documentation provided for review demonstrates that this patient has SIBO. For treatment of SIBO, Xifaxan has been proven to be effective for eradication of bacteria and symptom relief. Further, Xifaxan has been shown to be more effective with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. One prospective trial of patients with IBS and a positive breath test found that 86% of patients responded to Xifaxan with improvement in symptoms. For these reasons, the use of Xifaxan 550mg is supported as medically necessary for the treatment of this 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 internal medicine with sub-specialty certification in gastroenterology 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.