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

The patient has requested authorization and coverage for brand name medication, Lexapro 20 mg tablet. According to the records provided for review, this patient has been stable on brand name Lexapro for over 10 years for the maintenance of her major depressive disorder (MDD). The American Psychiatric Association (APA) guidelines indicate that patients treated for an uncomplicated MDD who exhibit a satisfactory response to an antidepressant medication should continue to receive a full therapeutic dose of that agent after achieving remission in order to prevent the recurrence of mood symptoms. Generic antidepressants are the first-line of pharmacological treatment of MDD. However, this patients records document failure of two prior antidepressant trials, long-term stabilization on brand name Lexapro, and the inability to tolerate the generic version of Lexapro. Abrupt discontinuation without cross-tapering of one antidepressant medication and switching to a different generic or brand name antidepressant medication carries a risk of relapse and destabilization of the patients mental illness due to her previous history of intolerance. Therefore, the requested brand name Lexapro authorization is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollees parent has requested authorization and coverage for a Bantam Easy Stand supine stander with hip abduction. This patient with cerebral palsy is at high risk for severe osteopenia, hip dislocations, contractures, and fractures. In patients with cerebral palsy, the rate of diminished bone mineral growth results in a failure to accrue bone mass. It is therefore important for patients with cerebral palsy to be weight bearing through the spine and lower extremities for bone, muscle, and joint health. Moreover, the patient needs to maintain his current range of motion and tissue health, as well as cardiac and pulmonary statuses, to prevent secondary complications. In order to achieve these goals with minimum side effects on his respiratory and circulatory system, he requires a supine stander with appropriate hip positioning, such as the requested Bantam Easy Stand supine stander with hip abduction. All told, the requested Bantam Easy Stand supine stander with hip abduction is likely to be more beneficial for the treatment of the patients condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Bantam Easy Stand supine stander with hip abduction is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for H.P. Acthar Gel 80 Unit/mL (2 x 5 mL vials), one per day, for 10 days. The records document that this patient has spastic paraparesis and is experiencing an exacerbation of her relapsing-remitting multiple sclerosis (RRMS). Her provider has recommended a course of treatment with Acthar Gel. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of RRMS exacerbations. The requested course of Acthar gel is clinically indicated in this patient based the current FDA approval. Given this support, the requested H.P. Acthar Gel 80 Unit/mL (2 x 5 mL vials), one per day, for 10 days, 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 enrollee is requesting authorization and coverage for home infusion therapy with Gammagard, 66 grams (divided into three daily doses of 22 grams each), every 4 weeks. The enrollee has a history of chronic inflammatory demyelinating polyneuropathy. The enrollee was referred to a pediatric hematologist-oncologist due to reports of getting sick more frequently. The enrollee reported when she gets up, she feels like vomiting and fatigues quickly. At a follow up, she reported chest pain, 5/10 in intensity, and bilateral leg bruising. Chronic inflammatory demyelinating polyneuropathy describes a group of related neuropathies, all of which are chronic, and cause demyelination and inflammation. The clinical course is slowly progressive in a majority of individuals, but a relapsing-remitting course is noted in at least one-third. Researchers reported a six-month therapy of intravenous immunoglobulin was more frequently effective or tolerated than intravenous methylprednisolone in individuals with chronic inflammatory demyelinating polyradiculoneuropathy. Literature describes results from the Privigen Impact on Mobility and Autonomy, and the Polyneuropathy and Treatment with Hizentra studies. Both studies aimed to evaluate the effectiveness and safety of intravenous immunoglobulin. Similar response rates and times to response were seen in both studies. In both studies, disability and impairments improved. The results showed that 47 percent of the participants responded after the induction dose, and the remaining 53 percent responded after the second dose. The improvement endured at 52 weeks for 69 percent of the participants.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric hematology-oncology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for acupuncture service. The enrollee has menopausal symptoms; including hot flashes, night sweats and mood swings. The enrollee is trying to avoid hormone replacement therapy. The enrollees physician explained that all non-hormonal medical management options have been exhausted except gabapentin.  The enrollee is not interested in gabapentin because of daytime sleepiness and dizziness. She is interested in acupuncture because she wants to rule out all possible treatment options prior to considering hormone replacement therapy. Scientific literature and studies have shown the efficacy of acupuncture for menopausal symptoms. Studies report a standardized six-week acupuncture treatment produced a fast and clinically relevant reduction in moderate-to-severe menopausal symptoms. Literature shows acupuncture significantly reduced the occurrence of hot flushes and sudden sweating, along with improving other symptoms, such as sleep disorders, tightness in the chest, irritability, and bone pain. Studies also demonstrated acupuncture reduced the number of hot flashes and other vasomotor symptoms and improved quality of life for menopausal women. The clinical benefits persisted for at least six months.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is a board certified acupuncturist 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Prolia. Ferrari and colleagues summarized the findings of the ongoing extension to the FREEDOM study, which revealed reductions in non-vertebral fractures with long-term Prolia treatment. Specifically, the authors noted that their findings support the use of Prolia for patients with osteoporosis and who remain at risk for fracture based on bone densitometry. The U.S. Food and Drug Administration (FDA) reported that, Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has demonstrated intolerance to first-line oral and intravenous bisphosphonate therapy for the treatment of her osteoporosis. The patient sustained a humerus fracture in a fall and is not a fragility fracture. However, she is at high risk for fracture, given her test results demonstrating osteopenia of the L1-4 and severe osteoporosis involving the femoral neck with a T score of -3.3. Moreover, the patient has documented intolerance to oral and intravenous bisphosphonates. Given these findings, the requested Prolia 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 internal medicine with subspecialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for acupuncture. The enrollee has anxiety, insomnia, fatigue, major depressive disorder, and developmental disorder. The enrollee has a therapist but declines medications. He reports that acupuncture has helped in the past. The enrollee reports he has been under severe stress and cannot concentrate enough to even read a book. The enrollee also has depression and has trouble falling asleep at night.  A governmental organization reports there is not enough evidence to determine if acupuncture can help people with depression. Researchers reviewed a number of therapy approaches for depression, but acupuncture was not one of them. A professional society does not recommend acupuncture for the treatment of depression. A literature review showed that, though depression severity was less with acupuncture than with no treatment, the quality of evidence was low, and the effect of acupuncture compared to psychological therapy was unclear. The risk of adverse events with acupuncture was also unclear. The authors report high-quality randomized controlled trials are needed to determine the effectiveness of acupunctureFinal Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is a licensed acupuncturist 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for subacute care services. The enrollee underwent a hematoma evacuation, due to a basal ganglia hemorrhage caused by MoyaMoya disease. The enrollee underwent a tracheostomy and percutaneous endoscopic gastrostomy tube placement due to brain injury.  The enrollee experienced respiratory failure and was weaned off the ventilator. The enrollee participated in occupational therapy, physical therapy, respiratory therapy, and speech-language therapy. Recent progress notes show no additional physical therapy interventions were provided. The family was to continue range of motion exercises.  Percutaneous endoscopic gastrostomy feedings had increased the enrollees weight and were well-tolerated.  The speech therapy goal of two hours per week speech therapy for communication, cognition and dysphagia could be performed in a non-subacute care setting.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for coverage for a CPAP device; humidifier, heated, used with positive airway pressure device and full night in-lab sleep study. The enrollee has obstructive sleep apnea, with symptoms of excessive daytime fatigue and somnolence. Comorbid conditions include depression, anxiety, and acid reflux. Her Epworth sleepiness scale score is normal and her Stop-Bang score is normal. The enrollee has been obese most of her adult life and has gained over 100 pounds in the last 10 years. She underwent a home sleep study which revealed obstructive, central, and mixed apneas. There were 106 hypopneas and 131 total respiratory disturbance events. The apnea-hypopnea index was 14.4 per hour. According to the literature, there are two categories of enrollees that should be considered for obstructive sleep apnea treatment. Symptomatic enrollees should be treated, regardless of severity, even if the obstructive sleep apnea is mild; as noted by an apnea-hypoapnea index of five to 15. Asymptomatic enrollees should be offered treatment when the apnea-hypoapnea index is greater than 15; even if asymptomatic, due to the risks of cardiovascular morbidity and mortality. Based on the American Academy of Sleep Medicine guidelines, there is no clinical rationale to offer both auto-continuous positive airway pressure at home and in-laboratory positive airway pressure titration to initiate positive airway pressure therapy. Either one is recommended. If the enrollee tolerates auto-continuous positive airway pressure with relief of symptoms, efficacy of treatment can be assessed by data download. If the enrollee is intolerant of auto-continuous positive airway pressure, then a titration can be offered at a later date.Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for positron emission tomography with concurrent acquired computed tomography for attenuation correction (PET/CT) scan. The requested PET/CT scan is not indicated for surveillance or diagnosis of colon cancer. The National Comprehensive Cancer Network (NCCN) guidelines discourage the routine use of PET/CT scanning for staging, baseline imaging, or routine follow-up. PET/CT scans performed without contrast and multiple slicing do not obviate the need for a contrast-enhanced diagnostic CT scan to work-up colon cancer. A CT scan would be preferred at baseline to look for a suspicious malignancy. This patients initial diagnosis was 10 years ago and he has a normal carcinoembryonic antigen (CEA). These factors do not support an indication for a PET/CT to evaluate for possible recurrence. Given these findings, the requested PET/CT scan is not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 been diagnosed with bilateral knee osteoarthritis. The provider noted the patient received a series of Synvisc-One injections to bilateral knees, which provided an improvement in symptoms. Physical examination findings included tenderness to palpation over the medial joint line, lateral joint line, and patellar tendons in bilateral knees, right greater than left. A month after the injections, the patient reported bilateral knee pain. Synvisc-One injections were administered again. In an undated letter, the patient reported corticosteroid injections result in an elevation of her blood glucose. The patient has requested reimbursement for Synvisc-One injections that were received in both knees for the second time. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc-One injections that were received in both knees the second time were medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of lasting benefit from prior Synvisc-One injections. As such, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc-One injections that were received in both knees the second time were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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.