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

The parent of an enrollee has requested authorization and coverage for a portable automated external defibrillator (AED).The 2016 study by Ackerman and colleagues evaluated sudden death in the young and found that home AEDs are important for these patients. Most pediatric cardiologists recommend that families obtain AEDs for their children with long QT and carry them, as AEDs are not always readily available in public. AEDs have been proven to save lives. Survival is greatest when the AED is placed within three minutes of a witnessed collapse. McLeod and colleagues have stated that prescribing an AED should be considered for children at increased risk of sudden arrhythmic death, especially when the risk/benefit ratio of an implantable defibrillator is unclear or delay to defibrillator implantation is deemed necessary.In this case, the submitted documentation supports that the requested portable AED is medically necessary. The patient has a genetic mutation which causes long QT syndrome type 2. Although the patient is currently asymptomatic on beta blocker medication, he is at risk of sudden death from this condition. Other than an implantable cardioverter defibrillator (ICD), there is no treatment to prevent sudden death if this arrhythmia should develop. The patient does not currently meet the criteria for an ICD, as he has not had an aborted episode of sudden death or documented ventricular arrhythmia. Furthermore, an ICD in active patients at this age carries increased risks of inappropriate shocks and lead fractures. A portable AED is necessary to be immediately available in the event that the patient does have a life-threatening arrhythmia. Under these circumstances, the requested portable AED is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 pediatrics, with subspecialty certification in pediatric cardiology, 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 intensive in-home family treatment (IIFT) comprised of: 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour weekly individual therapy in the office setting (code 90837); one hour weekly individual therapy in the home setting (code 90837); one hour weekly family therapy with enrollee present in the home setting (code 90847); and one hour weekly family therapy without the enrollee present in the home setting (code 90846); for six to nine months with a reduction in hours as the enrollees condition improves. Researchers evaluated the effectiveness of an IIFT program to prevent patient placement outside of the home. This patients provider noted that IIFT has been shown to reduce family separations and reduce psychiatric admissions for patients in this clinical setting. All told, the requested IIFT comprised of: 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour weekly individual therapy in the office setting (code 90837); one hour weekly individual therapy in the home setting (code 90837); one hour weekly family therapy with patient present in the home setting (code 90847); and one hour weekly family therapy without the patient present in the home setting (code 90846); for six to nine months with a reduction in hours as the patients condition improves, 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 subspecialty 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 magnetic resonance imaging (MRI) of the neck (CPT code C72141). The records provided for review document that this patient has neck pain but no neurological deficits. There is no history of trauma, malignancy or infection. Plain film x-ray results were not provided for review. While the patient has tried ice and analgesic medications, there is no record of any attempt of conservative management including physical therapy. According to the American College of Radiology (ACR) and National Imaging Associates (NIA) guidelines, a magnetic resonance imaging (MRI) of the cervical spine is not indicated in this clinical setting absent a six-week trial of physical therapy. The records do not document any infection, trauma or concerning symptoms to support an indication for an MRI of the cervical spine. Therefore, the requested MRI of the cervical spine is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for no more than three hours per month of direct supervision in the home of applied behavior analysis (ABA) therapy by a supervising board certified behavior analyst (BCBA) for 12 months (direct supervision in the home of ABA therapy by a supervising BCBA may be increased by one hour every two months, or as deemed necessary by the BCBA, based upon the enrollees response to direct supervision) utilizing the skills acquisition goals and timeline outlined in the Centers Treatment Plan. Based on the presenting information, the Behavior Analyst Certification Board (BACB) standards of practice and the medical necessity definition do not support the requested supervision hours. The BACB developed practice guidelines as well as subsequent clarification guidelines. These guidelines posit that the appropriate amount of supervision is two hours for every 10 hours of therapy. Further, the guidelines specify the BCBA should set the dosage of supervision. In this case, the provider recommended eight hours of supervision per month to meet the patients healthcare needs. The case also fails to meet the medically necessity definition. As the BCBA requested eight hours of supervision per month, the three hours of supervision per month are not enough to meet the essential needs of the patient. In addition, three hours of supervision per month are not consistent the scientifically based guidelines as determined by medical research. Finally, the request for three hours per month is based on convenience for the family. All told, no more than three hours per month of direct supervision in the home of ABA therapy by a supervising BCBA for 12 months (direct supervision in the home of ABA therapy by a supervising BCBA may be increased by one hour every two months, or as deemed necessary by the BCBA, based upon the patients response to direct supervision) utilizing the skills acquisition goals and timeline outlined in the Centers Treatment Plan, is 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 a licensed B.C.B.A board certified in psychology 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 CPT code 21121 (genioplasty sliding osteotomy single piece) done in conjunction with the approved procedure CPT code 21196 (reconstruction of mandibular rami and/or body, sagittal split). The submitted documentation fails to demonstrate the medical necessity of the requested services. The requested CPT code 21121 (genioplasty sliding osteotomy single piece) does not have a supported clinical role in treating this patients occlusion or temporomandibular joint disorder. There is a lack of peer-reviewed medical literature demonstrating that genioplasty is beneficial for treating malocclusion or temporomandibular joint disorder. Thus, CPT code 21121 (genioplasty sliding osteotomy single piece) is not medically necessary for the treatment of this patient. Based on the submitted documentation, the patients condition represents an abnormal structure of the body. Per the submitted records, this abnormal structure of the body is caused by developmental abnormalities. The abnormal structures which involve the mandible, maxilla and the dentition are mainly a result of developmental forces. Additionally, CPT code 21121 is not likely to improve function. The patients chin is mildly retruded, but this does not impair her oral or facial function. The requested CPT code 21121 is not likely to provide more than a minimal improvement in the appearance of the patient. Per the records, the amount of retrusion is a few millimeters, which constitutes a very minor cosmetic defect. Therefore, CPT code 21121 (genioplasty sliding osteotomy single piece) is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 enrollee is requesting authorization and coverage for a procedure to repair ventral hernia(s) and remove excessive and redundant skin and subcutaneous tissue of the abdomen and pannus. The enrollee has panniculitis. At an office visit, her general surgeon noted she had a ventral hernia and two umbilical hernias. The enrollee complained of excess skin that impeded her ability to undergo repair of her hernias. She also complained of a left groin bulge with associated pain. The enrollee previously weighed 445 pounds and now weighs 254 pounds. She has maintained this weight for the past three years with minor fluctuations. She was referred to a plastic surgeon, who noted the enrollee had a significant abdominal pannus, which may interfere with the hernia repairs due to the redundant skin and soft tissues. She has a history of recurrent skin breakdown and skin infections underneath the overhanging pannus, which have required topical and oral antibiotic treatments. Documentation shows a 43% body weight loss and a significant abdominal pannus, with a recurrent history of skin breakdown and infections underneath the overhanging pannus.  This condition constitutes an abnormal structure of the body, which has been caused by the disease of obesity. The review of systems is positive for skin rash.  The concurrent ventral hernia repair and panniculectomy will decrease dermatitis, and improve hygiene, mobility, and overall quality of life. The medical literature notes panniculectomy can be safely performed when indicated. A study shows the addition of a panniculectomy to ventral hernia repair does not increase complications that require an intervention. Ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation. This procedure is medically necessary for this enrollee because, based on photography in the record, the enrollees pannus is hanging below the pubis; there is documentation of recurrent skin infections and breakdown; the enrollee has had a weight loss of 191 pounds, which has remained stable over the last three years, and the procedure will be performed concurrently with ventral hernia repairs. The procedure will improve the functional impairment caused by the chronic rashes and will create a more normal appearance. Additionally, the requested procedure would provide more than a minimal improvement in the appearance of the enrollee.  Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic 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 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 ZTLido. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether ZTLido is medically necessary for the treatment of the patients medical condition. Reviewers reported that topical lidocaine plasters have been approved as first or second- line therapy for the treatment of post-herpetic neuralgia in the United States. Other reviewers reported in two uncontrolled, open label studies that included patients with moderate-to-severe low back pain, treatment with the lidocaine 5% plaster for six weeks significantly reduced both the intensity of the pain and its impact on the patients quality of life. These topical approaches are generally well tolerated. Per the authors, pharmacokinetic interactions with concomitant oral medications are minimal due to low systemic exposure. Researchers reported topical lidocaine demonstrated excellent risk/benefit ratios, safety, tolerance, and continued efficacy throughout long-term treatment for localized neuropathic pain. In this case, the patient reported neck and back pain and is taking numerous medications for pain relief. Avoiding additional oral systemic agents is appropriate. The medical evidence supports the requested medication in this clinical setting. Therefore, ZTLido 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 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for subcutaneous immunoglobulin infusions, specifically, Hizentra. IgG subclass deficiency is defined as a reduction in one or more subclasses of IgG by more than two standard deviations below the mean for age-matched controls. This patient does not have evidence of an IgG1 subclass deficiency based on the available documentation. The patients IgG1 level on a earlier date was 368 mg/dL, with a reference range of 382-929 mg/dL, and on a later date, it was 337 mg/dL. These measurements are not more than two standard deviations below the mean for age-matched controls and do not support a diagnosis of IgG subclass deficiency. In addition, the records do not include an assessment of antibody function. Quantitation of IgG subclasses provides insufficient information about antibody function. Without clear deficits of functional antibody, IgG subclass deficiency is not likely to be clinically significant. Based on the available documentation, the requested subcutaneous immunoglobulin infusions, specifically, Hizentra, is not medically necessary for 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 internal medicine with subspecialty certification 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara, 90 mg, every 7 weeks.Current medical literature supports dose escalation of Stelara to 90 mg, every 7 weeks, in this case. The patient has active disease symptoms. Iron deficiency and anemia are signs of active Crohns disease, and recurrent iron deficiency and anemia suggest persistent disease activity. In addition, fatigue can be a sign of active Crohns disease rather than anemia. A large randomized controlled trial has demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, which the patient has failed. Another study showed that dosing of Stelara at 90 mg, every 4 weeks, was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg, every 4 weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks.In this case, the patient has failed prior therapies, and failed to adequately respond while taking Stelara 90 mg every 8 weeks. Continuation of the current dose of 90 mg, every 8 weeks, is not sufficient and therefore may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Accordingly, Stelara 90 mg, every 7 weeks, 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 at this time. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for trigeminal nerve injections and greater occipital nerve injections. Current data on occipital nerve blocks remains mixed. Dilli and colleagues concluded that greater occipital nerve blocks did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Inan and colleagues and found that greater occipital nerve blocks were safe and demonstrated greater efficacy than placebo in the treatment of chronic migraine. This patient has a history of chronic migraine since second grade. She has been managed with Botox, but reports incomplete symptomatic relief around the seventh week of the treatment cycle. During pregnancy, treatment with trigeminal and occipital nerve blocks reportedly provided a substantial improvement in pain and ability to function. Oral medications carry a potential risk during breastfeeding. Current literature supports trigeminal and occipital nerve blocks during pregnancy and breastfeeding, for relief of migraines, as interval therapy for Botox. Therefore, trigeminal nerve injections and greater occipital nerve injections (are 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 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.