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

Nature of Statutory Criteria/Case Summary: The enrollees parent has requested authorization and coverage for In-Plan social language speech therapy program. This patient has autism with impairment of pragmatic language, the severity of which was likely underscored with the testing tools administered. The provider noted intermittent errors on substitution of th with /d, f/ and gliding of r on testing, but found that she had age-appropriate pragmatic language skills. Her parent has expressed concern regarding the patients ability to communicate with her peers. This patient is at risk of being socially isolated because of her impairments in the appropriate social use of pragmatic language. Researchers have recommended that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. Researchers have also discussed methods of exploring deficits in pragmatic language in children with autism using: 1) the Pragma test; 2) the Social Interaction Deviance Composite (SIDC) of Childrens Communication Checklist-2 (CCC-2); and 3) the Theory of Mind subtest of the Developmental Neuropsychological Assessment, the results showed that children with autism differed from typically developing children in questions demanding context utilization. These tests were not used to evaluate this patients pragmatic language skills. Based on the available documentation, the requested In-Plan social language speech therapy program is medically necessary for treatment of this 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 neurology with special qualification in child 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a tricycle (Liberty Trike, 750-watt folding scooter/tricycle). The documentation does not reveal that a tricycle (Liberty Trike, 750-watt folding scooter/tricycle) is medically necessary for this patient. The records do not include an objective evaluation of the patients gait, a musculoskeletal examination, or a neurologic examination that indicate the patient has a mobility related deficit requiring the requested tricycle. The provider does not report that the patient has a deficit that it is unable to be safely resolved with the use of an appropriately fitted cane or walker. Moreover, the records do not describe that the patient is unable to perform mobility related activities of daily living (MRADLs) without an assistive device, or that the patient is able to safely navigate the requested tricycle in the van in which he lives to complete MRADLs. For these reasons, the requested tricycle (Liberty Trike, 750-watt folding scooter/tricycle) is not medically necessary for this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: An enrollee has requested authorization and coverage for Euflexxa injections for both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when everything else has been tried and the options are limited. In this case, there is a history of lasting benefit from prior viscosupplementation. The patients options are limited, as the patient does not want surgery, has tried and failed physical therapy, and is currently on addictive opioids. Under these circumstances, Euflexxa injections for both knees are medically necessary to treat 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 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

The patient has requested reimbursement for anesthesia services (CPT code 00811QZ) provided during a colonoscopy. The American Society of Anesthesiologists (ASA) guidelines for sedation and anesthesia in gastrointestinal (GI) endoscopy recommend anesthesia provider-administered sedation for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. In addition, minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. A review by Wernli and colleagues concluded that the use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient does not have significant comorbid health conditions and had a pre-procedure ASA score of 2. The patients airway was a Class II Mallampati score presenting for a colonoscopy. The physician reviewer found that documentation of a previous personal or family history documenting problems with anesthesia or with colonoscopy to suggest the need for MAC services. Overall, the current ASA guidelines do not support the use of MAC and propofol sedation a patient who does not have significant health conditions or airway concerns. The guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, which was the case with this patients procedure. The review by Wernli and colleagues concluded that the use of anesthesia services in low-risk patients, such as this patient, was associated with increased complications. Based on the available information provided for review, the anesthesia services (CPT code 00811QZ) provided during a colonoscopy were not medically necessary for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for deep brain stimulation (DBS). Standard therapies for medically refractory epilepsy include anti-epileptic medications, surgical resection, vagal nerve stimulation, responsive neurostimulation, and DBS. The records provided for review document that this patient is already on four anti-epileptic medications and the addition of another or alternative medications has an extremely low likelihood of providing substantial improvement. The patient is not a good candidate for additional invasive monitoring given the complications related to most recent procedure. This rules the patient out as a candidate for surgical resection. DBS is U.S. Food and Drug Administration (FDA) approved for use in this clinical setting. This patient has endured multiple craniotomies in an attempt at seizure focus localization and resection, all of which have failed. Given this support, the requested DBS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested DBS is likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography with computerized tomography for attenuation (PET/CT).National Comprehensive Cancer Network (NCCN) guidelines for both pancreatic and extrahepatic biliary carcinoma advocate the use of conventional CT of the chest and CT or MRI of the abdomen and pelvis every 8 weeks to assess treatment success/failure in these two types of malignancies unless conventional or prior PET/CT imaging has been equivocal. In such unusual cases, PET/CT imaging has proven to be of use as a problem solver.In this case, while conventional imaging techniques may be used to assess the degree of metastatic disease, the original PET/CT scanning reported an ill-defined area of increased metabolic activity in the region of the pancreatic head abutting the second duodenum, which could represent the primary tumor. Despite the patients decreasing CA19-9 tumor marker, it would be important to assess the metabolic nature and size of what is probably the primary tumor, not just the metastatic disease. Since treatment decisions hinge on a quantitative improvement in the appearance and physiology of the likely primary tumor, positron emission tomography with computerized tomography for attenuation (PET/CT) would be justified and necessary, at this mid-chemotherapy point in treatment, as the best imaging option. Accordingly, the requested positron emission tomography with computerized tomography for attenuation (PET/CT) is medically necessary to treat 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liver ablation.Findings:  Two of three physician reviewers found that aggressive approaches to liver metastasis have been pursued in several types of cancer, particularly colon and hepatocellular cancer. In these cancers, isolated liver metastases have been surgically excised and there have been long term survivors. In most cases, such an approach has been used when there is no extra-hepatic metastasis and the liver metastasis appears to be isolated to that organ, and the lesion is resectable. In this case, the patients follow-up CT scan showed progression of a liver lesion that was concerning for metastasis as well as an enlarging retroperitoneal node that was noted to be suspicious for metastasis. In view of the patients extrahepatic disease and the nature of ovarian cancer, as well as the small uncontrolled reports in ovarian cancer, ablation of the liver metastasis is of unknown clinical benefit. Accordingly, the requested liver ablation procedure  is not likely to be more beneficial for treatment of the patients condition than any other available standard treatments.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for treatment by an orthopedic specialist. Given the notes available, the patient has ongoing musculoskeletal complaints. She has pain in the cervical, thoracic and lumbar spine. On physical examination, the provider noted that there was tenderness to palpation over the cervical and thoracic spine paraspinals, positive straight leg raise bilaterally, and abnormal sensation in the L4 and L5 dermatomes. Her examination is concerning for L4 and L5 radiculopathy given her sensory changes and the positive straight leg raise. Referral to orthopedic surgery is indicated for further assessment of her radicular complaints. Therefore, evaluation by an orthopedic specialist is medically necessary for this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Miconazole/Monistat 7 cream, Percocet (acetaminophen and oxycodone) 10-325 #90, and stool softener 250 mg. Miconazole/Monistat 7 cream is not supported as medically necessary for treatment of this patient based on the available records. Monistat is effective for the treatment of acute vaginitis. The records available for review do not support that this patient has symptoms of candidal vaginitis. There is no documentation of a physical examination or laboratory test results consistent with candidal vaginitis. If the patient is having symptoms consistent with vaginitis, physical examination and laboratory testing are required to determine the appropriate treatment. Considering the available documentation, the requested Miconazole/Monistat 7 cream is not medically necessary. Regarding the continued use of Percocet, the documentation does not indicate that the patient has had a meaningful improvement in function while taking this medication. The Centers for Disease Control and Prevention (CDC) supports the use of opiate medications for non-cancer related pain when alternative therapies have not provided sufficient pain relief or are not tolerated, when there is documentation of functional improvement, and when the benefits of opioid therapy outweigh the potential harms. In this case, the patient has shown minimal improvement in function while taking this medication and she continues to have a depressed mood. Her medication regimen includes benzodiazepines, which increases the risk for adverse outcomes when taken concomitantly with opiate medications. Although the CURES reports have been consistent, the records do not include a recent urine toxicology screen. Given these findings, the continued use of Percocet (acetaminophen and oxycodone) 10-325 #90, is not medically necessary for treatment of this patient. In addition, the requested stool softener is not based on documentation of constipation or other bowel complaints. Although a stool softener may be indicated to treat constipation when taking opiate analgesic medications, there is no documentation that this patient has had any issues while taking Percocet or other medications in her regimen. Thus, the requested stool softener 250 mg is not medically necessary for this patient. 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 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

The patient has requested authorization and coverage for Electric wheelchair, a new walker or repair of the enrollees current walker, handrails for the enrollees home, and bathtub bars. The records provided for review support that this patients diagnoses include cervicalgia, back pain, and chest pain. The documentation does not reveal that there has been a face-to-face evaluation by a physician or a physical therapist of the patient and home determining that the requested items are appropriate for this patient and her home. The records do not include a thorough mobility evaluation or documentation that the patient is unable to perform usual activities of daily living (ADLs) within the home without a power mobility device. There was no formal gait evaluation revealing that she is unable to ameliorate her mobility deficits with an appropriately fitted walker or cane. There was no documentation of a home assessment to ensure that a power mobility device can fit in the doorways and would be safe to maneuver within the home. Thus, the requested electric wheelchair is not medically necessary. In addition, there is no evidence of an evaluation of the patients current walker. Without a recent evaluation of the patient and her current walker, it remains unknown whether the device can be repaired or should be replaced, or if the current cane is the appropriate assistive device for this patient. Thus, the request to replace or repair the patients current walker is not medically necessary. Moreover, there is no evidence of a physical therapy evaluation of the patient or a home assessment to establish that handrails or bathtub bars are required. All told, the requested electric wheelchair, a new walker or repair of the patients current walker, handrails for the patients home, and bathtub bars, are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

The patient has requested authorization and coverage for treatment by a podiatrist. After careful review of the enclosed information and the pertinent guidelines for this case, the patient should receive at least one visit with a podiatrist for a comprehensive foot evaluation. Documentation enclosed in this case advised that the patient is a type I diabetic with hyperglycemia. Absent in this chart is a comprehensive foot evaluation. Studies find that a comprehensive foot examination at least once a year is beneficial in staving off foot pathology due to complications of diabetes. This patient should undergo a comprehensive foot examination by a podiatrist to determine whether further treatment is needed. Therefore, the requested treatment by a podiatrist for a comprehensive foot evaluation and treatment is medically necessary. 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 podiatry 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.