Persius/hicric huggingface dataset:
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 spinal canal (CPT 72141). The records document that this patient presents with neck and upper back pain. The patient was noted to have sustained an injury about seven years prior that was managed with physical therapy and acupuncture without lingering pain. The records do not document any recent history of trauma, neurologic impairment, or suspicion of severe illness such as malignancy. In this clinical setting, specifically advanced imaging such as MRI is not recommended by the medical literature (Cohen; Nakashima, et al.). Initial treatment should include an anti-inflammatory medication such as naproxen and physical therapy. MRI is not recommended during the initial evaluation stage. Based on current data, a cervical spinal MRI is not indicated for this patient with neck pain without neurologic impairment or historical or examination findings suggestive of serious pathology such as myelopathy, atlantoaxial subluxation, or metastases. All told, the requested MRI of spinal canal (CPT 72141) 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 orthopedic surgery with subspecialty certification in sports 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 patients parent has requested authorization and coverage for 13 hours per month of 1:1 applied behavioral analysis (ABA), in addition to the 22 hours of direct 1:1 ABA already approved by the Health Plan. The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that for an individualized ABA treatment plan, a developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. Researchers report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. In this case, ABA therapy is the most evidence-based treatment for this patients diagnosis of autism. The patients treatment plan includes a wide breadth of outlined goals and how the requested hours will address the essential needs of this patient. Given the scope of treatment and challenging behaviors present, the requested services are medically indicated. In this patients case, 13 hours per month of 1:1 applied behavioral analysis (ABA), in addition to the 22 hours of direct 1:1 ABA already approved by the Health Plan, are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, 13 hours per month of 1:1 applied behavioral analysis (ABA), in addition to the 22 hours of direct 1:1 ABA already approved by the Health Plan, 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a Monovisc injection in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to 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. 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 this case, the options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties for mild osteoarthritis. Therefore, Monovisc injection in both knees is medically necessary for the treatment of the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy.Findings:  The physician reviewer found that is a lack of medical evidence to support that treatment with proton therapy is associated with a clinical benefit compared to treatment with photons. In addition, proton therapy has not been validated in comparative randomized studies as compared to conventional treatment with photons. With regard to prostate cancer, there is insufficient clinical data to discern that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques. A recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy (IMRT) with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, the study reported no difference in disease control between the two modalities. Per the American Society of Radiation Oncology (ASTRO), Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO and state that there is inadequate data showing benefits with proton therapy over photons and IMRT technique. Given these findings, the requested proton beam radiation therapy 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 board certified in radiation 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 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 authorization and coverage for Nutropin AQ. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. The patients recent growth pattern indicates that catch-up growth is unlikely without somatotropin (brand name Nutropin AQ) therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nutropin AQ 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 Nurtec ODT (rimegepant). This patient presents with a history of migraines. Treatment has included nortriptyline. The patients provider has recommended treatment with Nurtec ODT. Migraine is a common neurological disorder with several treatment options. Nurtec ODT is from the CGRP family of medications. Its efficacy in management of migraine has been shown in several studies. As a result of the available evidence, the U.S. Food and Drug Administration (FDA) approved Nurtec ODT for migraine management. In the medical literature, Croop and colleagues noted that, In the acute treatment of migraine, a single 75 mg dose of rimegepant in an orally disintegrating tablet formulation was more effective than placebo. Given this support, the requested Nurtec ODT (rimegepant) 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 with subspecialty certification in vascular 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 magnetic resonance imaging (MRI) of right breast, without and/or with contrast material. Findings:  The physician reviewer found that there is a lack of data in current medical literature to support the use of breast MRI to evaluate patients with normal mammography and sonography results who report breast pain or palpable lumps. Kushwaha and colleagues note in a study of 799 patients that when correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population, breast pain was not found to be a sign of breast cancer. For diagnostic purposes, palpable breast lumps require a biopsy. In this case, while the patient reports breast pain, given that the patients normal mammogram and ultrasound results, the requested service is not medically indicated. Therefore, MRI of right breast, without and/or with contrast material, is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 sub-specialty certification in medical 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Functional impairments due to acquired brain insults such as stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery (Alawieh, et al.). As noted in the medical literature, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in subsequent stages (Kubis). There is a general consensus that initiating rehabilitative measures earlier in the post-stroke course enhances outcomes (Belagaje, et al.). Comorbidities are associated with poorer outcomes after stroke (Desilles, et al.). This patients records document that they sustained an ischemic stroke in late January 2021. The patients condition was complicated by edema requiring hemicraniectomy and by hemorrhagic transformation of the stroke. These multiple cerebral insults caused a severe early neurological injury burden. The patient has severe to profound neurological deficits that have persisted with minimal improvement. Repeat imaging has shown encephalomalacia, atrophy, and ventriculomegaly. Functionally, they have plateaued at requiring maximum to total assistance for their basic self-care and transfers. The patient has remained non-ambulatory. They are tolerating their enteral tube feeds, which are supplemented by oral feedings. There is a lack of documentation to support an indication an ongoing need for skilled nursing or therapy services on a regular basis as of the date of denial. The patients medical needs have been custodial in nature. Therefore, the SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intravenous immunoglobulin (IVIG) Gammaplex 15 grams weekly for three to six months. This patients medical records include a history and presentation that support diagnoses of Ehler-Danlos syndrome, postural orthostatic tachycardia syndrome (POTS), and mast cell activation syndrome. The patient complains of dizziness, nausea, and headaches, as well as epistaxis episodes and unprovoked hives. The patients provider has recommended treatment with Gammaplex IVIG. Based on current data, the therapy that has been demonstrated to be the safest and provide the most consistent therapeutic results is IVIG. The data suggests that the widespread dysregulation of the immune system, as evidenced by mast cell activation syndrome, may be a causative factor. Overall, the beneficial effects of IVIG have been established for symptom complexes associated with the trifecta diagnoses of Ehler-Danlos Syndrome, POTS, and mast cell activation syndrome. Given these findings, the requested IVIG Gammaplex 15 grams weekly for three to six months 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an echocardiogram at a tertiary care center.A follow-up echocardiogram done at the same laboratory, using similar technique, image acquisition, equipment and personnel, provides continuity to compare changes from prior examinations. Thus, the requested service is medically reasonable and necessary from a continuity of care standpoint. As the patient has already had subtle reductions in left ventricle function, a repeat scan done at the same echocardiogram laboratory and compared to similarly done prior studies will provide the best assessment of left ventricle function. This would provide the best reliability to the measurements of changes in left ventricle function, especially since her left ventricular ejection fraction was not completely normal on prior studies. According to Wang and Chu, reliable left ventricular ejection fraction results would be critical to her oncologic care, as this could affect further chemotherapy or radiation dosing. Therefore, the requested echocardiogram at a tertiary care center is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is 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 cardiovascular disease 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 Emgality 120 mg/mL injection pens - two injection pens for the first dose (loading dose), and then one injection pen once monthly for maintenance dose. Findings:  The physician reviewer found that Migraine is an episodic disorder, the centerpiece of which is a severe headache generally associated with nausea and/or light and sound sensitivity. Emgality is a calcitonin gene-related peptide (CGRP) antagonist that has been shown to be effective in preventative migraine management and is approved by the U.S. Food and Drug Administration for migraine prophylaxis. Additionally, concurrent Botox therapy is not a contraindication to Emgality and a case can be made of improved therapeutic effects when on both a CGRP antagonist and Botox. In this case, the patient has tried and failed multiple alternative medications. Additionally, the patient is on Botox therapy. Therefore, Emgality 120mg/mL injection pens - two injection pens for the first dose (loading dose), and then one injection pen once monthly for maintenance dose are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is 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 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:  An enrollee has requested authorization and coverage for 28 imiquimod 5% cream packets for 28 days.Imiquimod (Aldara) 5% cream has been  approved by the U.S. Food and Drug Administration and is indicated for the treatment of external genital and perianal warts/condyloma acuminata in individuals 12 years old and older. A systematic review of randomized trials by Grillo-Ardila  and colleagues found this drug superior to placebo for achieving complete and partial regression of anogenital warts. According to Komericki and colleagues, clearance rates from randomized trials for imiquimod 5% cream range from 35 to 75 percent, and recurrence rates range from 6 to 26 percent. In this case, a physical examination revealed that the patient has perianal warts. The medical literature indicates that imiquimod is a safe and effective treatment for perianal warts. Therefore, 28 imiquimod 5% cream packets for 28 days are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the medication is 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 dermatology 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.