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 12 additional physical therapy sessions. Kim and colleagues note that scoliosis may present as adolescent idiopathic scoliosis or adult degenerative scoliosis. Berdishevsky note that there are many therapeutic interventions for children with scoliosis, including observation, physiotherapy scoliosis specific exercises (PSSE), and bracing. Lotan and Kalichman note that case reports and small-scale clinical trials of poor methodological quality prevent a clear conclusion about the effectiveness of manual therapy in the treatment of adolescent idiopathic scoliosis. While PSSE are often recommended for the treatment of adolescent idiopathic scoliosis, there is a dearth of convincing evidence from high quality studies that establishes the benefit of these various methods with respect to outcomes such as scoliotic curve progression. Day and colleagues report that there is insufficient evidence to suggest that the Schroth and Scientific Exercise Approach to Scoliosis (SEAS), two types of PSSE methods, can effectively improve Cobb angles in patients with adolescent idiopathic scoliosis compared to no intervention. Romano and colleagues also note a lack of high-quality evidence to recommend the use of PSSE for adolescent idiopathic scoliosis. Plaszewski and colleagues conclude that higher quality reviews indicate that generally there is insufficient evidence to make a judgment on whether non-surgical interventions in adolescent idiopathic scoliosis are effective. In this case, the patient underwent thoracolumbar deformity correction. Postoperatively, he wore a brace and was referred to and underwent physical therapy. While the patient continues to report some symptoms, including at the right shoulder blade region and intermittent popping sensations, the records do not indicate impairments or other outcomes that would be changed or improved with continued formal physical therapy over a home exercise and conditioning program. Therefore, 12 additional physical therapy sessions are not medically necessary for the 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 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 patient has requested reimbursement for (1) arthroscopy with meniscectomy and arthrocentesis of the left knee, and (2) injection for a cartilage tear of the right knee. Current medical literature does not support the efficacy of arthroscopy in the setting of osteoarthrosis or arthroscopic partial meniscectomy for degenerative meniscal tearing. In a systematic review of knee arthroscopy versus conservative management in patients with degenerative knee disease, report, Over the long-term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.  there is uncertainty around the current evidence to support or oppose the use of surgery in mild to moderate knee osteoarthritis, and as no benefit has been demonstrated from low quality trials, it is possible that future higher quality trials for these surgical interventions may not contradict these results. while there were small favorable results of arthroscopic partial meniscectomy as a treatment for adults with nonobstructive meniscal tears up to six months as compared with conservative treatment, there were no differences at longer follow-up. In this case, the patient presented to her provider with bilateral knee pain. The records noted prior bilateral knee arthroscopies and diagnostic imaging revealed osteoarthritic findings. Given the lack of support in current medical literature of arthroscopy in this clinical setting, the arthroscopy with meniscectomy and arthrocentesis of the left knee was not medically necessary for the treatment of this patient. As corticosteroid injections may provide short-term temporary relief of arthritic symptoms, and the documents reflect that the patient tolerated a prior corticosteroid injection well, the injection for a cartilage tear of the right knee was medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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:  An enrollee has requested authorization and coverage for midwife/nurse practitioner services at an accredited birthing center.Birth centers around the country provide antepartum and peripartum care for people with low-risk pregnancies who desire an out-of-hospital birth experience and who are expected to have an uncomplicated birth. For such people, birth center care can result in greater satisfaction and the same or better outcomes as an in-hospital birth. Through a thorough informed consent process, the patient and her provider are able to make a joint decision on birth expectation and contingency plans in order to deliver a child safely in this manner. People with low-risk pregnancies are candidates for birth center care. Generally, a female with a term singleton pregnancy in vertex presentation, and no medical or obstetric conditions that increase the risk for serious intrapartum or postpartum complications can be defined as low risk by criteria defined by the American College of Obstetricians and Gynecologists (ACOG). In this case, the patient has had an uncomplicated pregnancy. Additionally, there are no medical or obstetric conditions that increase the risk for serious intrapartum or postpartum complications. Therefore, midwife/nurse practitioner services at an accredited birthing center are medically necessary for the patients pregnancy.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 obstetrics and gynecology 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 Entyvio (vedolizumab) infusions in a hospital setting.According to the Entyvio prescribing information approved by the U.S. Food & Drug Administration, Infusion-related reactions and hypersensitivity reactions have been reported, including anaphylaxis, dyspnea, bronchospasm, urticaria, flushing, rashThese reactions may occur with the first or subsequent infusions of Entyvio and may vary in their time of onset from during infusion or up to several hours post-infusion. Additionally, the prescribing information states, Serious infusion-related reactions and hypersensitivity reactions including anaphylaxis have been reported following Entyvio administration in clinical trials, including anaphylaxis, requiring treatment with antihistamine and intravenous hydrocortisone. According to Yajnik and colleagues, treatment-related emergent adverse events resulting in hospitalization has been reported. Checkley and colleagues state that there is limited information in handling infusion reactions such as infusion-related anaphylaxis in alternate care settings without direct physician oversight. In this case, the patient has had biologic-related adverse reactions, and has had anaphylaxis in the past. Thus, Entyvio infusions in a hospital setting are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the FDA, more data are required before widespread usage can be recommended. Researchers concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, medical literatures reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies remains to be determined. LINX has significant potential adverse effects and may be associated with poorer outcomes. Researchers noted that while laparoscopic magnetic sphincter augmentation and laparoscopic Nissen fundoplication are both effective and safe treatments for GERD, severe dysphagia requiring endoscopic intervention is more common with magnetic sphincter augmentation. Researchers found that erosion of the LINX device is an important but rare complication to recognize. Therefore, a LINX procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the chest (CPT 71250). The records document that this patient presents with small 2 mm pulmonary nodules that have been overall stable from May 2016 to May 2018. The patient is a never smoker with no prior history of cancer. She has a history of exposure to second-hand smoke and a family history of lung cancer in her father. Based on the available information, the pre-test probably is low that the nodules initially observed on CT in 2016 represent an indolent neoplastic process, especially in light of their two-year stability on repeat imaging. As noted in the medical literature, pulmonary nodules in this clinical setting do not require continued surveillance with CT imaging (MacMahon, et al.; McWilliams, et al.). Therefore, the requested CT of the chest (CPT 71250) is not medically necessary for evaluation of 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 internal medicine with subspecialty certifications 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Trulicity.Trulicity is a member of the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. According to Verges and colleagues, this class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Another important possible additional benefit of Trulicity relates to potential improvements in beta cell function. Vilsbll and Garber state that by treating with Trulicity relatively early in the course of diabetes, patients may be able to preserve beta cell function for the long term, halting or slowing down the progression of diabetes. Furthermore, according to Sheahan and colleagues, studies have recently demonstrated improved cardiovascular outcomes for patients who are taking Trulicity. In this case, the patient has been diagnosed with type 2 diabetes. Additionally, the patient has been successfully using Trulicity. Therefore, Trulicity is 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and  metabolism 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 digital breast tomosynthesis (3D mammogram).The main weakness of mammography is the detection of cancer in women with radiographic dense breasts. While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breasts. This is a result of the masking or camouflaging of non-calcified cancers by surrounding dense tissue. An advantage of tomosynthesis is better delineation and characterization of breast masses. The primary benefit of digital breast tomosynthesis would be expected to be for non-calcified mammographic findings, such as masses, asymmetries, and distortion. In the most basic application, digital breast tomosynthesis would allow visualization of cancers not apparent by conventional mammography, thus improving sensitivity. Kopans and colleagues found that the clarity with which calcifications were seen on digital breast tomosynthesis was equal to or better than conventional mammography. Further, Skaane and colleagues found that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Similarly, Rafferty and colleagues stated that the addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for non-cancer cases.In this case, the patient has known heterogeneously dense breasts. Patients with dense breasts benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis (3D mammogram) 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 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 Boost Nutritional Supplement. The records provided for review document that this patient has a history of feeding difficulties and human immunodeficiency virus (HIV). The provider charted that the patient requires soft foods, due to poor fitting dentures. The patient had unintentional weight loss before starting Boost Nutritional Supplements and she has lost weight since she stopped taking Boost. The patients recent body mass index (BMI) was 24.5 kg/m2. As noted in the medical literature, a lower BMI is associated with poorer health outcomes in HIV patients on treatment. Nutritional supplementation can increase lean body mass and grip strength in patients with HIV (Olson, et al.). Moreover, nutritional supplementation has been shown to decrease loss of muscle mass and onset of frailty (Nowson and OConnell). Undernutrition and underweight status is common in older patients, and oral liquid energy-dense and high-quality protein supplements have been shown to increase energy and protein intake. For these reasons, the requested Boost Nutritional Supplement is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested nutritional supplement 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the neck surgery (C3-4 arthroplasty and C6-7 revision arthroplasty). Current medical literature supports the use of artificial disc adjacent to a fusion as having excellent outcomes that are superior to additional fusion. Hao and colleagues report that the clinical outcome of revision of cervical adjacent segment disease by artificial cervical disc replacement is satisfactory. The authors further noted that the risk of intervertebral disc degeneration in adjacent segments is significantly lower than that of artificial cervical disc fusion due to the presence of certain motor function postoperatively. Park and colleagues also found that in a small case series, revision surgeries provided successful outcomes in failed artificial disc replacement of cervical spine without major complications. Reinas and colleagues note that multilevel cervical disc arthroplasty provided good clinical and radiological outcomes, preserving global and segmental cervical mobility, while having a beneficial effect on sagittal balance. The authors further noted that these results held for two to four levels, making this technique a valuable option in selected patients with cervical multilevel cervical disc disease. Given that current medical literature supports the use of an artificial disc and improved outcomes from multilevel artificial disc specifically in the setting of a prior fusion, the service at issue was medically indicated. Therefore, the neck surgery (C3-4 arthroplasty and C6-7 revision arthroplasty) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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.