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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for endovascular stent repair procedure with a one-day inpatient stay.According to researchers, Complex AAAs have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. The authors found, FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Moreover, researchers also found that with OSR, the odds for major complications, minor complications, and short-term mortality were significantly higher compared with complex endovascular aneurysm repair.In this case, the patient has a large AAA at risk for rupture. Based on the CTA report, the AAA was 6 centimeters in diameter. Additionally, the risk of rupture is heightened by severe, difficult to control hypertension and chronic back pain. As back pain is a common symptom of aneurysm rupture or impending rupture, it creates a potentially untenable situation to attempt to manage an AAA in a patient with chronic back pain conservatively. Due to the patients considerable comorbidities and the need to control the aorta suprarenal, an endovascular approach is medically necessary. It is also medically necessary to perform the repair with a device that would successfully exclude the aneurysm. Depending on the patients condition after the procedure, an inpatient hospital stay is reasonable and medically necessary. Therefore, the requested endovascular stent repair procedure with a one-day inpatient stay is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 vascular 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 magnetic resonance imaging (MRI). In this case, the records note that the patient has abnormal uterine bleeding. An ultrasound showed an ovarian cyst that was followed with repeat imaging, and further imaging with a computed tomography (CT) scan showed a large myxomatous uterus. Medical literature notes that a pelvic ultrasound is the modality of choice to assess uterine tumors such as leiomyomas and ovarian cysts. While an MRI may be indicated in some circumstances, at the discretion of the provider, for further evaluation of the location, size, or appearance of fibroids, in this case, the submitted documentation does not indicate that the provider has recommended an MRI for further evaluation, for alternative treatments such as uterine artery embolization, or for surgical planning. Therefore, MRI 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 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: The patient has requested authorization and coverage for Dexilant delayed-release 60 mg capsule. Dexilant, unlike other proton pump inhibitors (PPIs), is released in an extended fashion, resulting in an extended plasma concentration and a higher mean 24-hour intragastric pH than other PPIs. Fass and colleagues note that in a study of 163 patients with GERD taking twice-daily PPI to control heartburn, 88% were able to control symptoms with Dexilant once daily. While the American College of Gastroenterology (ACG) guidelines for the treatment of GERD recommend management with PPIs, in this case, the records note that the patient had failed trial two conventional PPIs, omeprazole and pantoprazole. In this clinical setting, given that it is unlikely that the patient will find relief with another conventional PPI, the requested medication is medically indicated.  Therefore, Dexilant delayed-release 60 mg capsule 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Orthovisc injection series in the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient is status post left knee arthroscopy, and partial medial and lateral meniscectomies, and has a diagnosis of osteoarthritis of the left knee. The patient has undergone postoperative rehabilitation and is progressing with an exercise program. As the patient has tried physical therapy and nonsteroidal anti-inflammatory drugs without relief, the provider has recommended viscosupplementation. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in the left knee are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: The patient has requested authorization and coverage for Signifor. Researchers describe tumor-induced hypoglycemia as a serious disorder most commonly caused by insulinoma or non-islet cell tumor hypoglycemia. The authors further report that in a case series, three patients with tumor-induced hypoglycemia refractory to guideline-recommended medical therapy, such as diazoxide, nonpasireotide somatostatin analogues, and glucocorticoids, the addition of pasireotide led to prompt improvement in the frequency and severity of hypoglycemic episodes. In this case, the patients hypoglycemia is likely related to a non-islet cell tumor.  The patients hypoglycemia persisted despite a trial of glucocorticoids, and somatostatin analogues and diazoxide may not be advisable as they may contribute to tumor progression. In this clinical setting, given that current medical literature supports the use of pasireotide for the treatment of hypoglycemia, the requested medication is medically indicated. Therefore, Signifor 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom ankle-foot orthotics (AFOs) and shoe lifts. The use of AFOs for patients that suffer with foot drop is well established in current medical literature. Medical literature notes a significant beneficial effect from customized AFOs in terms of spatial temporal gait parameters and ankle kinematic parameters compared to the barefoot gait of adults with drop foot gait. Medical literature reports that a study of 28 children with cerebral palsy showed that correction with an AFO is an effective treatment for equinus deformity. In this case, the records document that the patient has bilateral lower extremity equinovarus deformities. She used a wheelchair for ambulation but was also able to bear weight on her feet and walk. The patient was noted as using custom AFOs and shoe lifts that were worn down. Given that custom AFOs and shoe lifts can be tailored exactly to the specific biomechanical abnormalities of a patient with equinovarus type of foot drop, thus allowing for a better correction, the requested equipment is medically indicated. Therefore, custom AFOs and shoe lifts are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia service. Findings: The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. The study concluded, 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 underwent a colonoscopy. He did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no history of difficulties with anesthesia or sedation with past colonoscopies in the documentation submitted. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 2 airway score, without evidence of a difficult airway. The literature does not support the use of anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the service at issue was not medically indicated. Therefore, anesthesia service was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a power wheelchair.At issue is whether the requested power wheelchair is medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or outside of the home, including access to the community.According to medical literaturel, Obesity is a health condition that, through a complex interaction of biopsychosocial and environmental factors, is associated with mobility disability. The mobility disability experienced by persons with obesity is associated with reduced health related quality of life (HRQoL) compared to persons without obesity. Chronic health conditions such as hypertension, hyperlipidemia, heart disease, morbid obesity and diabetes, generally benefit from exercise, such as that afforded by ambulation or use of a wheelchair propelled by body power. Reliance on motorized mobility when ambulation or manual wheelchair use are feasible can have detrimental effects on cardiovascular health. In this case, the patient has chronic health conditions and is obese. Additionally, the patient has no focal neurological deficits or other evidence of impairment that would preclude use of a mobility device, such as a walker with seat, to accomplish his mobility-related activities of daily living. The patients deconditioning should be addressed by strengthening and greater levels of physical activity, not decreased levels of physical activity. In the short-term, a manual wheelchair would be appropriate for longer distance mobility while he builds his ambulatory capacity and endurance with his walker. Therefore, the requested power wheelchair is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. 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 authorization and coverage for tertiary level vascular surgery second opinion consultation. The records provided for review document that this patient has unique characteristics that warrant evaluation and treatment at a higher level of care. Specifically, the patients body mass index (BMI) supports a finding of morbid obesity and the duplex results suggest the potential development of recurrent deep vein thrombosis (DVT) that has not been addressed. There is concern for the possibility of an undiagnosed DVT in the left lower extremity. In this clinical setting, evaluation and treatment at the tertiary level of care is appropriate. Given these findings, the requested tertiary level vascular surgery second opinion consultation is medically necessary for 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 general surgery with subspecialty certification in vascular 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 physical therapy three times a week at a skilled nursing facility (SNF). The records provided for review document that this patient has a history of lower thoracic level spinal cord injury since January 2021, with paraplegia, neurogenic bladder, and neurogenic bowel. The primary goals of rehabilitation in this clinical setting are maximizing function given the patients current impairments (Nas, et al.). The patient has undergone extensive rehabilitation but has plateaued functionally at a level where he requires contact guard assistance for transfers, physical assistance for his lower body self-care, and a wheelchair for his mobility at a stand-by assistance level. The patients lower limb motor recovery has been absent to minimal and he does not have the lower body strength whereby functional ambulation is a goal (Chay and Kirshblum). The patient does not require additional physical therapy services as he has plateaued functionally, and he has not demonstrated the ability to improve further with therapy services. The patient can continue with self-directed exercise to improve strength. For these reasons, the requested physical therapy three times a week at a SNF 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for bariatric surgery.According to Mechanick and colleagues, Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Arterburn and colleagues indicate that National Institutes of Health guidelines recommend consideration of bariatric surgery in patients with BMI of 40 or higher or 35 or higher with serious obesity-related comorbidities. Additionally, the authors state that, Bariatric procedures should also be considered for patients with type 2 diabetes and a BMI of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment. In this case, the patient does not present with clinically severe or morbid obesity. The records reflect that the patient documents a BMI that is less than 40 but greater than 35 kg/m2, without associated life threatening obesity conditions such as sleep apnea, diabetes, hypertension or cardiac disease. The patient does not meet the minimum BMI at this time to be eligible for metabolic bariatric surgery. Therefore, the requested bariatric surgery is not medically necessary for treatment of the patients medical condition.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 general surgery with expertise in bariatric 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 patient has requested authorization and coverage for foot orthotics (CPT L3020). Findings:  The physician reviewer found that  foot orthotics are effective in reducing pain for patients with plantar fasciitis. In this case, the records document that the patient has pronation, plantar fasciitis, pain in the feet, and gait instability. Given that foot orthotics support abnormal foot biomechanics, foot medial column and arch abnormalities, and assist in improving gait stability, the requested equipment is medically indicated. Therefore, foot orthotics (CPT L3020) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer a licensed D.P.M., 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.