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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a gastroenterologist. In this case, the patient has experienced protracted symptoms, including changes in bowel habits, which warrant evaluation. Additionally, the patient has a history of positive fecal immunochemical test results for blood in the stool. In the setting of a change in bowel habits and a prior history of colorectal cancer, the patient should be evaluated for recurrence of cancer and functional change in bowel habits after bowel resection. Evaluation by a gastroenterologist is appropriate to perform a clinical evaluation of the patients symptoms, perform a colonoscopy for colorectal cancer surveillance, and for evaluation of positive fecal immunochemical test results. For these reasons, the request for a referral to a gastroenterologist is medically necessary for evaluation and treatment of 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 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: An enrollee has requested authorization and coverage for Cimzia. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  Psoriasis is a chronic inflammatory skin disease. Enrollees with this condition typically present with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic and pulmonary toxicity as well as limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Cimzia is a fragment crystallizable (Fc) free, pegylated, anti-tumor necrosis factor biologic that has demonstrated favorable results in ongoing, phase 3, randomized, double-blinded, placebo-controlled trials in adults with psoriasis. This enrollee has plaque psoriasis and psoriatic arthritis that affect the enrollee's quality of life. The enrollee did not respond to first-line anti-tumor necrosis factor therapy. Therefore, the enrollee requires an alternative anti-tumor necrosis factor treatment. Thus, Cimzia is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Ketamine HCL Solution nasal spray. The patient has complex regional pain syndrome, migraines, chronic fatigue syndrome, degenerative joint disease, spinal pain, degenerative disc disease, L4-5 disc displacement, lumbago with sciatica, and fibromyalgia.Findings:She had an anterior cervical microdiscectomy and fusions at levels C5-6 and C6-7. Subsequently, she was involved in a motor vehicle accident that exacerbated her back condition.  She has pain in her lower back and both legs. Her back pain wakes her up at night.  She also experiences tingling and numbness in her legs. She has tried epidural injections, Lyrica, Topomax, Celebrex, Amovig, Baclofen, Lidoderm patches, Naproxen, and Tylenol without relief. She has also gone to physical therapy and massage therapy. Review of the medical literature indicates there have been no trials of intra-nasal ketamine for CRPS.  One single study involved a small  number of patients who showed improvement lasting up to 60 minutes.  Intra-nasal esketamine has been approved for the treatment of depression but its use for CRPS is not supported by the literature. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the medication, Bionect Cream. Findings:  The physician reviewer found that according to the record, the enrollee presented to the physicians office to discuss concern about a facial rash and the way his skin feels. The physician notes indicate no rash was visible. The enrollee reports seeing a dermatologist with trials of Lamisil, steroid cream, facial wash and an unspecified prescription gel. However, there is no documentation in the record of dates or who prescribed the medications. Tacrolimus 0.1% ointment was prescribed for seborrheic dermatitis, with a recommendation to follow up with dermatology if not helpful. The medication list indicates Bionect 0.2% gel was ordered to start the next day. Per the medical literature, when assessing a patient with a new dermatologic condition, developing a differential diagnosis is essential to ensure the condition is not elusive as a work-up and potential therapy are considered.  Subsequent narrowing of that differential based on history and physical examination can allow a more targeted approach to diagnostic testing and triage, and hasten an effective treatment and resolution. Seborrheic dermatitis (SD) is a chronic, recurring inflammatory skin disorder that manifests as erythematous macules or plaques with varying levels of scaling associated with pruritus.  The condition tends to occur on seborrheic areas, such as the scalp, face, chest, back, axilla, and groin areas.  SD treatment focuses on clearing signs of the disease, ameliorating associated symptoms such as pruritus, and maintaining remission with long-term therapy.  The most commonly used treatment is topical anti-fungal and anti-inflammatory agents.  The medical records do not provide sufficient evidence the enrollee has tried and failed topical anti-fungals and anti-inflammatory agents.  Therefore, the requested medication, Bionect Cream, is not medically necessary for the treatment of this enrollees medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 occupational therapy services. Occupational therapy focuses on deficits in visuospatial, neurodevelopmental, and fine motor skills. This treatment modality addresses weakness of upper extremities including hands, as well as coordination deficits. The purpose and goal of occupational therapy in this patients case is to develop and improve skills needed to perform age appropriate activities for daily living and school performance. This patient presents with dysgraphia. He exhibits deficient ability to initiate, plan, organize and monitor letters and words on paper. These executive and motor difficulties accompany young patients with dysgraphia in various domains such as home, community, and school environments. This patient requires occupational therapy to learn and develop skills such as tying his shoelaces, writing, and reading at an age-appropriate level. Therefore, the requested occupational therapy services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: The patient has requested authorization and coverage for computed tomography (CT) scan of the brain and lungs and Decadron 24 mg per day. This patient has metastatic breast cancer, leptomeningeal disease, pulmonary embolism hemorrhage, and sepsis. She is status post treatment with chemotherapy and radiation therapy. At this time, the primary goal of the treatment is making the patient as comfortable as possible. Further imaging with a CT of the brain and lungs is not going to change her treatment course. Regarding dosing of Decadron, there is usually an initial loading dose and a recommended maximum dose of 16 mg per day. An effect is usually seen within a few days and the dose is then tapered. Findings: the physician reviewer found that this patient is currently receiving 18 mg per day of Decadron and an increase in her dose is unlikely to be of benefit. Therefore, the requested CT scan of the brain and lungs and Decadron 24 mg per day are not medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services and medication are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 proton beam radiation therapy. Per current peer-reviewed medical literature, the role of proton beam radiotherapy for management of clinically localized prostate cancer remains undetermined. There is a lack of high quality clinical outcomes reported to allow definitive conclusions regarding its safety and efficacy as compared to the standard of care radiation modality, which is photon radiotherapy. Further, a nationally recognized organization does not support proton beam radiotherapy in this patients setting outside the context of a clinical trial. Some reports suggest that proton beam radiotherapy may lead to excessive gastrointestinal and rectal toxicity as compared to photon radiation. One study evaluated 1368 patients treated with intensity modulated radiation therapy (IMRT) or proton beam radiotherapy and found that IMRT patients had a lower rate of gastrointestinal morbidity. The study reported that there were no significant differences in rates of other morbidities or additional therapies between IMRT and proton therapy. Therefore, proton beam radiation therapy was not and is not medically necessary for treatment of this patients prostate cancer. 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 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: An enrollee has requested authorization and coverage for Botox and combination therapy with Botox and Aimovig. The current medical evidence supports Botox in this clinical setting. This patient has a history of chronic migraine headaches. Botox is an appropriate treatment for migraine prophylaxis in this patients case. The medical records provided for review indicated that the patient has been receiving Botox injections for migraine prophylaxis, with documented therapeutic efficacy. The continued use of Botox as a prophylactic therapy is consistent with the generally accepted standards of practice. Therefore, Botox is medically necessary for the treatment of this patient.The submitted documentation does not support the medical necessity of combination therapy with Botox and Aimovig. There is a paucity of literature evaluating the use of Aimovig in patients who are concurrently receiving Botox injections. Trials of Aimovig evaluated patients who had not receive Botox for a few months prior to the start of therapy. A study found that there may be a role for the use of Aimovig in combination with oral prophylactic therapies, the position statement did not discuss the use of multiple injectable agents. Therefore, combination therapy with Botox and Aimovig is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested medications is 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 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 procedure to remove breast implants.Findings:  The physician reviewer found that: in medical literature, Tervaert and colleagues state that, autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. There is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. Balk and colleagues noted that, the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues found that following scientific validation of their safety, silicone implants have re-gained widespread acceptance for clinical use. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. This patient presents with generalized complaints, which have not been shown to be associated with the presence of silicone gel implants. Based on the medical information received for review, a procedure to remove breast implants  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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness. Moreover, the patient is extremely insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range. 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 board certified in internal medicine with subspecialty certification in diabetes, endocrinology 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: The patient was diagnosed with right shoulder osteoarthritis, right shoulder impingement syndrome, right shoulder pain, and right shoulder incomplete rotator cuff tear or rupture. The records noted that the patient received a right shoulder subacromial injection, which did not provide significant pain relief. Her prior treatment included physical therapy and medications, including meloxicam and cyclobenzaprine. The patients provider noted a magnetic resonance arthrogram of the right shoulder showed moderate acromioclavicular arthrosis, rotator cuff tendinosis, and a high grade partial tear of the supraspinatus. The patient has requested reimbursement for right shoulder arthroscopy with rotator cuff repair, subacromial decompression, and distal clavicle excision that was performed. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether right shoulder arthroscopy with rotator cuff repair, subacromial decompression, and distal clavicle excision that was performed were medically necessary for the treatment of the patients medical condition. Studies reported that if conservative management fails, surgical procedures are suggested, including arthroscopic debridement of the tear, debridement with acromioplasty, rotator cuff repair with or without acromioplasty, tear completion and repair, and transtendon procedure. The medical evidence supports the services at issue in this clinical setting. In this patients case, the records noted that the patient had adequate conservative measures for shoulder pain. The clinical notes documented that her prior treatment included physical therapy and injection therapy. The criteria for surgery was met, and the services at issue were medically indicated. Therefore, right shoulder arthroscopy with rotator cuff repair, subacromial decompression, and distal clavicle excision that was performed was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee has requested reimbursement  for wilderness therapy services. The enrollee has major depressive disorder and anxiety. She has a history of self-harm, suicidal ideation, and suicide attempts. The medical literature  recommends the least restrictive setting for treatment that will address the patients safety and promote improvement in the patients condition. Consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning must be given. The optimal treatment setting and the enrollees likelihood of benefit from a different level of care should be re-evaluated on an ongoing basis throughout the course of treatment. Review of the records indicates the enrollee had committed serious acts of self-harm prior to the partial hospital program. However, there is insufficient evidence in the records to support the requested treatment. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.