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 hyaluronan injections. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient presents with significant chronic bilateral knee pain. Functional limitations are noted in walking tolerance due to knee pain. Clinical examination findings are consistent with x-ray evidence of bilateral knee medial compartment osteoarthritis. Reasonable conservative treatment, including medications, activity modification, and exercise, have failed to provide adequate symptom relief. She has undergone two previous series of Hyalgan injections for the right knee, with pain reduction and functional improvement documented for at least six months. She desires to delay total knee replacement surgery. Evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, hyaluronan injections 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 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: At issue in this case is whether the requested clonazepam is medically necessary for treatment of the patients medical condition. A review of the records provided showed that the treating provider recommended tapering clonazepam by 25% every two to three months, and the patient was started on a trial of gabapentin 100mg three times a day for anxiety. The patient was undergoing supportive therapy and cognitive behavioral training as well as psychoeducation regarding the psychotropic medications. The patient was given relaxation therapy and was placed on Belsomra for insomnia. As noted in current medical literature, benzodiazepines are no longer considered to be first-line therapies because of the risks associated with chronic use. Given this concern for side effects, antiepileptic agents have been used more extensively for the treatment of anxiety. A review of the literature shows gabapentin to be an effective alternative for the treatment of anxiety. This patient was started on gabapentin, which has been shown to be safe and effective in the treatment of anxiety. The additional use of clonazepam is not indicated. Based on review of the records presented, clonazepam 1mg tablets is not supported as medically necessary for the treatment of this patients behavioral health condition.Final Result: The reviewer determined that the requested services 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient is requesting authorization and coverage of custom orthotics.Findings:  The physician reviewer found that as noted in current medical literature, the most significant and effective conservative treatment for hallux rigidus is the use of orthotic therapy. A study concluded that the most effective conservative treatment for hallux rigidus is the use of orthotic therapy in appropriately selected patients. Orthotics are utilized to control the biomechanics at the first MPJ, alleviating significant pressure and stress to this joint. This reduction in pressure and stress allows for pain reduction.The records document that this patient has been diagnosed with hallux rigidus, which has been controlled with the use of custom orthotics. During a medical visit, the provider noted that the patients current custom orthotics have worn down. The provider ordered custom orthotics to continue to control the patients pain related to hallux rigidus.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified podiatrist 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: This patient is a male with a diagnosis of chronic plaque psoriasis. This patient has failed first-line therapies with high potency topical steroids. The provider reported treatment with apremilast (Otezla) had shown good therapeutic effect in the past for this patient. Other injectable biologics and cytotoxic drugs have been avoided due to their immunosuppressive properties and potential side effects.At issue in this case is whether the requested Otezla is medically necessary for treatment of the patients medical condition. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently avoided because of renal, hepatic, and pulmonary toxicity and limited efficacy. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events. Otezla is U.S. Food and Drug Administration approved for the treatment of plaque psoriasis. In a study by Bissonnette and colleagues, Otezla was studied in more than 4,000 patients, and the safety profile was consistent across indications. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. He has failed treatment with high potency topical steroids, methotrexate and Humira. The patient has already been successfully treated with Otezla. Therefore, Otezla is medically necessary for treatment of the patients medical condition.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 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the fecal calprotectin test (CPT Code 83993) received on 12/20/18. The Health Plan has denied the testing at issue as investigational. The patient presented for an evaluation on 12/19/18, secondary to a diagnosis of Crohns disease. The provider noted that previous treatments have included prednisone, Remicade, Humira, Pentasa, and Simponi. On that date, the provider indicated she has been stable on Stelara every six weeks, for at least three months, with a last injection on 10/26/18. The patients current complaints included distension, reflux pain, and loose bowel movements approximately two to three times daily. The fecal calprotectin test was ordered and reported as normal.Findings:  Two out of three reviewers found that various studies have found that fecal calprotectin correlates with endoscopic findings of inflammation and serum markers of inflammation in Crohns disease.  Further studies have found that fecal calprotectin is useful to assess disease activity in Crohns disease . The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease recommend fecal calprotectin to assess disease activity in patients with Crohns disease. Additionally, the most recent American College of Gastroenterology guidelines for the management of Crohns disease supports the use of fecal calprotectin testing in the assessment of Crohns disease activity.  Final Result: The reviewers determined that the requested test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with a subspecialty 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

An enrollee has requested authorization and coverage for oxygen therapy. Indications for continuous long-term oxygen therapy include resting arterial oxygen tension less than or equal to 55 mmHg, a pulse oxygen saturation less than or equal to 88%, cor pulmonale, right heart failure, or erythrocytosis. In this case, the patient does not qualify for long-term oxygen therapy. His chest x-ray, spirometry and arterial blood gases were normal, which rule out any significant lung disease. Therefore, the requested oxygen therapy is not medically necessary.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 subspecialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with multiple sclerosis (MS). The medical records indicate ongoing and worsening function of the left lower extremity despite treatment with Avonex, Tysabri, Aubagio, and high dose steroids. The patients gait showed an increase in the muscle spasms and spasticity in the left side. There is weakness in the lower extremity and he requires the use of a cane and/or walker for ambulation. On 10/9/18, the provider noted the Bioness GO FES is indicated to help prevent falls. Without the device, the enrollee is must stop every two to three steps. Findings:  Three physician reviewers found that according to the available evidence, the Bioness GO functional electrical stimulator (FES) is not superior to standard available treatment modalities in this clinical setting. Two large randomized trials have shown improved patient satisfaction with FES. However, the authors reported that no significant difference was observed between FES and a standard ankle foot orthosis (AFO). A small randomized trial examining neuromuscular stimulation for footdrop in patients with multiple sclerosis revealed in the area of walking speed failed to demonstrate a clinically significant benefit to the neuromuscular stimulation over an exercise class (Esnouf, et al). In addition, Prenton and colleagues performed a meta-analysis of five randomized controlled trials which included over 800 patients comparing AFO to FES. The researchers concluded that AFOs have equally positive combined-orthotic effects as FES on key walking measures for foot drop. Given these findings, the Bioness GO FES device is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested device was not likely to be more beneficial for evaluation 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Case Summary: A patient who was diagnosed with an unresectable Stage 2 perihilar cholangiocarcinoma, bile duct cancer. The treatment discussed includes possible chemotherapy with radiation and evaluation for liver transplant. The patient began evaluation for egg preservation and underwent in vitro fertilization, specifically ovarian preservation in which seven mature oocytes were successfully retrieved and stored. MD Analysis:  At issue in this case is whether the fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) is medically necessary for treatment of this patient.According to the American Society of Reproductive Medicine (ASRM), egg retrieval and egg and/or embryo freezing (cryopreservation) is now a recognized option for women with cancer who are undergoing treatment that can be toxic to their ovaries and eggs, which can render them infertile. This option allows them to have children in the future. Although, they are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of chemotherapy. As noted in literature, treatment of malignancy...may necessitate surgical resection of reproductive organs or administration of gonadotoxic chemotherapy or radiation therapy. This often leads to infertility, which is a major quality of life concern. Researchers concluded, Cryopreservation of embryos is a proven effective technique for preserving reproductive capacity. In addition, researchers noted that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting, Sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice. Given this support, the fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) is medically necessary for treatment of this 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 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: a 57-year-old female with diagnoses of menopausal and female climacteric states, and hypothyroidism. Findings:  The physician reviewer found that the patient has a family history of ovarian and breast cancers. The patient had a pelvic ultrasound in 2015, which revealed an intact uterus and intact ovaries. Her most recent thyroid stimulating hormone (TSH) was performed in December 2018, and was suppressed at 0.02. The treatment plan included levothyroxine 125mcg daily and Cytomel 25mcg daily. Additional medications have included T4/T3, estrogen, progesterone, dehydroepiandrosterone (DHEA), testosterone, and growth hormone therapies. She underwent laboratory testing in March 2018 to monitor the hormones estrogen, progesterone, TSH, free T3 and T4, DHEA, as well as vitamin and nutrient levelsThe Endocrine Society guideline does not support DHEA replacement therapy for this patient since use of DHEA sulfate is not recommended by the Endocrine Society guidelines. In addition, testosterone replacement therapies in post-menopausal women are not approved by the U.S. Food and Drug Administration (FDA) because of limited clinical trial data demonstrating improved efficacy compared with placebo, and due to concerns about long-term safety. Further, the Endocrine Society does not recommend the general use of testosterone other than for hypoactive sexual desire disorder. There is no current indication for vitamin and nutrient level testing, as there is no report of vitamin deficiencies. The patient has a diagnosis of post-surgical hypothyroidism (E03.9). Thus, thyroid function tests need to be performed to monitor the patient while she remains on T4/T3 supplementation (Jonklaas, et al). Given this support, thyroid function tests are medically necessary for the patients diagnosis of hypothyroidism E03.9 (TSH, free T3 and T4). However, laboratory tests to monitor hormone levels in the blood: N95.1 (estrogen and progesterone), R53.83/E27.40 (DHEA-S), and E63.8 (nutrient levels), are not medically necessary. Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld for N95.1 (estrogen and progesterone), R53.83/E27.40 (DHEA-S), and E63.8 (nutrient levels). The Health Plans denial should be overturned for E03.9 (TSH, free T3 and T4).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. This patients records do not support the medical necessity of RTC services. This patient presents with some risk of harm (score 2) as the medical records indicate that the patient has not been actively suicidal and has not engaged in self-harm, but has a history of suicidal ideation. The patient demonstrated moderate functional impairment (score 3). While at home, the patient was noted to run away from home, abuse substances. However, while in treatment, the patient has demonstrated appropriate daily functioning as evidenced by intact activities of daily living and cooperation with his providers. The patient has some co-morbidity (score 2) given his recent substance abuse but no reported medical issues. The patients recovery environment is mildly stressful (score 2) as he is noted to have good relationship with his family and he denied stress at home of any significant nature. Overall, the patients recovery environment is supportive (score 2) as his parents are involved in his treatment. Further, although the patient reportedly demonstrated limited response to prior treatment (score 3), he has positively responded to the services and medications provided during this admission. Specifically, the patient has not exhibited significant mood or anxiety symptoms. The records suggest that any acute symptoms the patient demonstrated on admission have been resolved. The providers report that the patient has responded well to psychotropic medications and he has made progress in family therapy as well. The treatment progress notes did not indicate severe behavioral issues or any violent outbursts. The patient has been constructive in treatment (score 2) with documented active participation, and his parents have also worked well with the patients providers (score 2). This gives the patients presentation a composite score of 18, which correlates with intensive outpatient services. Thus, the patient was a candidate for treatment in a less restrictive setting. All told, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues. 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 psychiatry with subspecialty certification 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 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 private duty nursing in the home. This patients records demonstrate that she is stable, receiving feeding and routine catheter care. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines for SNF services, non-skilled person can reasonably provide this patients daily care. The patients daughter is providing adequate 24-hour custodial care. The providers note indicates there is no change in the patients condition and she does not have current skilled nursing needs. All told, the requested private duty nursing in the home is not supported as medically necessary for treatment of this patients medical condition. 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 internal medicine with expertise in skilled nursing facilities 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.