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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for brief hospital stay for inpatient electroencephalography (EEG). Findings:  The physician reviewer found that records document that this patient has a history of global developmental delay, with regression. She meets criteria for autism spectrum disorder. She also has a history of staring spells, concerning for seizures. The patient underwent evaluation with inpatient video EEG telemetry to, in order to capture the EEG during sleep and the staring spells for differential diagnosis. Capturing this patients staring episodes on video EEG for differential diagnosis and to direct appropriate treatment was appropriate to determine whether treatment with medication was indicated. Arican and colleagues noted that, electrical status epilepticus during slow-wave sleep (ESES) is an epilepsy syndrome with sleep-induced epileptic discharges and acquired impairment of cognition or behavior. The authors report that, The early diagnosis of this syndrome is essential since there is a significant correlation between permanent cognitive impairment and delayed diagnosis. Bennett-Back and colleagues described the results of video EEG telemetry in 323 children with paroxysmal events of unclear etiology. The authors found that the results of the study had a role in changing the diagnosis in 53% of patients in the study. A prospective study by Romero-Gonzalez and colleagues of 69 preschool aged children with autism spectrum disorder found that 42% had abnormalities in their EEG results. All told, the brief hospital stay for inpatient EEG was medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 in neurology with special qualification in child neurology and expertise in neurodevelopmental disabilities 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 the injectable medication Durolane to the right 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 has tried and failed other conservative treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), intraarticular corticosteroid injections, and bracing. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, the injectable medication Durolane to the right knee is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a portable oxygen concentrator. Medical literatures report that portable oxygen concentrators may be associated with better mobility for patients who are ambulatory. Khor and colleagues report comparable performance when walking between portable oxygen concentrators and traditional portable systems such as compressed oxygen cylinders. In this case, the patient is wheelchair bound and the records do not document that the patient is ambulatory. In this clinical setting, given that the current delivery system of supplemental oxygen from portable tanks is sufficient for patients who are wheelchair bound, the requested equipment is not medically indicated. Therefore, a portable oxygen concentrator is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary diseases and in sleep 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 HP Acthar Gel 80 unit/ml. The submitted documentation fails to demonstrate the medical necessity of the requested medication. Although corticosteroids are used as a first-line therapy for the treatment of polymyositis, these medications can have various side effects, including osteoporosis. There are standard steroid sparing treatments for polymyositis, including methotrexate and CellCept as well as azathioprine, calcineurin inhibitors, intravenous immune globulin (IVIG) and rituximab. Furthermore, physical therapy is an important part of the polymyositis treatment plan.In this case, the patient has osteoporosis related to steroid use and does need to utilize corticosteroid sparing therapy for the treatment of her osteoporosis. She has previously been treated with methotrexate and then CellCept for her polymyositis. The medical records indicate that the patient is using CellCept 500 mg, one tablet, twice daily, which is a low dose that can be further optimized to achieve control of the disease. In addition, the patient has not utilized other usual therapies for polymyositis, such as azathioprine, calcineurin inhibitors, IVIG or rituximab. Also, the medical records do not indicate that the patient is participating in regular physical therapy. Therefore, Acthar Gel 80 unit/ml is not medically necessary for the treatment of the patients polymyositis.Final Result: The reviewer determined that the requested medication 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 a sub-specialty certification in rheumatology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic nervous system function testing. Findings:  The physician reviewer found that Autonomic nervous system dysfunction may present with a myriad of symptoms including orthostatic intolerance, recurrent syncope, labile blood pressure, disorders of sweating and thermoregulation, neurogenic bladder, sexual dysfunction, gastrointestinal dysmotility, pupil abnormalities, and sleep disorders. These symptoms may be a consequence of genetic, neurodegenerative, autoimmune, or acquired disorders. Although autonomic symptoms may be among the most debilitating features of these progressive conditions, they are often treatable. According to the American Academy of Neurology (AAN), autonomic function tests are safe, noninvasive, and have an extremely high value-to-risk ratio. Postural tachycardia syndrome (POTS) is a clinical condition in which patients experience chronic symptoms of orthostatic intolerance. Head-up tilt (HUT) testing allows the laboratory to diagnose a patient with orthostatic hypotension. Autonomic laboratory testing is essential to make the diagnosis of POTS. In this case, the patient presented with symptoms suggestive of autonomic nervous system dysfunction. The patient underwent autonomic nerve function testing that revealed evidence of POTS. The patients treatment planning was initiated based on the POTS diagnosis. Based on the current medical literature, autonomic testing is safe, noninvasive, and appropriate for accurate diagnosis of this patients underlying autonomic system dysfunction and subsequent treatment of debilitating autonomic symptoms. For these reasons, autonomic nervous system function testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with subspecialty certification in vascular neurology and is 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: The patient has requested authorization and coverage for Xifaxan. Findings: There is sufficient support for the requested medication in this clinical setting. Studies have shown Xifaxan to be highly effective for the eradication of bacteria and symptom relief for small intestinal bacterial overgrowth. Results are sustained for several weeks after treatment. The provider has recommended Xifaxan tablets, three times daily for 14 days, which is consistent with regimens used in these studies. In this case, there is documentation of symptoms and testing consistent with small intestinal bacterial overgrowth. Therefore, the requested Xifaxan 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory service (infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, bacterial vaginosis associated bacteria-2 (BVAB-2), and Lactobacillus species). Workowski and colleagues report that guidelines for sexually transmitted infection (STI) screening include female patients over age 25 with a sex partner with concurrent partners. The guidelines do not specify the method of testing recommended. In this case, notes reported that the patient requested screening for STIs due to concern regarding possible exposure from a recent partner. Given that the service at issue included laboratory testing containing components necessary for appropriate STI screening, it was likely to be more beneficial for the evaluation of the patient than not screening for STIs. Therefore, laboratory service (infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, bacterial vaginosis associated bacteria-2 (BVAB-2), and Lactobacillus species) was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory service (infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, bacterial vaginosis associated bacteria-2 (BVAB-2), and Lactobacillus species) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment 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 obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myPath Melanoma gene expression profile test. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. There are some lesions that are considered challenging from a histopathological viewpoint. However, there is a lack of data in the peer-reviewed medical literature demonstrating improved patient health outcomes with use of the myPath Melanoma testing for evaluation and treatment planning purposes as compared to standard testing and assessment. The records provided for review document that this patient presented with neoplasm of uncertain behavior of skin. A pathology report demonstrated moderate atypical compound melanocytic nevus, lesional cells involving the peripheral biopsy margin. A sample was submitted for analysis with myPath Melanoma gene expression profile. On review of the current medical literature and guidelines, there is a lack of support for the myPath test for evaluation of this patient. Accordingly, the myPath Melanoma gene expression profile test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in hematology and medical oncology and is 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: The patient has requested reimbursement for monitored anesthesia care (MAC) services provided during a colonoscopy. The records provided for review indicate that this patient presented to their provider for a routine colonoscopy. The patients records include documentation of obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD). Preoperatively, the patient was given an ASA classification score of 2. As noted by the American Society for Gastrointestinal Endoscopy (ASGE), the presence of OSA represents a risk for difficulty with moderate sedation (Early, et al.). The ASGE further noted that anesthesia provider-administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. Per the ASGE, the medical conditions which represent clinical risk include potentially difficult airway and airway anatomy associated with difficult intubation. Given this patients ASA score of 2 and diagnosis of OSA, the use of MAC services during evaluation with colonoscopy were appropriate and consistent with ASGE recommendations. Therefore, the MAC services provided during a colonoscopy were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 in anesthesiology with subspecialty 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: The patient has requested reimbursement for monitored anesthesia care provided during a colonoscopy. According to the American Society of Anesthesiologists (ASA) guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care may be considered for prolonged or painful procedures. These may include procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. The guidelines further note that monitored anesthesia care may be considered for patients with previously anticipated intolerance to standard sedatives, psychological impediments to cooperation, ASA class of IV or V, or who are at risk for airway obstruction due to anatomic variant. Monitored care anesthesia may also be used for prolonged procedures requiring deep sedation. According to American Society for Gastrointestinal Endoscopy (ASGE) practice guidelines, consciousness during endoscopic procedures, unlike in surgery, is acceptable and is the goal during most procedures. In this case, despite being requested, the submitted records did not document that the patient met these criteria or other criteria found in current medical literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater 70 years, pregnancy, increased aspiration risk, ASA class three or higher, or morbid obesity. Therefore, monitored anesthesia care provided during a colonoscopy 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 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 Euflexxa injection series (one time per week for three weeks). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of benefitting from treatment with viscosupplementation with Euflexxa injections of both knees consistently for the last several years. The hyaluronan injections reportedly provided the patient was excellent pain relief and improved function, which lasted 5.5 months. Thus, the patient is a good candidate for additional viscosupplementation of both knees. Given these findings, the requested Euflexxa injection series (one time per week for three weeks) in both knees is 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 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.