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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor (CGM). CGM detects glucose variations, time in glycemic target, and time in hypoglycemia. These metrics have been shown to enhance a patients self-management of diabetes. In a study by Ida and colleagues aimed to investigate the effects of CGM devices in patients with type 2 diabetes mellitus, the authors found that the CGM group exhibited significantly lower HbA1c levels and spent less time with hypoglycemia. This patients records indicate that he has a diagnosis of diabetes of recent onset. However, there is a lack of documentation of a thorough evaluation and discussion on the goals of therapy with his primary care provider or nutritionist. According to the American Diabetes Association, a comprehensive medical evaluation includes initial and follow-up evaluations, assessment of complications, psychosocial assessment, management of comorbid conditions, and engagement of the patient throughout the process. In the absence of this documentation, a CGM is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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 has requested authorization and coverage for nitazoxanide twice daily for a therapy duration of 14 days. The documentation and current medical literature support the requested 14-day course. The risk of damaging a transplant with inadequate treatment supports the medical necessity of the prolonged course of therapy. Researchers found that a delay in treatment in a solid organ transplant patient may result in serious complications including acute renal failure. The authors concluded that, therapy with nitazoxanide (at least 14 days) may facilitate recovery. For these reasons, nitazoxanide twice daily for a therapy duration of 14 days is medically necessary for 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 subspecialty certification in nephrology 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 patients parent has requested authorization and coverage for immune globulin. The provider reports that this patient has a history of recurrent pneumonia in the context of poor response to pneumococcal vaccination. The patient has responded well to treatment with immunoglobulin replacement therapy . After stopping this therapy, he received Pneumovax, and had post vaccination antibody titers, which does not meet the accepted criteria of at least 70% titers. Therefore, the requested immune globulin is medically necessary for 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 subspecialty certification in allergy and immunology 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 the medication Epidiolex.The medical literature supports that the requested medication is medically necessary. Epidiolex is a pharmaceutical formulation of highly purified cannabidiol (CBD) in oral solution, 100 mg/ml, usually administered at 2-10 mg/kg/day. Silvestro and colleagues have explained that CBD is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. They have stated that this compound has shown efficacy as an anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic medication. The compounds neuroprotective activity appears linked to its excellent anti-inflammatory and antioxidant properties. A study has found that the results of scientific studies obtained so far for the use of CBD in clinical applications could represent hope for patients who are resistant to all conventional anti-epileptic drugs. Epidiolex has been demonstrated to be an effective long-term treatment option in Lennox Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and it is approved by the U.S. Food and Drug Administration (FDA) for those conditions. The pharmaceutical company which manufactures Epidiolex obtained FDA approval for the drug's use in Lennox Gastaut syndrome and Dravet syndrome, both of which are conditions eligible for the orphan drug pathway because this enabled them to bring the medication to market with fewer phase 3 pivotal efficacy randomized controlled clinical trials. Epidiolex does not have biological specificity for these two conditions, however, and medical literature has noted that open-label studies with 100 mg/ml CBD (Epidiolex) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of treatment resistant epilepsies.In this case, the patient has medically refractory epilepsy. She has been evaluated with video EEG telemetry at a major tertiary epilepsy center, and no surgically treatable lesion was found. She continues to have 1-2 prolonged generalized tonic seizures per week during sleep. This puts her at high risk for sudden unexpected death in epilepsy (SUDEP). As noted above, the medical literature supports the use of Epidiolex in patients with a spectrum of treatment resistant epilepsies. Accordingly, the medication Epidiolex is medically necessary for the patients 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 pediatrics, neurology, and neurology with special qualification in child neurology, and is actively practicing. The reviewer is an expert.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). This patient has a history of prostate cancer and a rising prostate specific antigen (PSA). Treatment has included radiation therapy and brachytherapy. A computed tomography (CT) scan revealed no evidence of metastasis. Biopsies demonstrated local recurrence. His provider has recommended treatment with HIFU. The National Comprehensive Cancer Network (NCCN) guidelines support HIFU for treatment of patients with radio recurrent prostate cancer. In addition, one recent study reported that treatment with HIFU has comparable outcomes to modalities such as surgery and cryotherapy with an acceptable side effect profile. Given this support, HIFU is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  The physician reviewer found that Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 31-year-old male who has been diagnosed with sprain of ligaments of cervical spine, strain of muscle, fascia, and tendon at neck level, cervicalgia, sprain of ligaments of lumbar spine, strain of muscle, fascia, and tendon of lower back, low back pain, sprain of ligaments of thoracic spine, strain of muscle and tendon of back wall of thorax, strain of muscle, fascia and tendon of pelvis, unspecified sprain of right shoulder joint, strain of muscle and tendon of the rotator cuff, left shoulder joint sprain, strain of muscles and tendons of the left rotator cuff, and headache. On 10/18/18, the provider noted the patient was injured in a car accident on 10/17/18. He complained of headaches, and pain in the neck, bilateral shoulders, mid-back, and low back. Physical examination findings on 10/18/18, included muscle spasm in the cervical, thoracic, and lumbar areas. Range of motion was decreased in the cervical, thoracic, and lumbar spine with pain. Strength was noted to be normal in the cervical spinal muscles, lumbar spinal muscles, upper extremities, and lower extremities. The patient received manual therapy and electrical muscle stimulation on this date. On 10/24/18 and 11/17/18, the patient received manual therapy, electrical muscle stimulation, and chiropractic adjustment. On 2/2/19, the patient reported improvement in his condition, although he continued to have symptoms. The patient received manual therapy, electrical muscle stimulation, and chiropractic adjustment on this date. There is no documentation of other treatments that were tried and failed. The patient has requested reimbursement for chiropractic services that were provided from 10/18/18 through 2/2/19. 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 chiropractic services that were provided from 10/18/18 through 2/2/19 were medically necessary for the treatment of the patients medical condition. A study by Leaver and colleagues reported that there is no evidence to suggest that manipulation is more effective in the treatment of acute and subacute neck pain than mobilization.The physician reviewer found  that neck manipulation did not provide more rapid recovery from an episode of neck pain or better outcomes in terms of pain, disability, function, or global effect than mobilization. Casazza reported that exercises directed by a physical therapist may decrease recurrent pain and the need for health care services. Casazza noted that spinal manipulation and chiropractic techniques are no more effective than established medical treatments, and adding them to established treatments does not improve outcomes. In this case, the patients complete medical history was not noted. The chiropractic treatment reports did not include full physical examination findings.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for genetic testing to determine if he has a form of trisomy 8. Since 2010, chromosomal microarray (CMA) has been recognized as standard of care for assessment of individuals with neurodevelopmental disorders, including autism spectrum disorders and intellectual disability. While the specific test requested to identify potential mosaic trisomy 8 is not described in the provided records, CMA would be the recommended and the most sensitive test to evaluate for this and other potential genetic causes of this patients neuropsychiatric concerns. More recently, it has been recognized that genetic diagnoses identified in those with neurodevelopmental disorders by CMA can impact recommended management. An enrollee has requested authorization and coverage for genetic testing to determine if he has a form of trisomy 8. Since 2010, chromosomal microarray (CMA) has been recognized as standard of care for assessment of individuals with neurodevelopmental disorders, including autism spectrum disorders and intellectual disability. While the specific test requested to identify potential mosaic trisomy 8 is not described in the provided records, CMA would be the recommended and the most sensitive test to evaluate for this and other potential genetic causes of this patients neuropsychiatric concerns. More recently, it has been recognized that genetic diagnoses identified in those with neurodevelopmental disorders by CMA can impact recommended management. Henderson and colleagues found that positive (abnormal) results of CMA had management implications for more than half of patients (54.5%), including in 42.1% of those with isolated neurodevelopmental disorders. The medical evidence supports genetic testing in this clinical setting. Therefore, genetic testing to determine if the patient has a form of trisomy 8 is medically necessary. found that positive (abnormal) results of CMA had management implications for more than half of patients (54.5%), including in 42.1% of those with isolated neurodevelopmental disorders. The medical evidence supports genetic testing in this clinical setting. Therefore, genetic testing to determine if the patient has a form of trisomy 8 is medically necessary.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual mental health therapy sessions, twice a month. With regard to first-line therapies for moderate major depressive disorder, researchers report that data supports use of antidepressant monotherapy, psychotherapy, and the combination of both. With worsening anxiety and depression symptoms, increasing the frequency of this patients psychotherapy while continuing in medication management is consistent with these current treatment recommendations. The records provided for review document major depressive disorder and anxiety despite treatment with multiple therapeutic agents. Specifically, the patients symptoms did not substantially improve with fluoxetine, escitalopram, or trazodone. Given the support in the medical literature, individual mental health therapy sessions, twice a month, 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 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

The patient was diagnosed with osteoarthritis (OA) of the left knee, left knee joint pain, and left knee chondromalacia. The provider noted the patient underwent left knee arthroscopy. He previously had been treated with left knee corticosteroid injections. The patient reported left knee pain, difficulty bearing weight, and difficulty ambulating. Physical examination findings revealed that left knee range of motion was 5 to 120 degrees with pain and crepitus. The patients recorded weight was 270 pounds with a body mass index (BMI) of 34.67. The records document that his prior treatment included physical therapy and medications, including meloxicam, tramadol, and hydrocodone-acetaminophen. The patient requested authorization and coverage for Euflexxa injections for the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. Researchers reported that intra-articular hyaluronic acid (IAHA) injections provide a symptomatic benefit for patients with knee osteoarthritis without major safety concerns. IAHA offers one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections for the left knee 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for pantoprazole 40 mg tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether pantoprazole 40 mg tablets are medically necessary for the treatment of the patients medical condition.Studies show PPIs are effective for the treatment of gastric erosions and ulcers. Despite concerns regarding the long-term safety of PPIs, the risk-benefit profiles strongly favor the use of PPIs in select patients. A PPI is recommended for patients that fail therapy or are Helicobacter pylori negative. In this case, the patient endorsed abdominal pain and was found to have gastric erosions during endoscopy. The medical evidence supports the requested medication in this clinical setting. Therefore, pantoprazole 40 mg tablets are 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: An enrollee has requested authorization and coverage for hyaluronan intra-articular injections. The medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current medical evidence does not support viscosupplementation as a standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited.  In this case, the records document a history of lasting benefit from prior viscosupplementation. Furthermore, his options are limited. The patient has tried and failed other conservative treatment, and the alternative option is a total knee arthroplasty. Therefore, hyaluronan intra-articular 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.