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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Forteo.The submitted documentation does not support that the requested medication is medically necessary. Authors state that in patients with newly diagnosed osteoporosis, suggested laboratory tests to identify secondary causes include serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone. They state that first-line treatment to prevent fractures consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy. Raloxifene, teriparatide, and denosumab are alternative effective treatments for certain subsets of patients and for those who are unable to take or whose condition does not respond to bisphosphonates. In this case, while the patient has low bone mass based on Z score and a history of tibial fracture under unknown circumstances, she has not tried and failed first-line therapy for her osteoporosis which includes oral or IV bisphosphonates. In addition, the submitted documentation does not identify any definitive contraindication to oral or IV bisphosphonates. Under these circumstances, the requested medication Forteo is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested reimbursement for orthoptic training sessions and prospective authorization and coverage for sixteen (16) future weekly sessions, including progress examinations administered after every eight (8) training sessions. The patient has been diagnosed with binocular dysfunction, convergence excess, convergence insufficiency, pursuit dysfunction, and saccade dysfunction. The patient was noted to have midline crossing problems and difficulty with concentration. The patient was noted to have scored below average in eye movement testing. The patients ability to visually track a moving target was noted to be inaccurate and inefficient. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with convergence insufficiency. In this case, the requested in-office treatment program does not correlate with studied protocols in the literature. The patient has multiple diagnoses, including binocular dysfunction, convergence excess, convergence insufficiency, pursuit dysfunction, and saccade dysfunction. The medical evidence does not support the requested services in this clinical setting. Therefore, orthoptic training sessions and sixteen (16) future weekly sessions, including progress examinations administered after every eight (8) training sessions were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 ophthalmology 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 patients parent has requested authorization and coverage for intensive in-home feeding therapy including an in-home feeding therapy evaluation. Feeding problems are common in childhood, and may be severe enough to result in failure to thrive, growth failure, and chronic illness. The least restrictive environment for such an approach is in the home, where the provider can directly address the patients behavioral and psychosocial issues. This patient with autism has extremely limited food repertoire and is dependent on infant formula to meet his nutritional needs. The nutritional balance in infant formula is not appropriate for a toddler, but the patient has refused PediaSure. After a thorough work-up, his providers recommended an intensive home-based feeding program to normalize his feeding behaviors and assure appropriate nutrition. This patients health and further development are dependent on this feeding therapy. Given these findings, the requested intensive in-home feeding therapy including an in-home feeding therapy evaluation 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 pediatrics with subspecialty certification in pediatric critical care 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 has requested reimbursement for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with medically monitored community based services, such IOP level of care services. Based on LOCUS, IOP programs last approximately three months in duration. The additional two weeks for this patient was within the standard of care. Accordingly, the IOP services 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 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 has requested reimbursement for knee and debridement/shaving of articular cartilage (chondroplasty), same or separate compartment. Researchers performed a systematic review of the role for arthroscopic meniscectomy in knees with degenerative changes. The authors reported that two randomized controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. The authors concluded that patients with symptomatic meniscal tears and degenerative changes in the knee might benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. This patient sustained a left knee injury. He felt a left knee pop with immediate onset of medial joint line pain. His symptoms were reported as constant with functional limitations in ambulation. Conservative treatment included ice, activity modification, medications, and compression with inadequate symptom improvement. Clinical examination findings were consistent with reported imaging evidence of a medial meniscus tear. He underwent left knee arthroscopy with partial medial meniscectomy and medial femoral condyle chondroplasty. The operative report noted the presence of extensive complex tearing of the posterior horn of the medial meniscus and grade 2 medial femoral condyle chondromalacia. Current evidence based medical literature supports the surgery at issue for treatment of this patients acute injury, complex medial meniscus tear, and failed conservative treatment. Therefore, the knee surgery and debridement/shaving of articular cartilage (chondroplasty), same or separate compartment, 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 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

The patient has requested authorization and coverage for Gammagard home infusions. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain. The records provided for review document that this patients symptoms and history are consistent with small fiber polyneuropathy. Further work-up has been suggestive of an autoimmune etiology. Based on the medical literature, the requested Gammagard infusions are medically necessary for treatment of this patient. Moreover, administering infusions at home is within the standard of care. Given these findings, the requested Gammagard home infusions 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with argininosuccinate lyase deficiency (ASLD). In the application for independent medical review, the parent reported that the patient has a family history of severe life threatening ASLD. The patient was noted to be doing well overall. The patient was being provided a low protein diet. The patients parent has requested authorization and coverage for Buphenyl. 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 Buphenyl is medically necessary for the treatment of the patients medical condition. Summar and colleagues reported, The urea cycle disorders are a group of inherited biochemical diseases caused by a complete or partial deficiency of any one of the enzymes or transport proteins required to convert toxic ammonia into urea and to produce arginine and citrulline. The clinical manifestations of these disorders are mostly the result of acute or chronic hyperammonemia, which affects the central nervous system. Affected individuals can also develop hepatic dysfunction. These disorders can present at any age from the immediate newborn to later in life. The Canadian Agency for Drugs and Technologies reported, Results from three short-term, non-randomized controlled studies suggested that glycerol phenylbutyrate (Ravicti) has similar effect in lowering ammonia levels in patients (adults or children) with urea cycle disorders when compared with sodium phenylbutyrate (Buphenyl). The risk of adverse events was similar between glycerol phenylbutyrate and sodium phenylbutyrate during the one-week to two-week treatment periods, and the majority of reported adverse events were mild. In this case, the patient has a family history of severe disease as well as testing positive for ASLD himself. Buphenyl is appropriate for this patient. The medical evidence supports the requested medication in this clinical setting. Therefore, Buphenyl is medically necessary for the 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 pediatrics with sub-specialty certification in pediatric critical care 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: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for future cancer treatments at a medical center with an on-site PICU. American Academy of Pediatrics (AAP) Standards for Pediatric Cancer Centers state that initial diagnostic assessment, induction therapy, and management of complications or recurrences should be provided in a pediatric center that has facilities with an immediately accessible and fully staffed, on-site PICU. The patient has a diagnosis of pre-B cell acute lymphoblastic leukemia, and had a near fatal episode during her induction chemotherapy. The patient developed neutropenic fever and septic shock and was admitted to an in-plan facility. With impending shock, a transfer was initiated. That same day, the patient had two bradycardic arrests requiring cardiopulmonary resuscitation. Fortunately, there was return of circulation, but the transfer itself could have been obviated if the patients initial admission had been at a medical center with an on-site PICU. Given the patients diagnosis and care needs, AAP Standards indicate that the patients future cancer treatments should be provided in a pediatric center that has facilities with an immediately accessible and fully staffed, on-site PICU. Accordingly, it is medically necessary for the patient to receive future cancer treatments at a medical center with an on-site PICU.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in hematology and medical oncology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Nutropin AQ Nuspin. The enrollee has been diagnosed with hypothyroidism due to Hashimotos thyroiditis, osteopenia of the lumbar spine and both hips, and idiopathic short stature (ISS). She takes Synthroid. Her insulin growth factor 1 (IGF1) level was 445. A bone age study reported normal skeletal age for her chronological age. She was 59.2 inches tall and weighs 113 pounds, 12 ounces. The mid-parental target height is 65.9 inches. Her pediatric endocrinologist has recommended growth hormone therapy with Nutropin injections. The pediatric endocrinologist reports growth hormone deficiency is a sub-normal condition, possibly caused by the childs under responsiveness to the growth hormone she is producing, even if the amount she is secreting is clinically normal. Treatment of ISS with growth hormone is supported by randomized controlled trials and consensus guidelines. The Food and Drug Administration approval for this indication is for non-growth hormone-deficient short stature. This is defined by a height standard deviation score less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The patient does not have a pretreatment height less than or equal to -2.25 standard deviations. The patient does not meet idiopathic short stature criteria and the request for Nutropin AQ Nuspin does not meet any nationally accepted criteria for use of growth hormone.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 pediatric endocrinology 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

The enrollee is requesting Imvexxy 10 MCG (estradiol, vaginal insert) for the treatment of postmenopausal thinning of the vaginal walls (atrophic vaginitis). Vaginal moisturizers have not been effective. The patient tried vaginal estradiol tablets and had a reaction and rash to the medication.  Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Use of estrogen therapy is appropriate for women with symptoms of vaginal atrophy in the setting of low estrogen levels, provided that there are no contraindications to this therapy (such as certain women with estrogen-dependent tumors). Adequate estrogen therapy leads to restoration of the normal vaginal acidic pH and microflora, thickening of the epithelium, increased vaginal secretions, and decreased vaginal dryness. The agents for vaginal estrogen therapy that are commercially available in the United States are conjugated estrogens (cream) and estradiol (cream, tablet, and ring). A systematic review of 19 randomized trials including over 4000 women that investigated local estrogen treatment found that creams, tablets, and rings were all similarly effective in relieving symptoms of vaginal atrophy. Therefore, Imvexxy (estradiol), a local estrogen therapy, is no more beneficial than the formulary products and there is no medical exception as supported by current medical literature for the requested medication, Imvexxy.  Final Result: The reviewer found that the requested medication is not medically necessary for the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology and 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 patient has been diagnosed with low back pain with lumbar radiculopathy. The patient reported difficulty ambulating in stores and difficulty completing tasks. Physical examination findings included the patient being able to walk without antalgic gait. Tenderness to palpation was noted over the lower back and paraspinal muscles. An occupational therapist noted that the patient did not require a mobility device in her home or for short distances in the community. The patient did not have a cane, walker or wheelchair. The provider noted that the patient was able to negotiate the stairs multiple times per day. The patient reported that she planned to keep the scooter in her car as her apartment is on the second floor and she does not have an elevator. The patient reported that she is taking an extended trip to Europe and needs a power operated vehicle. The provider noted that the patient does not have any intent or need to power operated vehicle for instrumental activity of daily living tasks, only community needs. The patient has requested authorization and coverage for a motor scooter for use in or outside the home. The Health Plan denied the request and reported that the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a motor scooter for use in or outside the home is medically necessary for the treatment of the patients medical condition. Researchers reported, Recent research including meta-analyses have clearly underlined the negative impact of seated occupational activities on overall mortality. In this case, there were no indications that the patient has mobility limitations that cause her to be unable to perform activities of daily living. Physical examination findings do not demonstrate significant neurological deficits or gait abnormalities. The provider noted that the patient was able to negotiate stairs multiple times daily. There is no documentation that the patient has undergone a trial with a power mobility device, indicating she can safely navigate a power mobility device. The medical evidence does not support the requested equipment in this clinical setting. Therefore, a motor scooter for use in or outside the home 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.