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

Nature of Statutory Criteria/ Case Summary: This is a patient with wide spread chronic pain and Ehlers Danlos Syndrome (EDS). A progress on 3/24/20 from her Pain Management physician reports that with a decrease in Percocet and increase in Methadone dose, her joint pain has decreased to 4/10. At issue is whether the Methadone HCL 5mg tablets (180 tablets/30 day supply), and Methadone HCL 5mg tablets (180 tablets/30 day supply), purchased on March 27, 2020, April 24, 2020 and May 22, 2020, is and was medically necessary to treat the enrollees medical condition. Literature reviewed states that opiates may be used for pain. However, the authors report that there may be significant medical problems with long term use specific to EDS with gastrointestinal issues (such as constipation and nausea), and an increase in the symptoms of mast cell activation syndrome (such as an allergic reaction, bleeding, unstable blood pressure, and multi-organ issues).  Other literature reported that patients with EDS reported that the most helpful methods for managing their pain are opioids, surgical interventions, splints or braces, and heat therapy. The patients medical record reports success with a reduction in her joint pain level with the use of Methadone without any untoward medical issues.  Final Result: The reviewer determined that the requested service was and is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology        and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual counseling. In one study of parents of children with autism spectrum disorder (ASD) diagnoses, Alnazly and Abojedi noted that, ASD has profound impacts on the lives of family members including the roles and responsibilities assumed in caring for individuals with ASD. Caring for children with ASD is associated with a higher incidence of parental stress, anxiety, and depression than caring for children with other developmental and physical disabilities and affects marital relationships and family functioning. In addition to experiencing several economic, physical, social, and psychological burdens, parents of children with ASD often report poor psychological wellbeing. Similarly, the American Psychiatrist Association (APA) noted that the use of quantitative measures can have a number of potential harms. Overreliance on quantitative measures may lead other key elements of the patients symptoms and life circumstances to be overlooked. In this case, the patient requested outpatient psychotherapy to address conflict with her in-laws as well as anxiety associated with caring for two young children, including one with ASD. The patient was evaluated and the provider determined that her test scores did not support an indication for the requested therapy. In addition to providing support for the patients current stressors, regular sessions with a therapist could also prevent further deterioration of her mental health. Given these findings, the requested individual counseling 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 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine (CPT 72156), MRI of the thoracic spine (CPT 72146), and/or MRI of the brain (CPT 70553). The patient has a neurological examination suggestive of multiple sclerosis. The patient demonstrated weakness after vigorous exercise. The patient demonstrated shaking of the neck and knee which are suggestive of spasms. These findings are suggestive of demyelinating disease as well as myelopathy. Thus, the requested MRI of the brain, cervical and thoracic spine are indicated as the patient has demonstrated symptoms in both the upper and lower locations in the body. The imaging with and without contrast is appropriate to assess the patient for active disease. Imaging with a high sensitivity 3T MRI is more likely to demonstrate faint disease in this clinical setting. For these reasons, the requested MRI of the cervical spine (CPT 72156), MRI of the thoracic spine (CPT 72146), and MRI of the brain (CPT 70553) are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services performed during her colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine colonoscopy. She did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed documentation of a previous history of difficulties with anesthesia or sedation with past colonoscopies. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 2. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, anesthesia services performed during the patients colonoscopy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue 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 anesthesiology 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 Balversa (erdafitinib) 4 mg tablet, two (2) tablets daily. The National Comprehensive Cancer Network recommends surgical debulking with adjunctive therapy, including bevacizumab or olaparib or niraparib, as primary treatment. Balversa is not included in the recommended adjunctive regimens.  Balversa is not approved by the U.S. Food and Drug Administration for the treatment of ovarian and fallopian tube cancers. The major drug compendia and medical literature do not support the use of Balversa for the treatment of fallopian tube cancer. In this case, this treatment is not considered a standard of care. Therefore, Balversa (erdafitinib) 4 mg tablet, two (2) tablets daily is not medically necessary for the treatment of this patient.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 sub-specialty in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 units daily for 10 days.The submitted documentation supports that the requested medication is medically necessary. In this case, the patient has relapsing remitting multiple sclerosis. Records reflect that the patient has acute exacerbation of disease with severe fatigue, disabling motion sickness, ataxia, and severe cognitive symptoms. Records indicate that it is difficult for the patient to go an inpatient facility to receive IV steroids. The use of H.P. Acthar Gel is indicated under such conditions where the patient is not able to tolerate steroids or transport to an inpatient facility poses a barrier. Under these circumstances, the requested medication H.P. Acthar Gel 80 units daily for 10 days is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cialis 20 mg tablets. In this case, the patient has had normal testosterone levels. Based on the records, the work-up was inadequate in the setting of normal testosterone levels.  A complete work-up includes physical examination and laboratory testing. Testosterone levels should be checked in all men with erectile dysfunction. If there has not been a recent medical work-up, a comprehensive metabolic work-up is recommended. Additionally, vascular testing and nocturnal penile tumescence testing may be appropriate. For some patients, vascular testing may uncover evidence of silent peripheral vascular disease. In some cases, nocturnal penile tumescence testing may be helpful in ruling out psychological causes of erectile dysfunction. In this patients case, there is no indication of risk factors other than antidepressants and age. The records do not document the medical necessity of Cialis 20 mg tablets. Therefore, Cialis 20 mg tablets are not medically necessary for the treatment of this patient.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 urology 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:  The enrollee requested coverage for a Myocycle functional neuromuscular electrical stimulation. The patient is a 34-year-old male who sustained a spinal cord injury from a gunshot wound at T1-T6 with complete cord lesion and resultant lower limb paralysis. The treating physician requested a Myocycle home functional neuromuscular electrical stimulation device. The physician indicated the patient was an excellent candidate for the equipment due to the nature of his condition and his noted willingness to comply with the prescribed functional neuromuscular electrical stimulation cycling program. The physician stated that the cycle therapy system had multiple medical, physical, and functional benefits that made it medically necessary for the patient. The patient is a young individual who could make functional gains after his spinal cord injury. The Myocycle can also slow or prevent contractures, spasm, and skin breakdown. The scientific evidence in peer-reviewed literature supports improvement in health outcome including bone density, muscle mass, and mobility. The Myocycle functional neuromuscular electrical stimulation has received approval from the Food and Drug Administration and it has been deemed effective for this diagnosis. The patient is a good candidate for the Myocycle.Final Result: The reviewers determined that the Myocycle functional neuromuscular electrical stimulation provided on 4/22/20 was likely to be more beneficial than any available standard therapy for the treatment of the enrollees medical condition.Credentials/Qualifications: One physician reviewer is board certified in neurology and two physician reviewers are board certified in physical medicine and rehabilitation. All physician reviewers are actively practicing. All 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 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 right first metatarsophalangeal joint (MTP) joint synthetic cartilage implant surgery (CPT 28291). Baumhauer and colleagues performed a prospective, randomized, controlled, non-inferiority clinical trial to compare the safety and efficacy of a synthetic cartilage bone implant to first MTP arthrodesis in patients with advanced-stage hallux rigidus. The authors demonstrated equivalent pain relief and functional outcomes over two years. The authors concluded that synthetic implants are an excellent alternative to arthrodesis in patients who wished to maintain first MTP motion. This patient presented with a history of chronic right great toe pain with functional limitations. Clinical examination findings documented bony proliferation around the first MTP joint of her right foot, joint effusion, and painful limited dorsiflexion with crepitus. There was radiographic evidence of complete loss of joint space, cystic degeneration of the head of the metatarsal and bony proliferation over the dorsal aspect of the joint. She underwent right first MTP joint synthetic cartilage implant surgery. The provider noted that the patient did not want a fusion procedure. Evidence based medical literature supports the use of a synthetic cartilage implant as an option in this enrollees medical condition to maintain first MTP joint motion. A Level 1 prospective randomized study demonstrated the safety and efficacy of MTP joint synthetic cartilage implant surgery as an alternative to arthrodesis at two years (Glazebrook, et al.). Given these findings, the right first MTP joint synthetic cartilage implant surgery (CPT 28291) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the right first MTP joint synthetic cartilage implant surgery (CPT 28291) was 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 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 orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy revision (CPT 43848) and hiatal hernia repair (CPT 43281). Sleeve revision has not been documented as a standard treatment for weight regain or enlarged sleeve based on a lack of durable long-term outcomes. Further prospective clinical trials are required to compare the outcomes from revisional sleeve gastrectomy with other standard procedures when primary laparoscopic sleeve gastrectomy has failed. Researchers noted, Further prospective clinical trials are required to compare the outcomes of revisional sleeve gastrectomy with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after laparoscopic sleeve gastrectomy. Re-sleeving a dilated sleeve gastrectomy has not been shown in the high-level published literature to result in durable long-term (greater than three-year) weight loss. Although there are some studies with small patient numbers and non-randomized case series with short follow-up, additional research is needed to determine if the requested procedure is a safe, effective and durable treatment for weight regain.   In this patients case, the medical records do not document hiatal hernia. Thus, hiatal hernia repair (CPT 43281) is also not supported. Therefore, laparoscopic sleeve gastrectomy revision (CPT 43848) and hiatal hernia repair (CPT 43281) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

An enrollee has requested authorization and coverage for Stelara Prefilled Syringe. The submitted documentation does not support that the requested medication is medically necessary. Peer reviewed medical literature supports that Stelara (ustekinumab) is a recommended treatment of both psoriatic arthritis and psoriasis. In this case, however, the patient has recently started Enbrel (etanercept), a tumor necrosis factor (TNF) blocker, and the submitted documentation has no indication of failure of Enbrel or of a provider rationale for an additional medication (Stelara) at this time. Under these circumstances, the requested Stelara Prefilled Syringe is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Cuvitru 35 Gram weekly subcutaneous infusions. For patients with autoimmune polyneuropathies, the rate of disability improvement has been significantly higher in those treated with immunoglobulin replacement therapy than in those treated with placebo, and changes can be seen as early as one month after the initiation of therapy. There are many years of evidence in peer reviewed journals demonstrating benefit from immunoglobulin replacement therapy in autoimmune polyneuropathies. In this case, the patient has been diagnosed with autoimmune autonomic polyneuropathy and has significant and disabling symptoms that prevent her from performing her activities of daily living. Records also reflect that the patient has demonstrated insufficient response to conservative therapies. Under these circumstances, the requested Cuvitru 35 Gram weekly subcutaneous infusions are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine and 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.