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 skilled nursing facility (SNF) including speech therapy, physical therapy, and occupational therapy. The records document that this patient was originally hospitalized with urosepsis and possible pneumonia. She received fluid resuscitation and antibiotics. The patients hospital course was notable for pneumoperitoneum, which resolved with conservative care, and an exacerbation of her chronic scleroderma resulting in gangrenous fingers and toes, which was also conservatively managed. She was started on a vasodilator sildenafil, which has been noted in the literature to confer a benefit on ischemic digital lesions in the setting of systemic sclerosis (Hachulla, et al.). After the patient was medically stabilized, she was transferred to a SNF for further care, including nursing care and rehabilitation. She has been tolerating an oral diet. The patient has gangrenous digits that may autoamputate but are otherwise being treated conservatively with a vasodilator and supportive care. The patient does not have ongoing complex or intensive wound care needs. The patients other multiple chronic conditions can also be followed on an ambulatory basis. From the functional standpoint, that patient has not made any clinically significant functional progress with rehabilitation. She improved to set-up/supervision status for eating but has otherwise remained totally dependent for all basic self-care and mobility, including transfers. The patient has been at a custodial level of care. There is a lack of any indication in the records to support an indication for additional rehabilitation. There is a lack of support for transition back to a SNF level of care based on the available documentation. Accordingly, the requested SNF including speech therapy, physical therapy, and occupational therapy are not medically necessary for 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the mixing and preparation of antigens for immunotherapy injections. In this case, the provider reported a plan to monitor the patient and to see the patient in one year following preparation of allergy immunotherapy. The patient received vials for subcutaneous immunology therapy. The records do not document weekly injection showing the prepared serums were to be administered under the supervision in a professional setting, as is generally required by practice guidelines. Administration of allergy immunotherapy at home, and not at a professionals office is a deviation from standard therapy in this clinical setting. Therefore, the mixing and preparation of antigens for immunotherapy injections was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the mixing and preparation of antigens for immunotherapy injections was not 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 services at issue were not 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 upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in allergy and immunology 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for MAKOplasty surgery with preoperative imaging studies associated with the customized right knee replacement. The records provided document that this patient has a history of chronic right knee pain. The patients provider has recommended MAKOplasty surgery given the patients lack of response to conservative measures such as medications, injections, and activity modification. In the peer-reviewed medical literature, Cho and colleagues noted that there robotically assisted surgery can improve the accuracy of prosthetic alignment in total knee arthroplasty (TKA) procedures. However, the authors concluded that despite the enhanced accuracy with robotic assistance, the authors concluded that there were no functional benefits at 10-year follow-up. Similarly, Kim and colleagues found that, At a minimum follow-up of 10 years, we found no differences between robotic-assisted TKA and conventional TKA in terms of functional outcome scores, aseptic loosening, overall survivorship, and complications. Given these findings, the requested MAKOplasty surgery with preoperative imaging studies associated with the customized right knee replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Botox injections (onabotulinumtoxinA), every ten weeks. Zidan and colleagues report that while the current standard protocol for onabotulinumtoxinA for the treatment of chronic migraine injections consists of fixed-site injections every 12 weeks, it is unclear if this protocol is optimal for chronic migraine as in clinical practice, migraine patients frequently describe a period of increased headache frequency and intensity in the few weeks preceding their next injections. Masters-Israilov and Robbins report that most patients with chronic migraines receiving onabotulinumtoxinA experience wear-off, most commonly occurring between two to four weeks before the next injection in cycles of 12-week injections. The authors conclude that clinicians may consider increasing the units used from the treatment onset to reduce the frequent need for bridging therapies. Allowing more frequent Botox treatments may reduce the need for bridging therapies such as nerve block injections and intramuscular injections in between Botox treatments. In this case, given that the patient has tried and failed multiple medications, including Botox on a 12-week cycle, the requested medication regimen is medically indicated. Therefore, Botox injections (onabotulinumtoxinA), every ten weeks, are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for bilateral Botox injections. Herd and colleagues found that, Botulinum toxin may reduce the number of migraine days per month in the chronic migraine population by 3.1 days. Frampton and Silberstein noted that the safety and efficacy of Botox was demonstrated in two phase III studies. The authors commented that the totality of evidence from clinical trials suggests that Botox is an effective and generally well tolerated option for the prevention of chronic migraine that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. This patients records document complaints of chronic non-specific headaches for several years that have been treated with medication management using several different classes of medications unsuccessfully. The patient previously underwent treatment with Botox therapy for headaches with reported benefit. The records substantiate that the patient experienced daily migraines headaches lasting for over four hours that have not responded to other treatments. Based on this information, the patient meets criteria for repeating Botox injections. Therefore, the bilateral Botox injections were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech therapy services. The available records document that this patient has severe expressive, receptive and pragmatic language impairment due to autism spectrum disorder. Although the patient scored below the first percentile for expressive and receptive language on the Oral and Written Language Scales Second Edition (OWLS-2), speech therapy reports indicate progressive improvement in intelligibility of speech. This is despite the patient missing several months of speech therapy and having predominantly telehealth sessions during the pandemic. The provider noted that the patient has met several goals, and the patient has shown progress towards other goals. The patients mother reported a regression of language skills and increased frustration since speech therapy has stopped. The patients mother has requested speech therapy services for the patient. Baumer and Spence recommend treatment of patients with autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services such as speech, occupational, and physical therapies. The American Academy of Pediatrics (AAP) stated that, All children with autism spectrum disorder should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder. Bellomo and colleagues discussed the challenges that children with autism have faced during the pandemic. The authors concluded that, Children with autism spectrum disorder are a particularly vulnerable population in the pandemic due to the potential for exacerbation of autism spectrum disorder symptoms, limited access to therapy, and the overwhelming responsibility placed on their caregivers. Moreover, the requested speech therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. For these reasons, the requested speech therapy services 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 5 mg. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and non-opioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Washington Agency Medical Directors Group Interagency guidelines state that providers should reserve opioids for acute pain resulting from severe injuries or medical conditions, surgical procedures, or when alternatives (non-opioid options) are ineffective or contraindicated. If opioids are prescribed, it should be at the lowest necessary dose and for the shortest duration (usually less than 14 days). The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended an appropriate amount of oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action. For these reasons, the requested oxycodone 5 mg is not medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services. Per the American Society of Anesthesiology (ASA) guidelines on monitored anesthesia care, indications for monitored anesthesia care include the nature of the procedure, the patients clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation. Unlike monitored anesthesia care, moderate sedation is a proceduralist-directed service that does not include a qualified anesthesia providers periprocedural assessment. Monitored anesthesia care includes all aspects of anesthesia care such as a pre-procedure assessment and optimization, intraprocedural care and post-procedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. According to the ASA, patient risk factors include significant medical conditions such as extremes of age, severe pulmonary, cardiac, renal, or hepatic disease, pregnancy, the abuse of drugs or alcohol, uncooperative patients, a potentially difficult airway for positive-pressure ventilation, and patients with anatomy that is associated with more difficult intubation. This patients second-degree atrioventricular block and hypertension are cardiac risk factors that can be exacerbated while receiving sedation, either by the anesthetic drugs themselves or hypoxic conditions created by providing sedation. Furthermore, the sedation required by this patient would be difficult to achieve and safely deliver by a non-anesthesia provider since all agents which can depress breathing function and exacerbate any pre-existing cardiopulmonary disease. For these reasons, the anesthesia services were medically necessary for 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 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 Group 4 Permobil F5 Corpus VS vertical standing power wheelchair with features (1) power seat elevator (E2300), (2) power standing function (E2301), and (3) stand and drive package (K0108NU). There is some medical literature suggesting that the power seat elevator and power stander can have beneficial effects in terms of improving function and providing some of the physiological benefits of standing in patients who are unable to stand. Rice and colleagues concluded that the preliminary results of the study indicated that with use of anterior tilt, safety of meal preparation and functional reach in the vertical direction significantly improved. However, additional research is needed to examine the long-term influence of anterior tilt on functional activities, physical health, and user satisfaction among a large and diverse group of power wheelchair users. There is still a lack of medical literature supporting the use of power wheelchair functions such as power seat elevator, power standing function, or stand and drive package, in terms of improving function and reducing the risks associated with spinal cord injury including osteoporosis and skin breakdown. Therefore, the requested Group 5 Permobil F5 Corpus VS vertical standing power wheelchair with features (1) power seat elevator (E2300), (2) power standing function (E2301), and (3) stand and drive package (K0108NU) 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,  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 a history of osteoarthritis of the left knee and associated pain. The patient has tried ibuprofen, bracing, physical therapy, acupuncture, and corticosteroid injections which no longer work. However, he benefitted from viscosupplementation injections provided previously. The provider has recommended a series of Euflexxa injections (J7323) for left knee. At issue is whether a series of Euflexxa injections (J7323) for left knee is medically necessary for the treatment of this patient. 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 benefit from viscosupplementation injections to the left knee provided. Furthermore, prior treatment with physical therapy, bracing, acupuncture, ibuprofen and corticosteroid injections were not effective. In this clinical setting, the requested series of Euflexxa injections (J7323) for left knee is medically necessary for 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 orthopaedic 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.