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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a LifeVest wearable cardioverter defibrillator (CPT code K0606). This patient sustained a non-ST elevation myocardial infarction (NSTEMI) with a troponin of 33 and a left ventricle ejection fraction (LVEF) of 20%. In this clinical circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope, or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an LVEF less than 35% despite appropriate treatment. A prophylactic wearable external defibrillator is indicated when accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. Placement of a prophylactic defibrillator before this time has elapsed has not been associated with improved patient outcomes. For these reasons, the LifeVest wearable cardioverter defibrillator (CPT code K0606) was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the device 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 subspecialty certification in cardiovascular disease 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

The enrollee requested authorization and coverage for an electrophysiology study and catheter ablation procedure. The enrollee has a history of extra heartbeats. Her physician reports these are very frequent. They are causing symptoms of chest pain, shortness of breath, and lightheadedness. She is unable to sleep because of these symptoms and has gone to the emergency room because of the discomfort. The enrollee has tried medications and experienced bad side effects. Her physician wants to use energy to make tiny scars in the heart to stop the extra heartbeats from happening. Literature shows that, if the extra heartbeats are not treated, they can cause other illnesses and problems. Since the enrollee cannot take the medications, this procedure is a good way to fix the problem.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease and are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The patient has a composite score which is consistent with medically monitored residence based services, similar to the services provided at the current RTC facility. Therefore, the RTC services 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 psychiatry with subspecialty certification in child and adolescent 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 authorization and coverage for L5-S1 lumbar laminectomy with S1 fusion. A review of the literature includes moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability. In this case, the records document a history of chronic low back pain with right more than left sciatic pain. There is a history of paresthesias and intermittent numbness in the lower extremities. There is evidence of disc-osteophyte complexes bilaterally at L5-S1 on magnetic resonance imaging (MRI). Epidural steroid injections at L5-S1 have been effective in relieving the right-sided radicular pain on a temporary basis indicating the presence of neurocompression on the right side. The patient has tried and exhausted conservative treatment. The current medical literature reveals that fusion in addition to laminectomy results in greater success than discectomy alone in the lumbar spine. Therefore, the requested L5-S1 lumbar laminectomy with S1 fusion 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.
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 Omnitrope. The records provided for review document that this patients growth rate is poor at 2.64 cm per year, which indicates abnormal growth. The most recent bone age prediction is 165 cm, which is significantly below his mid-parental target height of 171.5 cm. In addition, this patient has late onset CAH, which is associated with short stature, if left untreated. Consistent with the U.S. Food and Drug Administration (FDA) and Endocrine Society guidelines, treatment with GH is appropriate for well-selected patients with CAH who have poor height prediction and poor growth. Moreover, some studies have shown that GH with GnRH analogs could improve height in children with CAH. All told, the requested Omnitrope 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 pediatrics with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for right knee replacement surgery. The enrollee has advanced arthritis of the right knee.  The enrollee has a body mass index of 39.31.  Options were discussed with the enrollee during a follow-up visit with her orthopedist; including weight loss.  The enrollee understands the increased risk of illness and even death due to her high body mass index and wishes to proceed with a right total knee arthroplasty. The enrollee reports she needs the surgery as soon as possible.  She cannot stand without a walker and can only walk a short distance with her walker before her knees buckle and give out. Research shows people with a high body mass index are at higher risk for infection and dislocation after knee surgery. Research shows people with a high body mass index who have knee surgery are also at risk for longer operating times, longer hospital stays, and higher rates of implant failure than people with a lower body mass index. Studies show people with a body mass index greater than 30 experienced more complications compared to people with a lower body mass index, and these complications increased as the body mass index increased.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 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 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 referral to an orthopedic specialist. Current evidence-based, peer-reviewed medical literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for the initial evaluation and treatment. This patient presents with complaints of right fourth finger pain and swelling. He reported that he sprained his finger and he experiences pain while performing activities of daily living. There is radiographic evidence of periarticular soft tissue swelling at the fourth proximal interphalangeal joint with no evidence of acute fracture or dislocation. There is a lack of documentation that the patient has failed initial conservative management. Evaluation and management of these complaints is within the expertise of his primary care provider. Therefore, the request for referral to an orthopedic specialist is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 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

The patient has requested authorization and coverage for a Gallium 68 scan. Gallium 68 is used with positron emission tomography (PET) for localization of somatostatin receptor-positive neuroendocrine tumors for treatment planning at diagnosis or for suspected recurrence. The records provided for review document that this patient underwent treatment and was determined to have a good prognosis. Since that time, the patient has not demonstrated concerning signs or symptoms of recurrence. Moreover, Gallium 68 scans are not indicated for surveillance in this clinical setting. Therefore, the requested Gallium 68 scan is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 certifications in medical oncology and hematology 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 patient has requested authorization and coverage for intravenous immunoglobulin (IVIG). Human herpesvirus 6 (HHV6) can cause illness or acute rejection in patients with a liver transplant. Multiple therapies, including Valcyte, cidofovir, and foscarnet have shown efficacy in treatment. However, there is a lack of high-quality medical literature to support the use of IVIG as safe and effective for the treatment of HHV6 in immunosuppressed patients with a liver transplant. Overall, there is a lack of medical studies to support the use of IVIG. In addition, the records do not document that the patient has exhausted the current standard of care for HHV6. All told, IVIG 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 subspecialty 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left breast and under armpit area. Medical literature notes that ultrasound is the first-line investigation before mammography, MRI or biopsy, which may be indicated for suspicious abnormalities. This patient has undergone a thorough imaging evaluation for her recurrent chest wall and breast pain. Imaging has included a left breast ultrasound and MRI studies in March 2019 and May 2019, with unremarkable findings. There has been no documented change in the patients symptom complex. The current medical literature does not support a repeat MRI in this clinical setting. All told, the requested MRI of the left breast and under armpit area is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 plastic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the Botox injections billed were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patients diagnoses include face pain, bruxism, myofascial pain, spasm of muscle, and tinnitus. However, the patient does not have a diagnosis supporting an indication for Botox. Specifically, the medical records do not demonstrate that the patient has a neurogenic or musculoskeletal disorder with magnetic resonance imaging (MRI) evidence of nerve root compromise or electromyography findings consistent with a muscle disorder. There is also lack of documentation that the patient has failed to respond to conservative therapy with muscle relaxants, anti-depressants, anticonvulsants and non-steroidal anti-inflammatory drugs (NSAIDs). All told, the Botox injections billed were 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 Botox injections billed were 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 services at issue were not likely to be 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 reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain management 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 enrollee is requesting authorization and coverage for a Group 3 power wheelchair. The enrollee has C6/C7 tetraplegia, resulting from a motor vehicle accident. He underwent surgery. He received physical and occupational therapy. He is now dependent for assistance with all activities of daily living.  The enrollees wife reports the enrollee does not have any feeling below his chest, and he has weakness in his shoulders and arms. He cannot move his hands or legs. The enrollee cannot propel a standard weight manual wheelchair. Continued use of a manual wheelchair puts the enrollee at risk for injury to his upper extremities. Power wheelchairs are recommended for people with mobility limitations that prevent them from participating in activities of daily living; such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation can also be defined as a limitation which places the person at a higher risk for injury or death when attempting to perform activities of daily living. Group 3 power wheelchairs are supported for people with limitations due to spinal cord injuries. This enrollee cannot move in a manual wheelchair.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 neck prolotherapy. A review of the medical literature reveals an absence of high quality studies demonstrating the safety and efficacy of prolotherapy for the treatment of chronic neck pain. A review by Chou and colleagues concluded that that the current evidence does not support prolotherapy as effective for the treatment of low back and radicular pain. Overall, the body of scientific evidence does not permit conclusions concerning the effect of prolotherapy on health outcomes for chronic neck or back pain. The records provided for review document that the patients treatment has included trigger point and prolotherapy injections. However, there is a lack of evidence that the patient has failed standard therapies for the treatment of chronic neck pain. Therefore, the requested neck prolotherapy is 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 anesthesiology with subspecialty certification in pain management 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 enrollee is requesting reimbursement for intensive out enrollee program (IOP) level of care services. The enrollee has bipolar disorder. Her most recent episode showed severe depression The enrollee entered the intensive out enrollee program (IOP) level of care. The care plan indicated the enrollee reported anxiety that interfered with her ability to function. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. For risk of harm, the enrollees score is 3, due to no active suicidal/homicidal ideation exists, but extreme distress and/or a history of suicidal/homicidal behavior exists. For functional status, the enrollees score is 3, due to appearance and hygiene may fall below usual standards on a frequent basis. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For recovery environment level of stress, the enrollees score is 4, due to an inability to meet needs for physical and/or material well being. For recovery environment level of support, the enrollees score is 3, due to a few supportive resources exist in the current environment and may be capable of providing some help if needed. For treatment and recovery history, the enrollees score is 3, due to previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 3, due to the enrollee does not use available resources independently or does so only in cases of extreme need. The enrollees composite LOCUS score is 21, which correlates with Level 4, medically monitored non-residential services.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.