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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for (1) administration of the Remicade infusion at a hospital-based outpatient infusion center provided by Childrens Hospital and Research Center at Oakland, and (2) administration of Remicade infusions at a hospital-based outpatient infusion center for one year. Reporters note that infliximab infusions are a common treatment for children and adolescents with inflammatory bowel disease, and infusions have traditionally been provided at hospital-based infusion centers. The authors further note that in conducting a quality improvement approach to increase the number of external infliximab infusions, 40% of patients were considered by their providers to be poor candidates for external infusions due to considerations such as poor prior infusion reactions or significant psychosocial concerns. In this case, the patient has Crohns disease and had responded to treatment with infliximab, with normalization of inflammatory markers despite persistent anemia and recurrence of symptoms. The documentation reflects challenges with vascular access, due to both the patients anxiety and challenging IV access. Given these challenges, this patient is not an appropriate candidate for non-hospital-based infusions, and the requested services are medically indicated in this clinical setting. Therefore, (1) administration of the Remicade infusion at a hospital-based outpatient infusion center provided by Childrens Hospital and Research Center at Oakland, and (2) administration of Remicade infusions at a hospital-based outpatient infusion center for one year was and is medically necessary for the 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 pediatrics with sub-specialty certification in pediatric 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intraosseous nerve ablation (codes 22899, C9752, C9753). In a randomized control trial, Khalil and colleagues found that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of pain and function at three months in patients with chronic vertebrogenic related lower back pain. Lorio and colleagues note that guidelines by the International Society for the Advancement of Spine Surgery support the use of intraosseous ablation of the basivertebral nerve for chronic low back pain for patients who have had chronic low back pain for at least six months, have tried and failed six months of non-surgical management, and demonstrate Modic changes on at least one endplate on magnetic resonance imaging (MRI). In this case, the patient has a diagnosis of lumber radiculopathy and reports low back pain radiating into the left buttock and left leg, and associated numbness and tingling of the left leg. A physical examination reported a positive straight leg test, suggestive of lumbar radiculitis/radiculopathy. While the current medical literature supports the use of intraosseous nerve ablation for chronic low back due to discogenic back pain identified by Modic changes on MRI, there is a lack of support for its efficacy for patients with lumbar radiculopathy. Therefore, intraosseous nerve ablation (codes 22899, C9752, C9753) is 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 anesthesiology with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the head, jaw, neck, ears, and throat. Per the National Comprehensive Cancer Network (NCCN) guidelines, for patients with Hodgkin lymphoma, in the long-term follow-up, there is no indication for MRI. The records document that this patient has been evaluated with a computed tomography (CT) of the sinuses, neck, and thorax. The CT of the sinuses noted mild mucosal thickening in the bilateral maxillary, ethmoid, and frontal sinuses, mild deviation of nasal septum, and possible 7 mm left nasal polyp. The CT of the thorax showed mild emphysematous changes, aortic and arterial atherosclerosis, stable bi-apical scarring and coarse calcifications associated with focal pleural thickening on the left. These findings and the providers impressions do not support an indication for further imaging with MRI. Moreover, the clinical notes and physical assessment findings do not suggest that MRI findings would be beneficial for this patients care. Given these findings, the requested MRI of the head, jaw, neck, ears, and throat 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgery services.Findings:  The physician reviewer found that The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, given that the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery, the requested services are medically indicated. Therefore, facial feminization surgery services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender health 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 mobile cardiac outpatient telemetry (MCOT). Findings:  The physician reviewer found that cardiac monitoring during recurrent symptoms with non-real-time monitoring devices, such as 48-hour Holter monitoring or event monitoring, would have been sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Similarly, self-activated non-real-time and non-continuous monitoring devices are effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real-time monitoring devices with auto-triggering capability are appropriate. There is a lack of documentation that the patient was unable to manage these standard monitoring devices or that these options were used to evaluate the patients condition. Current expert consensus guidelines endorsed by several national organizations also consider patient activated event recorders and other offline monitoring devices appropriate initial tests for evaluation of supraventricular dysrhythmias. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques. Given these findings, MCOT was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the MCOT was not likely to be more beneficial for evaluation 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 evaluation 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 internal medicine with subspecialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for a positioning pillow and compression socks.Scleroderma/systemic sclerosis is a rare condition that typically affects young to middle-aged women. It is characterized by hardening and tightening of the skin and connective tissues that is caused by an overproduction and accumulation of collagen. The exact cause is unknown, but the condition is felt to be largely autoimmune in nature (Cutolo, M., et al.). The disease manifestations are heterogenous, affecting multiple organ systems. Edema is one of the hallmarks of the early phase of scleroderma/systemic sclerosis. This edema, which is nonfibrotic and interstitial, is caused by pathology in the endothelium resulting in vascular leak, underscoring the importance of targeting treatment towards the primary disease (Bruni, C., et al.). Treatment for scleroderma/systemic sclerosis, in general, should be individually tailored, but early combination therapy with vasodilators, immunosuppression and antifibrotic drugs is typically recommended to mitigate disease progression (Fernandez-Codina, A., et al.; Cutolo, M., et al.).In this case, the patient has been followed by a specialist in rheumatology, who has been recommending disease-modifying treatment for the patients underlying scleroderma/systemic sclerosis condition. There is no documented recommendation, however, from either the rheumatologist or the patient's primary care provider for compression socks or leg elevation using a special positioning pillow for any of the patient's symptoms, findings or conditions. There are no indications that the patient cannot empirically try elevating her legs using standard household pillows or addressing her leg swelling with over-the-counter compression stockings/socks to address her symptomatology on an empiric basis. Records also indicate that the patients GERD has been stable on proton pump inhibitor therapy, and there has been no documented recommendation for a positioning pillow for her GERD, as well as no indication that this could not be addressed with standard household pillows. Under these circumstances, the requested positioning pillow and compression socks are not medically necessary for treatment of the patients medical conditions (severe leg pain from erythema nodosum, lumps on legs, and GERD).Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical conditions. 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 requested authorization and coverage for laparoscopic sleeve gastrectomy. In this case, the patient has a diagnosis of morbid obesity despite multiple dietary efforts. The documentation reflects that a thorough multidisciplinary evaluation including psychological, dietary and medical workups have cleared her for weight loss surgery. Given that this patient meets current medical guidelines for bariatric surgery, the requested service is medically indicated. Therefore, laparoscopic sleeve gastrectomy is medically necessary for the 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gel-One (hyaluronic acid) injection in the left knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Gel-One (hyaluronic acid) injection in the left knee is medically necessary for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg 28 tablets. In reviewing studies of patients treated with doses of rifaximin ranging from 600 mg to 1600 mg daily for a duration ranging from five to 28 days, Gatta and Scarpignato noted that rifaximin treatment appeared effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). In this case, the patient has a documented diagnosis of SIBO with persistent associated symptoms. Given that current medical literature supports the use of rifaximin in the requested dosage and duration for the treatment of SIBO, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg 28 tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient hospitalization services and prospective authorization and coverage for skilled nursing facility (SNF) services. The records indicate that this patient has a history of glioblastoma multiforme. There is evidence of progressive disease on imaging. The patient has completed at least one course of palliative chemotherapy and she is otherwise medically stable. Based on the available reports, there is no documentation of any skilled nursing needs to support SNF services. On physical examination, the patient is lethargic to obtunded. She currently lacks the ability to meaningfully participate in skilled rehabilitation. The patient has been fed via gastrostomy feeding tube for several months without issue and management of the gastrostomy tube does not require inpatient hospitalization or SNF level of care services. The records suggest that the patient is a candidate for custodial level of care services. Overall, there is a lack of indication for inpatient hospitalization services, or for prospective SNF services. Therefore, the inpatient hospitalization services and prospective SNF services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. Current medical literature does not support an MRI in the absence of a prior radiographic evaluation. In this case, the patient has chronic left knee and ankle pain. A radiographic evaluation of the bilateral knees on previously was unremarkable. The documents do not reflect extenuating circumstances to support the need for an MRI without completion of the x-rays and the ultrasound ordered most recently. Given that the provider has recommended radiographic evaluation, and that a more recent study would be appropriate prior to MRI evaluation, the requested service is not medically indicated. Therefore, MRI of the left knee is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adalimumab (Humira) 40 mg/0.4 mL Pen Injector Kit, quantity 2 every 28 days. According to the American College of Rheumatology (ACR), there is ample evidence to support the use of a tumor necrosis factor inhibitor (TNFi) in patients whose active ankylosing spondylitis has progressed despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs). The ACR noted that the lack of response or intolerance to at least two different NSAIDs at maximal doses over one month, or incomplete responses to at least two different NSAIDs over two months, supports escalating to treatment with a TNFi agent. In this patients case, email correspondence noted that the patient has tried two NSAIDs. She reports that she has tried naproxen in the past. Additionally, she reported gastrointestinal intolerance with NSAIDs. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested adalimumab (Humira) 40 mg/0.4 mL Pen Injector Kit, quantity 2 every 28 days is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.