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 authorization and coverage for weekly parent-child interaction therapy, weekly child-directed therapy (CDI), weekly verbal directed therapy (VDI), weekly Fad-ins, and community exposure. Findings:  The physician reviewer found that records provided for review document that this patient has a history of anxiety, selective mutism, difficulty engaging in social settings and communication with others. The patients provider has recommended treatment with parent-child interaction therapy, CDI, VDI and Fad-ins with community exposure. This therapeutic regimen is consistent with recommendations in the medical literature. Muris and Ollendick describe that selective mutism is characterized by a consistent failure to speak in specific settings (e.g., school, social situations) despite speaking normally in other settings. Oerbeck and colleagues noted that selective mutism is considered difficult to treat. The authors found that in-person with the patient for 12-16 weeks yielded gains that were largely maintained in a five-year follow up. Catchpole and colleagues reported on a cohort of 33 children with selective mutism who were treated with parent-child interaction therapy principles and behavioral techniques. The authors reported that, Results showed significant and large gains in speaking behaviors across contexts from pre- to post-treatment. Moreover, the requested 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 not primarily for the convenience of the patient or provider. Given this support, the requested weekly parent-child interaction therapy, weekly CDI, weekly VDI, weekly Fad-ins, and community exposure 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in both knees. Findings:  The physician reviewer found that 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 patients case, there is a history of prior viscosupplementation which was greatly beneficial. The patient is attempting to delay or avoid bilateral total knee arthroplasties. Given these findings, the requested Euflexxa injections in both knees are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for varicocelectomy. Findings:  The physician reviewer found that first-line treatment options include medications such as antibiotics, anti-inflammatory agents, antidepressants, and neuroleptics. In addition, modalities including acupuncture, pelvic floor physical therapy, and psychotherapy may be beneficial. Minor nerve blocks, transcutaneous electrical stimulation and pulsed radiofrequency have also been utilized with some degree of efficacy. Once conservative options are exhausted surgical procedures may be considered as a last resort. The records provided for review document that this patient has testicular pain that has been present for a few months and at least partially responded to conservative therapy. There is a lack of support for diagnosis of varicocele. Treatment with varicocelectomy is not a clinically appropriate and generally accepted standard for management of this patients medical condition. Therefore, the requested varicocelectomy is not 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for knee arthroscopy (CPT 29875, 29880, and 29877).Lamplot and Brophy concluded, Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Ji and colleagues indicate, Positive McMurray sign implies good postoperative outcomes for the patients with meniscal tear associated with osteoarthritis. For patients with osteoarthritis, those whose positive McMurray signs are in line with their radiological findings indicate they are eligible candidates for arthroscopic meniscectomy. Our study suggests that McMurray sign can be used as an indication for both symptomatic meniscal tear and postoperative outcomes. Finally, Mezhov and colleagues found, First-line trial of conservative therapy is recommended for the treatment of degenerative meniscal tears in older adults. The exception to this may be when mechanical symptoms, such as knee locking, predominate.In this case, the patient sustained a fall injury to her right knee. The patient is noted to have osteoarthritic findings on imaging. There was no detailed indication of recent, comprehensive and reasonable conservative treatment provided to this patient for her knee pain beyond medication and crutches. Additionally, there are no mechanical symptoms (locking, giving way) clearly arising from the meniscal tear. There is no documentation of orthopedic testing, including McMurrays test, to document internal derangement. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines. Therefore, the requested knee arthroscopy is not medically necessary for treatment of the patients medical condition.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 Tysabri. The American Academy of Neurology practice guideline for adults with multiple sclerosis (MS) note that multiple studies have shown the benefits of disease-modifying therapies (DMTs) in reducing relapses of MS. The guidelines recommend that clinicians prescribe alemtuzumab, fingolimod, or natalizumab (brand name Tysabri) for people with highly active MS. Butzkueven and colleagues report that a ten-year interim analysis supports the robust real-world effectiveness and well-established safety profile of natalizumab in the treatment of relapsing-remitting MS. In this case, the patient has a diagnosis of relapsing-remitting MS. Given that current medical literature supports the use of natalizumab for the treatment of active MS, and as the patient reports good response on Tysabri without side effects, the requested medication is medically indicated. Therefore, Tysabri is 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent (dupilumab) 20 mg/1.14 mL Valbuena and colleagues describe actinic prurigo as a chronic photodermatosis with onset in childhood or before 20 years of age. It is a rare condition without a clear optimal therapy or guidelines for management. In this case, the patient has recurrent disease. Given that the patient has tried and failed multiple therapies and the good safety profile of Dupixent generally, the requested medication is medically indicated as the next step in therapy for this patient. Therefore, Dupixent (dupilumab) 20 mg/1.14 mL is 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 dermatology 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 Bravo pH monitoring and manometry tube placement provided on 3/12/20. Current medical literature supports the use of a pH study to evaluate for acid reflux above the lower esophageal sphincter and to confirm the presence of reflux before anti-reflux surgery. Yodice and colleagues note that a thorough pre-operative assessment, including technologies such as pH-impedance studies, is crucial to select appropriate surgical candidates. The authors further note that pH testing is a key test to consider for patients with GERD-like symptoms. Gyawali and colleagues note that endoscopy and pH or pH-impedance monitoring may assist in diagnosing GERD. In this case, the records noted a history of GERD and a hiatal hernia. Following the endoscopy with pH study, the provider recommended hernia repair surgery. In this clinical setting, given the patients persistent symptoms of reflux despite PPI therapy and the presence of a hiatal hernia, the service at issue was medically indicated. Therefore, Bravo pH monitoring and manometry tube placement provided on 3/12/20 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an intensive inpatient feeding program, CPT codes 92526, 99223, and 99233. Current medical literature on pediatric feeding disorders supports the use of multidisciplinary programs that incorporate behavioral intervention with nutritional management. Romano and colleagues report that management of non-organic feeding disorders may be on an inpatient or outpatient basis. In an evidence-based systemic review, Gosa and colleagues concluded that joint nutrition and behavior intervention programs, systematic desensitization, and operant conditioning behavioral therapy approaches may be effective in improving the functional feeding and swallowing outcomes in children. In this case, the patient is four years old and does not eat solid food despite participating in outpatient feeding programs since age one-and-a-half. The records noted that the patient had undergone medical evaluation, including EGD, without explanatory findings, and was considered to have oral aversion and oral motor dysphagia. Although the patient has not yet developed pathological sequelae of the feeding disorder, such as being underweight or having a micronutrient deficiency, he is functionally disabled and at risk of complications due to his acceptance of a very narrow range of foods, and at this point, warrants a higher level of care. Given that the patient has not benefited from appropriate outpatient interventions for his highly atypical and age-inappropriate pattern of oral intake, the requested services are medically indicated. Therefore, an intensive inpatient feeding program, CPT codes 92526, 99223, and 99233 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 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 reimbursement for wearable cardioverter defibrillator while awaiting implantable cardioverter defibrillator (ICD) placement. Current guidelines advocate the use of a wearable cardioverter defibrillator for a period of 90 days following an initial diagnosis of severe LV dysfunction in patients with an ejection fraction of 35% or less, or within 40 days of an acute myocardial infarction. This timeframe allows for recovery of LV function spontaneously, with guideline directed optimal medical therapy, or with revascularization. The records note that this patient underwent revascularization on late 2020 and the provider recommended a wearable cardioverter defibrillator. However, there is a lack of documentation of any contraindication to placement of an ICD three months following the initial wearable cardioverter defibrillator placement. Thus, use of the wearable cardioverter defibrillator from March of 2021 to May of 2021 falls outside of the guideline recommendations. Therefore, the wearable cardioverter defibrillator while awaiting ICD placement was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 cardiology 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 Repatha Pushtronex system. Findings: The American College of Cardiology takes note of non-statin therapies for lowering His low-density lipoprotein (LDL) cholesterol for the management of atherosclerotic cardiovascular disease risk. In higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia, alirocumab and evolocumab (brand name Repatha) may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe. In this case, the records do not document that the patient has been unable to achieve an LDL goal of under 70 mg/dL while taking the combination of maximally tolerated statin plus ezetimibe, or that the patient is unable to tolerate these drugs. In this clinical setting, the submitted records do not document that the medication at issue was and is medically indicated to manage the patients hypercholesterolemia. Therefore, Repatha Pushtronex system was not and is not medically necessary for the 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 internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment - Bioness L300 GO functional electric stimulator (FES) and supplies. Findings:  The physician reviewer found that a lack of evidence in current medical literature demonstrating that exposure to lower limb orthotic devices employing functional electrical stimulation (FES) improves gait in persons with central neurological weakness. In a comprehensive review of the literature comparing FES-aided lower limb orthoses and conventional or mechanical orthoses, Johnston and colleagues reported that studies that directly compared ankle-foot orthotics (AFO) and FES did not indicate overall superiority of one over the other. The authors further noted that the evidence on AFO and FES improving gait kinematics was weak. While there are some potential benefits to exogenously stimulating lower limb effector muscles that have lost effective connections with the central nervous system, it is not evident that the potential benefits of FES-aided orthoses, such as a lighter weight and the potential of a decreased likelihood of skin breakdown, outweigh their disadvantages, such as a lack of stabilizing support during stance phase and potential for mechanical or technological complications including lead misapplication, lead failure or dislodgement, battery drainage or failure, and device failure. Given the lack of data supporting the use of the requested equipment as favorably altering neurological recovery, the requested equipment and supplies are not medically indicated. Therefore, durable medical equipment - Bioness L300 GO FES and supplies are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a chest computed tomography (CT) scan. Medical literature notes that CT has high sensitivity and reasonable specificity for the detection of lung cancer, with demonstrated benefit in screening persons at high risk. In this case, the records noted a five mm pleural-based nodule within the posterior right upper pulmonary lobe. Based on the patients age, smoking history, the location of the nodule, and PET avidity, the patient is at high risk for lung cancer. The proximity of the nodule near the pleura raises concern for local spread, with the potential for early involvement of the pleural layers. In this clinical setting, a repeat chest CT scan at a three-month interval is medically indicated. Therefore, a chest CT scan is medically necessary for the evaluation 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 internal medicine with sub-specialty certifications in pulmonary disease and in critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.