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

The patient has requested authorization and coverage for treatment by a pulmonary specialist, a breathing machine and oxygen, cough syrup with codeine, Albuterol solutions for the enrollees nebulizer, and Ventolin HFA  mg inhaler #18. The records provided for review document that the patients complaints include a cough, but there is no notation of other pulmonary complaints. The records report that the patient is a smoker, so she may require treatment with some of the requested medications. However, the records do not include a recent pulmonary function test (PFT) to support a current indication for the requested medications. Evaluation by a pulmonary specialist can help rule out smoking-related lung disease and determine whether the requested breathing machine and oxygen, cough syrup with codeine, Albuterol  solutions for her nebulizer and Ventolin HFA inhaler are indicated. Given these findings, the requested treatment by a pulmonary specialist is medically necessary, while the breathing machine and oxygen, cough syrup with codeine, Albuterol solutions for the patients nebulizer, and Ventolin HFA inhaler #18 are not supported as medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in pulmonary 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

The patient is a 12-year-old male who has been diagnosed with short stature. According to the provided growth charts, the patient has been growing close to the 20th percentile since the age of four years old. On 10/1/18, his bone age was 11 years old at a chronological age of 11 years and three months. On 12/20/18, the records noted the patients mothers height was 52 and the patients fathers height was 511. On 2/1/19, the patient underwent a growth hormone (GH) stimulation test with clonidine and L-dopa, which he failed. On 2/22/19, the patients height was 55 inches. On 4/19/19, the patients height was 55 and 3/8 inches. There was no documentation provided of the patients testicular volume. On 3/15/19, magnetic resonance imaging (MRI) of the brain was normal. On 6/18/19, the provider noted the patient was started on GH therapy in April 2019. The patients parent has requested authorization and coverage for a Nutropin AQ Nuspin Pen Injector 20 mg/2 mL. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a Nutropin AQ Nuspin Pen Injector 20 mg/2 mL is medically necessary for the treatment of the patients medical condition. Wilson and colleagues reported that considerable variability exists in the diagnosis of GH deficiency, which remains a clinical challenge. The physician reviewer found that related to the continuum between severe GH deficiency and normality, marked variability in GH assays, arbitrary cutoffs conventionally used to define GH deficiency on the basis of GH stimulation tests, and the lack of reproducibility of GH stimulation tests. Grimberg and colleagues reported a limit of 10 ng/mL in GH stimulation testing only predicts GH deficiency 25% of the time. In this case, the patients estimated predicted adult height is 58. This is a normal adult height for his genetic potential and is also normal adult height for a male. Based on the growth chart provided, there is no evidence of growth failure, and the patient has been growing consistently around the 20th percentile. The failed GH stimulation test in the absence of growth failure does not establish the diagnosis of GH deficiency. The medical evidence does not support the requested medication in this clinical setting.  Therefore, Nutropin AQ Nuspin Pen Injector 20 mg/2 mL is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for laboratory testing CPT 82523GA. N-terminal telopeptide of type I collagen (NTX) is a biochemical marker of type I collagen breakdown. Current data suggests that NTX measurement during the rapid phase of bone loss may be useful in assessing the rate of ongoing bone loss (Shieh, et al.). Higher levels of early post-menopausal NTX have been most strongly associated with greater bone loss across the menopausal transition, and more strongly associated with rate of bone loss in the lumbar spine than in the femoral neck. Prior studies have also found that higher levels of bone resorption markers are associated with faster rates of bone loss and it can be used in perimenopausal patients to determine those at higher risk of faster bone loss (Shieh, et al.; Vasikaran, et al.). NTX data is also used to monitor response to bisphosphonates for osteoporosis, as a decrease in NTX has been associated with an increase in spine bone density (Baxter, et al.). The measurement of the NTX was likely to be more beneficial for evaluation of this patients osteoporosis than standard available testing. The physician reviewer found that  results of the test can help determine secondary causes and management of the patients severe osteoporosis. Given these findings, the laboratory testing CPT 82523GA was likely to be more beneficial for evaluation of the patients osteoporosis than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory testing CPT 82523GA was likely to be more beneficial for evaluation of the patients osteoporosis than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old female who has been diagnosed with osteoarthritis of the left knee. On 5/24/12, the patient underwent a left knee partial medial meniscectomy. On 4/19/13, the patient underwent a third Orthovisc injection to the left knee. She reported 50% to 60% improvement with prior Orthovisc injections. On 6/26/19, the patient reported left knee pain with swelling, stiffness, and medial tenderness. Physical examination findings included tenderness over the left knee medial and lateral joint lines. The patient has requested authorization and coverage for Orthovisc injections to the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections to the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, her options are limited, with the alternative being a total knee arthroplasty. The physician reviewer found that medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections to the left knee 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a sleep study (CPT codes 95810 and 95811). The American Academy of Sleep Medicine (AASM) guidelines established clinical practice recommendations for the diagnosis of OSA in adults. The AASM recommends that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. The AASM noted that, if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. This patient has a high probability for OSA, given his history of snoring, difficulty sleeping, daytime sleepiness and obesity. The AASM supports use of a home sleep study in this clinical setting. If the home sleep study is non-diagnostic, then the patient might require further evaluation with a lab-attended sleep study. The physician reviewer found that  the patient can proceed with a home sleep study. Therefore, the requested sleep study (CPT codes 95810 and 95811) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for treatment by an eye specialist. This patients records support the requested treatment by an eye specialist. The documentation indicates that the patient is a diabetic. The American Academy of Ophthalmology supports an annual dilated eye examination by an eye specialist to rule out diabetic retinopathy for patients with diabetes. In addition, this patient was a prior glaucoma suspect, which requires follow-up one to two times a year. The physician reviewer found that based on these findings, treatment by an eye specialist is medically necessary for 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 enrollee requested authorization and coverage for bilateral hip replacement surgery. The enrollee has symptomatic osteoarthritis of bilateral hips. X-ray of the hips shows mild to moderate bilateral hip joint space narrowing with marked osteophytosis. The enrollee wants to have bilateral hip replacement surgery due to her refractory hip pain that is now causing her lower back and knee pain. However, due to her current smoking status, she is required by her surgeon to stop smoking at least six weeks prior to surgery in order to decrease the perioperative risks associated with total hip replacement surgery. As per the enrollees telephone encounter, she reports not understanding why smoking would affect surgery since she had other surgeries in the past while smoking. While the enrollee was willing to talk with Health Education for smoking cessation options, the records indicate the enrollees statements that she was more concerned about finding a surgeon who will operate on her despite her smoking status rather than to quit smoking. Current literature supports cessation of tobacco use before total joint arthroplasty procedure. A systematic review and meta-analysis of primary joint arthroplasty procedures indicate tobacco use before total hip and total knee arthroplasty significantly increases the risk of wound complications and periprosthetic joint infection (PJI). While this increased risk is present for both current and former tobacco users, current tobacco users had a significantly higher risk of wound complications and PJI compared to former tobacco users and should thus, quit before the surgery. Studies have also found smoking is associated with significantly increased risk of aseptic loosening of the prosthesis, deep infection and all-cause revisions after total hip arthroplasty (THA). Aseptic loosening of the prosthesis is considered one of the most common complications associated with THA failure. Literature indicates that smoking cessation four to six weeks before surgery can diminish this perioperative risks and complications. Based on the review of the records and the medical literature for bilateral hip replacement surgery, smoking cessation is medically necessary to minimize the risks of perioperative infection and optimize the benefits by minimizing complications of surgery to treat this enrollees medical condition. Elective bilateral hip replacement surgery is not considered medically necessary for enrollees who are current tobacco users. Final Result: The reviewer determined that the requested services were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Genesight genetic testing, ketamine infusions, and ketamine nasal spray. The Health Plan denied the requests and reported that the requested services and medications are not medically necessary for the evaluation and treatment of this patient. At issue in this case is whether Genesight genetic testing, ketamine infusions, and ketamine nasal spray are medically necessary for the treatment of the patients medical condition. The Health Quality Ontario study noted that there is uncertainty about the use of the Genesight psychotropic pharmacogenomic genetic panel to guide medication selection. It was associated with improvements in some patient outcomes, but not others. Murrough and colleagues reported that ketamine infusions were associated with a rapid antidepressant effect in treatment resistant depression that was predictive of a sustained effect. Naidoo and colleagues reported intraperitoneal ketamine administration resulted in favorable concentrations in the brain and plasma. However, intranasal ketamine administration demonstrated moderately low drug levels post administration. In this case, the patient has been diagnosed with major depressive disorder and anxiety. Per the records, this patient reported a depressed mood, loss of interest/pleasure, fatigue, and thoughts of death/self-harm. The medical evidence supports ketamine infusions in this clinical setting. Therefore, ketamine infusions are medically necessary for the treatment of this patient. Genesight genetic testing and intranasal ketamine are not medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are partially medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for dual-diagnosis residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. This patients records document that he presents as fidgety and restless with COWS scoring in mild to moderate range. He does not have any documented biomedical conditions that interfere with his progress. The patient does have comorbid ADHD and depressive symptoms. He has not demonstrated readiness to change, given his continued use while in RTC, which indicates even less chance of success at a lower level of care. The patients history is positive for relapse despite incarceration. In addition, he states that he is now scared to leave treatment at this stage. The patients recovery environment includes living with his girlfriend who has also been unable to maintain sobriety. The patient requires safe and stable living environments in order to develop his recovery skills. These findings qualify the patient for ASAM Level III treatment, which is at least what patient has been receiving at the current facility. Given the severity of the patients illness, dual-diagnosis RTC level of care was and is 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 expertise in addiction 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

 The patients parent has requested authorization and coverage for tacrolimus 0.1% ointment. Atopic dermatitis is a chronic, highly pruritic inflammatory disorder of the skin. The disease may be associated with complications that include secondary infections. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. The physician reviewer found that  the treatment of patients with atopic dermatitis. In addition, the U.S. Food and Drug Administration (FDA) issued a recommendation for its topical use in patients two years of age and older that have moderate-to-severe atopic dermatitis and that have not responded to other treatments. This patient has moderate-to-severe atopic dermatitis that did not respond to a long-term topical corticosteroids therapy. Moreover, topical tacrolimus is an FDA approved second-line treatment for pediatric patients with atopic dermatitis two years of age and older. The patients condition has failed treatment with steroidal cream and emollients but improved on tacrolimus. Given this support, the requested tacrolimus 0.1% ointment 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for esophageal Bravo pH probe monitoring. The enrollee has a history consistent with rumination syndrome. He had frequent, non-forceful regurgitation of food but did not have signs of gastroesophageal reflux disease (GERD) as he had no nocturnal symptoms or pain. His pediatric gastroenterologist indicates based on family history, the enrollee seemed to have rumination syndrome. He underwent an esophagogastroduodenoscopy (EGD) with biopsy and Bravo pH probe, which showed findings consistent with rumination syndrome. The studies showed normal visual upper endoscopy, Hill Grade II lower esophageal sphincter (LES) region, and no hiatal hernia, with successful placement of a Bravo pH probe. Biopsies did not show any significant esophagitis. Bravo pH probe showed positive severe, excessive GERD recorded, but time course seemed very consistent with rumination as vast majority of GERD occurs in daytime and almost resolves completely when asleep. The doctor ordered omeprazole 10mg capsule, orally twice a day to protect esophagus and teeth and wait until the enrollee is older to try breathing techniques to decrease rumination events. The record indicates the enrollee presented with non-forceful regurgitation of food. He had previously been tried on Zantac which did not help.  His Bravo probe showed severe, excessive GERD (Gastroesophageal Reflux Disease), with the majority of GERD events in the daytime with resolution while the enrollee was sleeping (interpreted to be consistent with rumination). Biopsies showed normal esophageal mucosa. Clinical notes indicate the enrollee has up to 40 regurgitation events per day, as well as rumination noises. In this case, where the provider was concerned for rumination based on clinical assessment, the literature indicates neither ph-impedance testing nor simple acid reflux testing are the diagnostic methods of choice. In fact, objective testing is not required to render a diagnosis of rumination syndrome as this diagnosis is based on Rome IV criteria, which are primarily clinical. Failure to respond to antacid therapy is also consistent with the diagnosis. Based on the medical literature, the multiple reflux events as were clinically witnessed would confirm a diagnosis of rumination and would not require Bravo pH testing. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.