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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for durable medical equipment - binaural behind the ear hearing aids. Findings:  The physician reviewer found that here is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In this patients case, the records document very mild hearing loss with 100% word recognition scores at 55 dB and 45 dB, and speech recognition thresholds of 25 dB and 15 dB in the right and left ears respectively. Given the lack of evidence in current medical literature of the benefits to be derived from hearing aids at this level of mild hearing loss, the requested equipment is not medically indicated. Therefore, durable medical equipment - binaural behind the ear hearing aids are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 (RT 300 FES therapy system). Findings:  The physician reviewer found that There is a lack of evidence in current medical literature demonstrating that exposure to passive exercise, such as would be provided by the requested device, improves function or health outcomes in a clinically significant manner for neurological conditions, including complete traumatic paraplegia. Hofer and Schwab report that while treatment options using neurostimulation to enable or enhance intense training appear promising, regaining lost motor function remains challenging, and characterizing long-term benefits and side-effects in clinical trials also remains crucial. Ralston and colleagues noted that in a study of 14 patients with recent spinal cord injury, there were no clear effects of FES cycling on increasing urine output, decreasing lower limb swelling and spasticity. Mayson and Harris note that more rigorous research involving a greater number of participants is needed before determining the efficacy of FES cycling as an intervention for youth with spinal cord injury. Tweedy and colleagues note that patients with traumatic spinal cord injury benefit from active exercise using volitionally intact muscles, and the general encouragement of active participation in educational, social, recreational, avocational and vocational activities. Given that current medical literature does reflect that the use of the requested device would improve cardiovascular health, pulmonary health or other health parameters in any clinically significant manner, the requested device is not medically indicated. Therefore, durable medical equipment (RT 300 FES therapy system) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The records provided for review document that this patient failed treatment with multiple medications and psychotherapy, and she presents with persistent depressive symptoms. She has been treated with 10 different psychotropic agents from four drug classes including tricyclic antidepressants, selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors. The patients provider has recommended treatment with TMS, which is U.S. Food and Drug Administration (FDA) approved for the treatment of patients in the acute phase of major depressive disorder. Perera and colleagues found that, Daily left prefrontal TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Given the support in the medical literature, the requested TMS 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services (CPT codes 29876, 20610, and 29866). The records indicate that this patient underwent lateral meniscus transplantation, articular cartilage paste grafting of the lateral tibial plateau, chondroplasty of the lateral femoral condyle, and debridement. The provider noted that CPT codes 29866, 29876, and 20610 were performed. CPT code 29866 is an articular cartilage paste graft procedure that has been shown to be safe and effective at long-term follow-up (Stone, et al.). CPT code 29876 applies to synovectomy, which was done at the site of the scar tissue. This procedure is routinely performed to obtain exposure to the surgical site and to debride inflammatory hypertrophied synovium that causes pain. CPT code 20610 applies to injecting the joint with a local anesthetic after the procedure, which is consistent with the current standard of care. These procedures were appropriate for this patient given the extent of articular cartilage loss. All told, the surgical services provided on 10/6/20 by M.D., (CPT codes 29876, 20610, and 29866) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the surgical services (CPT codes 29876, 20610, and 29866) were 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: The patients parent has requested authorization and coverage for surgery services (CPT codes 57410 - manipulation procedures on the vagina, and 49320 - laparoscopic procedures on the abdomen, peritoneum, and omentum). Findings:  The physician reviewer found that many etiologies, including gynecologic and gastrointestinal pathologies, may cause pelvic pain in adolescents. Diseases typically associated with such pain, such as autoimmune causes, may be ruled out based on the patients history and physical examination. The diagnosis of endometriosis, which is associated with pain, may be challenging in adolescents, and treatment typically consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and hormone therapy. Laparoscopy may be an option if pain persists following medical therapy, or if diagnostic testing is recommended prior to the initiation of hormone therapy due to age or side effects. In this case, the submitted records did not include sufficient documentation, including a well-documented history, physical examination, and medical workup, to fully assess the possible etiologies of this patients pain. Given the insufficient clinical documentation submitted for review, the requested services are not medically indicated at this time. Therefore, surgery services (CPT codes 57410 - manipulation procedures on the vagina, and 49320 - laparoscopic procedures on the abdomen, peritoneum, and omentum) are 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 obstetrics and gynecology 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 Taltz. Menter and colleagues note that the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines on the management and treatment of psoriasis with biologics recommend ixekizumab (brand name Taltz) as a monotherapy treatment option in adult patients with erythrodermic psoriasis. In this case, the patient has a relatively new onset psoriasis on the extremities that has not responded to topical steroids or Enbrel. The patient has a history of deep vein thrombosis and daily alcohol intake, and resides in an area endemic to coccidiomycosis, a fungal infection. Given that the patient has a diagnosis of psoriasis and reports good response to Taltz, the requested medication is medically indicated. Therefore, Taltz 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 authorization and coverage for Entyvio 300 mg infusions administered every six weeks. Entyvio has been demonstrated to be safe and effective for the treatment of patients with moderate to severe ulcerative colitis. Entyvio is supported as primary therapy for moderate to severe ulcerative colitis by the American College of Gastroenterology (ACG) guidelines. Dose intensification of Entyvio with infusion more frequently than every eight weeks has been studied in high-quality clinical trials. In the randomized placebo-controlled GEMINI I and II trials, patients who failed to achieve remission by week six showed improvement with Entyvio dosed at every four weeks rather than every eight weeks. The GEMINI long-term safety (LTS) study showed that a significant portion of patients with ulcerative colitis who lost response to Entyvio dosed at every eight weeks regained response with four-week dosing. The records provided for review indicate that the patients ulcerative colitis has partially responded to treatment with Entyvio dosed at every eight weeks. The Entyvio level documented in this case is unlikely to achieve sustained remission while dosed at every eight weeks. Without an increase in Entyvio dose, the patient is at risk for complications of ulcerative colitis. For these reasons, the requested Entyvio 300 mg infusions administered every six weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyrem 500 mg/mL oral solution. Xyrem is indicated to treat narcolepsy type 1 or 2 when a patient fails or unable to tolerate wake promoting medications. Type 2 narcolepsy is associated with cataplexy. Diagnosis of narcolepsy requires a sleep study with MSLT showing sleep latency below eight minutes associated with two sleep onset REM sleep. This patients sleep study and MSLT do not meet these criteria. The MSLT demonstrated severe idiopathic hypersomnia with no SOREM with a mean sleep latency of 6.3 minutes over five naps. Xyrem is not U.S. Food and Drug Administration (FDA) approved or recommended for patients with idiopathic hypersomnia. For these reasons, the requested Xyrem 500 mg/mL oral solution is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for in-office phototherapy. Sidbury and colleagues report that despite its relapsing and remitting nature, the majority of patients with atopic dermatitis (AD) can achieve clinical improvement and disease control with nonpharmacologic interventions such as emollient use, conventional topical therapies, including corticosteroids and calcineurin inhibitors, and environmental and occupational modifications, when necessary. The authors note that phototherapy is recommended as a treatment for both acute and chronic AD, after failure of the measures mentioned above. The authors further note that there are no studies to date that document the efficacy or safety of home light therapy for patients with AD or contrast its use with in-office phototherapy. In this case, given that the patient has failed first line treatment with topical emollients and steroids, the requested service is medically indicated. Therefore, in-office phototherapy 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Caris Molecular Intelligence expanded cancer molecular panel. In a randomized clinical trial, researchers report that while cancers of the gallbladder and bile ducts are rarely curable, broad-based mutational profiling for patients diagnosed with a gastrointestinal malignancy has led to the discovery of mutations in the gene encoding isocitrate dehydrogenase 1 (IDH1) in tumors from a subset of patients with cholangiocarcinoma. The authors further note that such a specific metabolic abnormality in this largely incurable type of gastrointestinal cancer presents a potentially new target for therapy. Researchers report that recently, fibroblast growth factor (FGF) receptor 2 translocations have been identified as a potential target for tyrosine kinase inhibitor therapies in patients with advanced stage cholangiocarcinoma. Reseachers note that Larotrectinib may be an effective and safe therapy for patients with tropomyosin receptor kinases (TRK) fusion-positive tumors. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of additional molecular testing in cases of metastatic disease. In this case, the patient has an advanced tumor at stage 4A. In this clinical setting, current medical literature supports the use of mutational testing as consistent with the standard of care. Therefore, a Caris Molecular Intelligence expanded cancer molecular panel is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Caris Molecular Intelligence expanded cancer molecular panel is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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 power wheelchair, group 3 standard (HCPCS K0856).In this case, the patient has a history of traumatic spinal cord injury with chronic residual motor impairments that preclude ambulation and independent propulsion of a manual wheelchair. Moreover, the patients functional deficits are consistent with his level of injury (Chay, W. and Kirshblum, S.). He has been independently operating a power wheelchair, as well as driving an adapted van while seated in his power wheelchair which is locked via a pin system into the driver's seat area. The use of assistive devices for mobility by persons with the patients condition, in general, is considered crucial (Florio J, et al.). The records in the present case indicate that the patient has more than one power wheelchair, at least one of which was found to be operational and in good condition. The patient has elected not to outfit this power wheelchair with lockdown pins due to concerns of future obsolescence. However, any new power wheelchair model is also at risk for discontinuation at any time and future obsolescence. Under these circumstances, the requested power wheelchair, group 3 standard (HCPCS K0856) is not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. 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 intravenous (IV) antibiotics. Studies note that many infections can be managed with oral antibiotics, which avoid the adverse effects of intravenous administration. In this case, while the patient references planned gum surgery, the current medical literature does not support the use of IV antibiotics to prevent the spread of an oral infection or for the treatment of periodontal disease. Given that the documentation does not reflect evidence of bacterial infection, the requested medication is not medically indicated. Therefore, IV antibiotics are 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 sub-specialty certification in infectious 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.