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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a low dose CT scan of the lungs. The submitted documentation supports that the requested services are medically necessary. The patient is considered high risk based on his personal smoking history as well as his family history of lung cancer. Two findings that necessitate follow-up on the most recent CT include a new partially solid nodule as well as increased size of a solid nodule. According to the American College of Radiology lung CT screening reporting and data system, or LUNG-RADS, the new partially solid nodule qualifies as a category 3 nodule, requiring six month follow-up CT. Additionally, the increase in size of the solid nodule also warrants follow up. Under these circumstances, six month follow-up chest CT scanning is medically necessary to demonstrate stability of both of the nodules. Accordingly, a low dose CT scan of the lungs is medically necessary to treat the patients medical condition.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 diagnostic radiology 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 air and associated ground ambulance transportation services.  The current medical literature has established that patient health outcomes are improved when medical care is delivered in conjunction with a solid social structure in place.  In this case, a family-centered support network with medical power of attorney was the goal. At the time of transport, the patient was not a candidate for commercial air travel or prolonged ground transport. Her severe pain and emotional state necessitated pain control. Moreover, she required oxygen and close in-flight monitoring by a trained aeromedical flight crew. Given the patients condition, safe transport could not have been accomplished by other means, and that relocation for family, social support, and medical power of attorney was in the best interest of the patient. Therefore, the air and associated ground ambulance transportation services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 emergency 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 vertical sleeve gastrectomy. Applying the guidelines from the American Association of Clinical Endocrinologists (AACE), the Obesity Society, and American Society for Metabolic and Bariatric Surgery, (ASMBS), this patient does not meet the criteria for bariatric surgery at this time. The records do not document clinically severe obesity with a BMI of 40 kg/m2, or 35 kg/m2 or greater with serious co-morbid condition such as diabetes, hypertension, coronary artery disease or obstructive sleep apnea. Moreover, the records do not include a multidisciplinary evaluation and clearance for the requested surgical intervention. All told, the requested vertical sleeve gastrectomy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in bariatric 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 an UPWalker. A review of the literature does not reveal that the requested UPWalker is medically necessary for this patient. The physical examination did demonstrated that the patient is able to complete her mobility-related activities of daily living with her current assistive device. The records do not include an objective shoulder examination supporting that the patient has limitations that would not allow her to use a standard walker or rolling walker. The neurology notes indicate other than her left homonymous hemianopia the rest of her neurological examination was intact. There is no objective documentation of abnormal muscle motor strength on a physical examination in the submitted medical records. Therefore, the requested UPWalker is not medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for deep brain stimulation (DBS). The records provided for review document that this patient is status post two invasive surgical procedures in an attempt to make her a suitable candidate for resection of a seizure focus and she has failed to respond adequately to medical therapy. Based on the records reviewed, the patient is a candidate for two standard surgical interventions for her medically refractory epilepsy with either responsive neurostimulation or vagal nerve stimulation. However, there is a lack of data supporting a role for DBS for treatment of this patients medically refractory epilepsy. Moreover, the current medical literature does not support a role for DBS in this clinical setting over standard neurosurgical therapies including responsive neurostimulation and vagal nerve stimulation. All told, the requested DBS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in neurological surgery and is actively practicing. One Reviewer is board certified in neurological surgery and is actively practicing.  One Reviewer is board certified in neurological surgery and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient who was diagnosed with osteoarthritis of the right knee. The patient reported right knee pain. Physical examination findings included tenderness over the medial joint line of the right knee. She received a Euflexxa series in September 2018, which provided five months of pain relief. The patient reported right knee pain. The provider noted that cortisone injections somewhat relieved her right knee pain. The patient stated that she would like to postpone a total knee arthroplasty as long as possible. The patient has requested authorization and coverage for Euflexxa injections in the right knee only. 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 Euflexxa injections in the right knee only 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 individuals 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, there is documentation of lasting relief from prior viscosupplementation injections. Furthermore, her options are limited. The patient has tried and failed conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in the right knee only 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for laboratory services. Antiphospholipid antibody syndrome is a known etiology associated with cerebral infarction and transient ischemic attacks (TIA). Patients with this syndrome are at risk of hypercoagulability and future events (Bala, et al.). In this case, the patient presented with symptoms that frequently occur with TIA. The presence of positive laboratory testing would have helped guide the patients management. Although not essential in every TIA work-up, this testing can be useful to the patient if antibodies are discovered, as it will help guide therapy (Mustonen, et al.). Therefore, the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three 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.Findings: 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.Credentials/Qualifications:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing.  One Reviewer is board certified in neurology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old male who was diagnosed psoriatic arthritis (PsA). On 5/16/19, an infectious disease consultation noted that lumbar puncture results did not suggest active Lyme disease. A left knee effusion was noted to be resolved. On 5/20/19, the patient was noted to have a history of left knee Lyme arthritis. He had taken Humira for four to five years but this was stopped due to Lyme arthritis. The provider noted that Humira had been held for six weeks. On 5/20/19, the patients knee pain and swelling were noted to be nearly resolved. The patient reported pain in the right third metacarpophalangeal (MCP) joint and the fifth proximal interphalangeal (PIP) joint. No psoriatic lesions were noted. The physical examination revealed synovitis in the right third PIP joint. Tenderness was noted in the PIP joints. Left knee range of motion was full without pain. The treatment plan included holding stronger immunosuppressant medications due to Lyme disease and starting Otezla as a low risk option. The patient has requested authorization and coverage for Otezla 30 mg tablets. 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 Otezla 30 mg tablets are medically necessary for the treatment of the patients medical condition. Current medical evidence does not support the requested medication in this clinical setting.  Gossec and colleagues noted recommendations address conventional synthetic disease modifying antirheumatic drugs (csDMARDs) as an initial therapy after failure of nonsteroidal anti-inflammatory drugs (NSAIDs) and local therapy for active disease, followed, if necessary, by a biological disease modifying antirheumatic drug (bDMARD) or a targeted synthetic DMARD (tsDMARD). The first bDMARD would usually be a tumor necrosis factor (TNF) inhibitor. bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate. Haber and colleagues concluded apremilast should be reserved for patients who are unable to take disease-modifying antirheumatic drugs. In this case, the medical records did not demonstrate a failure of or contraindication to NSAIDs and csDMARDs, like methotrexate. These medications have proven safety and efficacy.The physician reviewer found that, Otezla 30 mg tablets 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a transthoracic echocardiogram. To provide direction on the appropriate use of transthoracic echocardiogram, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) published guidelines (Douglas, et al.; Fleisher, et al.). The ACCF and AHA guidelines state that transthoracic echocardiogram may be indicated for patients with dyspnea of unknown origin, heart failure with worsening dyspnea, changes in clinical status, or previously documented left ventricular dysfunction who have not undergone assessment within one year. Based on these recommendations, transthoracic echocardiogram for the evaluation of cardiac structure and function in patients with arrhythmias is indicated for frequent premature ventricular contractions or for sustained or non-sustained atrial fibrillation, supraventricular tachycardia or ventricular tachycardia. This patient had a benign first-degree AV block and is reportedly asymptomatic. Evaluation of this asymptomatic patients ventricular function with a transthoracic echocardiogram is not consistent with the current guidelines. Therefore, the requested transthoracic echocardiogram is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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 Humatrope growth hormone. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether the requested Humatrope growth hormone is medically necessary for treatment of the patients medical condition. Tritos and Klibanski reported that GH therapy has beneficial effects on stature growth in several conditions characterized by GH insensitivity, including chronic renal failure, Turner syndrome, Prader-Willi syndrome, postnatal growth delay in patients with intrauterine growth retardation who do not demonstrate catch-up growth, idiopathic short stature, short stature homeobox-containing (SHOX) gene mutations, and Noonan syndrome. Per the Endocrine Society clinical practice guideline states, confirmation of GH deficiency before beginning therapy is crucial and usually involves biochemical testing. The American Association of Clinical Endocrinologists guidelines indicate that GH therapy should only be prescribed for adults with a history of hypothalamic-pituitary disease and biochemically proven GH deficiency. Cook and colleagues reported orthobiologics, including stem cells, osteoinductive growth factors, osteoconductive matrices, and anabolic agents, lack standardized outcome measures for comparison of biologic agents in clinical fracture repair trials. There is a limited understanding of the biological activity of these agents at the bone repair site, and have limited efficacy in clinical applications. In this case, the patient underwent a procedure for short stature. The medical records do not show any evidence of GH deficiency. The laboratory results showed an IGF-1 level in the normal range. There is a lack of clinical studies that document the use of GH therapy for nonunion fractures. The medical evidence does not support the requested medication in this clinical setting. Therefore, Humatrope growth hormone is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 and prospective authorization and coverage for laser hair removal of the face, neck, chest, torso, buttocks, back and upper legs. The documentation available for review provides evidence that this patient meets the criteria for gender dysphoria for which she was able start treatment in 2018. In review of the dysphoric symptoms in this patients history, she has had significant increasing distress related to the male hair pattern on her body and face. The provider recommended laser treatment in September through November 2018. The delay of treatment would have directly affected her mental health. On 3/25/19, the provider documented the patients extensive hair pattern with about 60% reduction following laser treatment in 2018. The patient had a significant hair pattern justifying treatment at that stage. Despite the laser and hormonal treatment, she is still in need of further hair removal. The laser hair removal on the patients face and body is consistent with accepted clinical practice in the field of transgender care. The patient is planned to undergo genitalia surgery. Hair removal is indicated prior to this upcoming surgery. Given these considerations, the records support the medical necessity of laser hair removal to the patients face, neck, chest, torso, buttocks, back and upper legs. 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 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 the right knee. Evidence from 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 standard 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 case, the patients treatment options are limited. The patient has tried and failed non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and arthroscopic surgery with the alternative being a total knee arthroplasty. His osteoarthritis is mild and does not require a total knee arthroplasty. As such, the requested Euflexxa injections of the right knee are medically necessary.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.