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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mandibular maxillary advancement surgery. Findings:  The physician reviewer found that Based on the available clinical documentation, the requested maxillomandibular advancement surgery is medically necessary for treatment of this patients obstructive sleep apnea (OSA). The provider has recommended maxillomandibular advancement consisting of Le Forte 1 osteotomy for the midface and bilateral sagittal split osteotomy for the mandible with facial bone contouring for correcting the persistent maxilla-mandibular discrepancy and asymmetry. One accepted indication for maxillomandibular advancement is OSA, with significant improvements in apnea/hypopnea index (AHI) as compared to patients treated with multilevel airway surgery without skeletal intervention. In this case, polysomnography revealed an AHI of 1.2 events per hour, respiratory disturbance index (RDI) of 7.5 events per hour, and lowest oxygen saturation of 85%. The current medical literature supports the requested mandibular maxillary advancement surgery to address this patients medical condition. Therefore, the requested mandibular maxillary advancement surgery 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 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 Talicia 250 mg - 12.5 mg - 10 mg capsules. The American College of Gastroenterology (ACG) notes that first-line treatment of Helicobacter pylori may include proton pump inhibitor (PPI) with clarithromycin and metronidazole. The American Gastroenterological Association (AGA) recommends a salvage regimen consisting of PPI  with levofloxacin, bismuth, and metronidazole for the treatment of Helicobacter pylori. A rifabutin-based salvage regimen may be recommended after other treatment failures. In this case, while the patient has attempted unspecified antibiotics, given that the records do not show trial and failure of first-line regimens, the requested medication is not medically indicated. Therefore, Talicia 250 mg - 12.5 mg - 10 mg capsules 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter implantation of a permanent leadless pacemaker into the right ventricle. On review of the current peer-reviewed medical literature, there is a lack of support for the requested leadless pacemaker for treatment of this patients high-grade atrioventricular (AV) block in the presence of atrial fibrillation. Leadless cardiac pacing holds promise as a permanent cardiac pacing option for patients requiring single ventricle pacing and appears both safe and efficacious in the short-term. However long-term comparative trials are not available and remain to be determined. One study reported successful implantation on 96% of patients, which was less than conventional lead device placement, as well as significant side effects in 6.7% of patients at six-month follow-up. In addition, this patients tricuspid regurgitation is described as severe and is not likely to worsen with placement of a leaded system. All told, the requested transcatheter implantation of a permanent leadless pacemaker into the right ventricle is not 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 requested services are not 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 services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL. Findings:  The physician reviewer found that The American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for low density lipoprotein (LDL) cholesterol lowering in patients for management of atherosclerotic cardiovascular disease risk. As noted by the ACC, Repatha may be considered when the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or in the setting of familial homozygous or heterozygous hypercholesterolemia. The records provided for review indicate that this patient has a contraindication to statin therapy given his unexplained elevated liver function tests. In addition, the magnitude of the patients LDL cholesterol elevation is consistent with familial hypercholesterolemia, which is further supported by the positive family history of early coronary artery disease. For these reasons, the requested Repatha SureClick 140 mg/mL is 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 requested medication 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 medication is 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is 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 patient has requested reimbursement for general anesthesia services. The American Dental Association (ADA) recommends moderate sedation for patients with American Society of Anesthesiologists (ASA) score of III or IV, and obesity, especially when associated with airway associated morbidity. The ADA also reports that deep sedation or general anesthesia may be appropriate for mentally or physically challenged patients. The American Academy of Pediatric Dentistry (AAPD) states that general anesthesia may be indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability;  patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring significant surgical procedures;  patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and  patients requiring immediate, comprehensive oral/dental care (Cote, et al.). The records provided for review document that this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction. However, there is a lack of documentation that this patient has an anesthesia classification score ASA of 3 or 4, or evidence of a difficult airway. The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2. The diagnosis of attention deficit disorder (ADD) is not considered a developmental disability that prevents a patient from undergoing a tooth extraction without sedation or general anesthesia. Moreover, the patients preoperative blood pressure was charted as 148/89, which does not constitute a hypertensive urgency or emergency. The providers records do not include sufficient documentation to support an indication for general anesthesia for the tooth extraction. Therefore, the general anesthesia services were 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xeljanz (5 mg, twice daily). The current medical evidence supports the requested medication in this clinical setting. There is a large body of growing evidence that Janus kinase (JAK) inhibitors, such as tofacitinib, are safe and efficacious for the treatment of alopecia areata/totalis. The provider has recommended the JAK inhibitor, tofacitinib. The patient has severe alopecia areata with 75% involvement of the scalp. Per the submitted records, the patient has tried and failed clobetasol, squaric acid, topical tofacitinib, anthralin, and intralesional Kenalog. There is sufficient support for the requested medication in this patients case. Therefore, the requested medication, Xeljanz (5 mg, twice daily) 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 magnetic resonance imaging (MRI) scan of the brain before and after contrast, MRI of the upper spinal canal before and after contrast, MRI of middle spinal canal before and after contrast, and/or MRI of lower spinal canal before and after contrast. The available records document that this patient has undergone extensive neurological evaluation for symptoms including dizziness, postural orthostatic tachycardia syndrome (POTS), and postural headaches. The patient was recently evaluated as part of a multidisciplinary assessment. The patients provider will utilize a heavily T2-weighted MRI of the brain as well as spine for assess for possible cerebrospinal fluid (CSF) leak. Although computed tomography (CT) myelogram is beneficial in the evaluation of patients for suspected CSF leak, it is not utilized as a first-line tool due to radiation, invasive nature of the procedure, and post-procedure headaches. Starling and colleagues evaluated the sensitivity of MRI compared to CT myelogram. The authors concluded that MRI is highly sensitive and noninvasive, which supports its use in the initial evaluation of patients with suspected CSF leak. In this patients clinical scenario, after multidisciplinary discussion and multiple consultations including a CSF leak specialist, the requested MRI examinations are indicated. Therefore, the requested MRI scan of the brain before and after contrast, MRI of the upper spinal canal before and after contrast, MRI of middle spinal canal before and after contrast, and MRI of lower spinal canal before and after contrast are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dissection and fusion of the cervical area and lumbar area of the spine, specifically at C5-C7 and L4-L5 and L5-S1. In this case, the records document several recommendations against the requested service by neurosurgery. Despite being requested, the submitted records did not include support from a spine surgeon or neurosurgeon for the requested service. In this clinical setting, given that the records do not support the requested service and document that the patients providers are advising against surgery, the requested service is not medically indicated. Therefore, dissection and fusion of the cervical area and lumbar area of the spine, specifically at C5-C7 and L4-L5 and L5-S1, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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 whole breast ultrasound. The American College of Radiology (ACR) appropriateness criteria note that for women with dense breast tissue without additional risk factors, whole breast ultrasound may be useful as an adjunct to mammography for incremental cancer detection. The ACR notes that the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. While the National Comprehensive Cancer Network (NCCN) guidelines on breast cancer do not currently include screening recommendation in women with dense breasts, current medical literature supports the use of whole breast ultrasound in women with dense breasts, though there is an increased risk of false positives. Medical literatures report that the addition of automated breast ultrasonography in a generalizable cohort of women with dense breasts increased the cancer detection yield of clinically important cancers, but it also increased the number of false-positive results. Medical literatures note that supplemental screening whole-breast sonography increases the cancer detection yield by 2.391 cancers per 1000 women with dense breast tissue over that of mammography alone but also raises the number of false-positive results. In this case, the patient is a 61-year-old female with average risk who presented for breast cancer screening.  She has documented dense breasts noted on the mammogram, and her provider recommended a whole breast ultrasound. In this case, given that current medical literature and the ACR support the use of whole breast ultrasound for breast screening in women with average-risk, the requested service is medically indicated. Therefore, whole breast ultrasound is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 interventional radiology and 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 authorization and coverage for Corlanor (5 mg tablet twice a day). Findings:  The physician reviewer found that ivabradine is safe and effective in significantly improving heart rate and quality-of-life in patients with hyperadrenergic POTS as the predominant subtype. In this case, given the patients confirmed diagnosis of POTS improvement with Corlanor, the requested medication is medically indicated. Therefore, Corlanor (5 mg tablet twice a day) 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 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 trigger point injections. In the medical literature, Gerwin noted that myofascial pain syndromes caused by trigger points in muscle are a common cause of local and generalized pain. However, the authors concluded that there is a lack of adequate studies to support the use of trigger point injections in the treatment of patients with nonspecific low back pain. Urits and colleagues described myofascial pain syndrome (MPS) as a regional pain disorder that is characterized by the presence of trigger points (TrPs) within muscles or fasciatypically diagnosed via physical exam, and the general agreement for diagnostic criteria includes the presence of TrPs, pain upon palpation, a referred pain pattern, and a local twitch response. The authors discussed the available treatment options and reported that, More research is needed to form uniformly-accepted diagnostic criteria and treatments. In this case, the patient has a history of thoracic compression fracture of T7-8. The patient presents with complaints of low back pain radiating into the lower extremities. The patients physical examination of the spine was unremarkable without evidence of trigger points identified. The provider charted that the patients thoracic pain should be managed with an epidural steroid injection to treat suspected thoracic radiculopathy. Furthermore, there were no findings on physical examination of thoracic muscle trigger points consistent with a primary muscle spasm as the cause for the patients symptoms. The providers clinical documentation suggests that the underlying cause of the patients pain is thoracic radiculopathy. Thus, the requested trigger point injections are not indicated for treatment of this patient. For these reasons, the requested trigger point injections are 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.