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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modifications to the existing power wheelchair including HCPCS Code E1007  power seat tilt and recline; HCPCS Code E2311  electronic seat; HCPCS Code E1012  power foot platform; HCPCS Code E2313  harness upgrade; HCPCS Code E2376  expandable controller with joystick. Ehlers-Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic pain, and fatigue. In addition to pain related to mechanical factors at the affected joints, a generalized hyperalgesia has been described. This hyperalgesia may be due to a sensitized central nervous system, which suggests an underlying pain mechanism similar to fibromyalgia. Ehlers-Danlos hypermobility syndrome can have significant to profound impacts on overall function, including mobility. In a meta-analysis, pain, fatigue and psychosocial distress were also shown to have a significant impact on disability. Rehabilitation aims to reduce disability in order to improve quality of life, but the evidence related to the effectiveness of specific treatments for reducing disability is limited. The records provided for review document a history of Ehlers-Danlos hypermobility syndrome and chronic low back pain relieved by positional changes. The patient is reportedly independent with these positional changes. However, there is a lack of documentation to support an indication for the requested modifications to his existing power wheelchair. The requested power seat tilt and recline, electronic seat, power foot platform, harness upgrade, and expandable controller with joystick are not supported since the patient has sufficient capacity to effectuate pressure relief. All told, the requested modifications to the existing power wheelchair including HCPCS Code E1007  power seat tilt and recline; HCPCS Code E2311  electronic seat; HCPCS Code E1012  power foot platform; HCPCS Code E2313  harness upgrade; HCPCS Code E2376  expandable controller with joystick are not medically necessary for treatment of this patient to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. 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 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 physical therapy. Findings:  The physician reviewer found that Persistence of symptoms beyond the generally accepted time frame of two weeks for recovery of concussion is referred to as post-concussion syndrome. The mainstay of treatment for concussion and post-concussion syndrome include rest, gradual return to activities, and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns for this condition, but there is a lack of data to draw conclusions about the effectiveness of individualized rehabilitation for post-concussion syndrome patients. The records provided for review document chronic, persistent symptoms following remote head traumas. The patient has some subjective clinical benefit from rehabilitation efforts. Treatment has included adequate rehabilitation and education to be independent with a home exercise and self-management program. Although the patient reports ongoing symptoms, there is a lack of expectation that additional formal physical therapy will result in a marginally significant benefit over an independent program. All told, the requested physical therapy 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 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 caudal epidural injections with imaging guidance and under general anesthesia, every three months. Findings:  The physician reviewer found that submitted documentation supports the medical necessity of a portion of the requested services. Parr and colleagues concluded that there was good evidence for short-term and long-term relief of chronic pain secondary to disc herniation or radiculitis with local anesthetic and steroids. Further, the authors noted fair evidence for caudal epidural injections in managing chronic axial or discogenic pain, spinal stenosis, and post-surgery syndrome. Chou and colleagues reported that epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function, however, the benefits were small and not sustained, and there was no effect on long-term surgery risk. The authors further noted that limited evidence suggested no effectiveness for spinal stenosis. In this case, the patient has chronic low back and leg pain. He has back surgery syndrome and lumbar radiculopathy. He has developed scar tissue and chronic intractable nerve pain due to multiple spine surgeries and procedures. The patient has reported relief from caudal epidural steroid injections two to three times yearly, and he had requested sedation for the procedures due to severe procedural anxiety and pain related to advancing the epidural needle through scar tissue. While the current medical literature supports a caudal epidural steroid injection as an option for the management of radiculopathy and post-surgery syndrome, ongoing or continuing injection therapy is not medically indicated at this time. Responses to individual injections will determine the medical necessity of ongoing injections. In this clinical setting, the records do not reflect that general anesthesia is medically indicated over standard sedation. Current medical evidence supports conscious sedation in this patients case. Therefore, a caudal epidural injection is medically necessary for the treatment of this patient. The medical necessity of additional caudal epidural injections has not been demonstrated at this time. Additionally, general anesthesia is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: An enrollee has requested reimbursement for autonomic testing. Researchers note that the diagnostic evaluation of a patient with suspected postural orthostatic tachycardia syndrome (POTS) requires a careful clinical history and examination involving an assessment of pupillary responses, an evaluation for sudomotor and vasomotor signs, and an assessment for joint hypermobility,  laboratory testing, and autonomic testing. The author further notes that the purpose of autonomic testing is to confirm a POTS diagnosis, exclude other causes of orthostatic intolerance, and provide for characterization of POTS into neuropathic and hyperadrenergic subtypes. Researchers found that a large subset of POTS patients have sudomotor abnormalities which are typically patchy in distribution but do not correlate with other tests of autonomic function. In this case, the patient presented to her provider. The records noted she was status post COVID-19 infection with a past medical history of optic neuritis. The patient reported persistent headaches and atypical chest pains, and her neurologist recommended testing for autonomic dysfunction. In this clinical setting, testing for autonomic function was important in the diagnostic evaluation of this patient and had important therapeutic implications. Therefore, autonomic testing was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the autonomic testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Computed Tomography (CT) of the abdomen, without contrast material.Findings: Hirsutism is a clinical feature of polycystic ovarian syndrome. However, it can also be a feature of adrenal lesions. Adrenal imaging is indicated to look for an adrenal mass if a patient has a markedly elevated serum dehydroepiandrosterone sulfate (DHEA-S) concentration that is greater than 700 mcg/dL [18.9 micromol/L]. If imaging is indicated, then Computed Tomography (CT) is the modality of choice. Adrenal incidentalomas are a common cause of nonfunctioning adrenal masses and can be incidentally found on imaging. Therefore, radiologic testing is not indicated and may be misleading when the required DHEA-S concentration is not met. The patients lab results indicate that their dehydroepiandrosterone (DHEA) levels are elevated at 435, but they are still under the criteria indicated for radiologic testing. Under these circumstances, the requested Computed Tomography (CT) of the abdomen, without contrast material is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for phenoxybenzamine HCL 10 mg capsule. Whelton and colleagues note that alpha blockers are not used as first-line therapy for hypertension as they are less effective for the prevention of cardiovascular disease than other first-step agents, such as thiazide diuretics. The authors further note that selective alpha-1 blockers such as doxazosin, prazosin, and terazosin are considered second-line agents. In this case, the patient has a diagnosis of essential hypertension. Given that alpha blockers such as phenoxybenzamine are not recommended as first-line therapy for hypertension, and that the documentation does not reflect that the patient has tried and failed selective alpha-1 blockers, the requested medication is not medically indicated. Therefore, phenoxybenzamine HCL 10 mg capsule 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan (generic name rifaximin) for the treatment of irritable bowel syndrome with diarrhea (IBS-D). Gatta and Scarpignato note that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Morariu and colleagues found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of IBS by possibly counteracting SIBO. In this case, the records show that the patient has SIBO, confirmed on a breath test, and IBS-D. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve the symptoms of irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablet 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 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: An enrollee has requested authorization and coverage for Repatha SureClick 140mg/ml.The submitted medical records do not support that the requested medication is medically necessary. While the patient has a mild elevation of low-density lipoprotein (LDL) cholesterol (129 off statins), there is no detailed documentation of cardiovascular disease, myocardial infarction (MI), transient ischemic attack (TIA) or stroke in the submitted medical records. The patients electrocardiogram (EKG) does not show a prior MI. She is reportedly intolerant of two statin medications, though at a higher dose (40-80mg atorvastatin) her LDL was 62 based on the labs and notes provided. The patient does not have familial hypercholesterolemia or objective documented atherosclerotic cardiovascular or cerebrovascular disease which would be an indication for Repatha PCSK9 therapy if titrated statins plus ezetimibe were ineffective or not tolerated.In addition, the submitted records do not document trials of lower dose (better tolerated) statin therapy combined with ezetimibe or other dosing strategies to achieve the desired LDL goals (Mancini, G., et al.). Therefore, the submitted records do not document clinical atherosclerotic cardiovascular or cerebrovascular disease, nor do they detail a failure of titrated statin/ezetimibe therapy in the setting of diabetes with other documented cardiovascular risk factors. Under these circumstances, the requested Repatha SureClick 140mg/ml is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Whole Exome Genomic Sequencing Reanalysis Testing (CPT 81417).Findings: Three out of three physician reviewers found that the requested Whole Exome Genomic Sequencing Reanalysis Testing (CPT 81417) is likely to be more beneficial than any other available standard therapy for the patients condition.Wright and colleagues state that analysis of whole exome sequencing has rapidly become not only acceptable, but essential in identifying underlying genetic conditions, especially in children. Extensive medical literature supports this process. The number of identified genes and pathogenic variants recognized to be associated with human disease is growing exponentially (Wright, C., et al.). Wenger and colleagues conducted a study of 40 individuals with previously non-diagnostic exome, and they found a diagnosis in 4 of these individuals (10%). For each of these individuals, the publication that allowed for diagnosis was published within one year of the initial negative exome report, and for one individual, the gene was published one month after the initial non-diagnostic exome (Wenger, A., et al.). Ewans and colleagues conducted a study published one year later which also found an additional 11% diagnosis rate (from a cohort of 54 patients) when reanalysis was performed only one year after an initial non-diagnostic exome. Wright and colleagues conducted a study that showed an increase in diagnostic rate from 27% to 40% (an increase of 13%) with reanalysis of non-diagnostic exome from a cohort of 1,133 children with neurodevelopmental disorders (Wright, C., et al.).In this case, the patient has a medical history of developmental delay, autism, dysmorphic features, seizures, and language regression. Prior to exome sequencing, the patient had normal fragile X testing, a normal microarray, and normal MECP2 testing. She initially underwent whole exome sequencing five years ago, with no pathogenic variants in genes associated with her symptoms found at the time. Since the cause of the patients symptoms is still unknown and unsolved, a reanalysis of her exome data would be appropriate to identify underlying genetic conditions. Thus, the requested Whole Exome Genomic Sequencing Reanalysis Testing (CPT 81417) is likely to be more beneficial than any other available standard therapy for the patients condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard therapy for the patients 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 patients parent has requested authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 1, due to a lack of recent clinical records.In terms of functional status, the records support a score of 1, minimal functional impairment, due to a lack of recent clinical records. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of autism spectrum disorder. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to struggles with academic performance and adjusting to online schooling. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents involvement and participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment as his symptoms worsened due to difficulty participating in virtual treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, due to a reported lack of engagement with virtual treatment. Thus, the patient has a total score of 16. In this case, the recommended level of care is intensive outpatient services. Therefore, RTC services 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 psychiatry with sub-specialty certification in child and adolescent 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 a 3-piece penile prosthesis procedure. Researchers conclude that penile prosthesis remains an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. In this case, while the records do not reflect physical findings and ejaculatory dysfunction, the documents reflect that the patients condition has been prolonged. He has tried and failed multiple treatment modalities, including psychotropic agents. In this clinical setting, the requested service is medically indicated. Therefore, a 3-piece penile prosthesis procedure 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.