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 computed tomography (CT) scan of the abdomen/pelvis (CPT 74178) and CT scan of the head (CPT 70470). The records provided for review demonstrate that this patient was diagnosed with breast cancer in 2009 and she is status post modified radical mastectomy and adjuvant systemic chemotherapy. The records document that she has a history of transaminitis and fatty infiltration of the liver. The patient presented to her provider in June 2020 with complaints of pain in the right shoulder blade region, mid back, hips, and knees. In this clinical setting, the provider recommended imaging studies as dictated by the physical findings and patient symptoms, not for routine follow-up. Given these findings, the requested CT scan of the abdomen/pelvis (CPT 74178) and CT scan of the head (CPT 70470) are medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 a Convaid Cruiser pediatric wheelchair with accessories. The ANSI/RESNA WC19 (WC19) standard specifies design and performance requirements for wheelchairs to be suitable for use in the safe transportation of children. Unlike a non-custom commercial stroller, the Convaid Cruiser pediatric wheelchair fulfills WC19 standards, enabling the patient to be safely transported on a school bus. Researchers stressed the importance of a five-point, wheelchair-integrated crash-tested harness, and wheelchair tiedown and occupant restraint system (WTORS) for the safest transportation of children with disabilities who use wheelchairs. Researchers concluded that individually designed wheelchairs should be maintained for children with cerebral palsy. Given the current medical literature and the patients diagnosis in this case, the requested equipment is medically indicated. The requested equipment will ameliorate the patients lack of safe dependent mobility. Without a custom wheelchair, the patient is at risk of developing abnormal posture due to poor truncal tone. He is also at risk of injury should his caretakers fall while carrying him. Therefore, a Convaid Cruiser pediatric wheelchair with accessories is medically necessary to prevent disease, disability, and other health conditions or their progression and to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child neurology 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 authorization and coverage for bilateral wrist cortisone injections and ancillary procedures. Corticosteroid injection is a recommended treatment option for carpal tunnel syndrome, before considering surgery. To manage musculoskeletal conditions, corticosteroid injections into articular, periarticular, or soft tissue structures relieve pain, reduce inflammation, and improve mobility. Indications for carpal tunnel syndrome injection include median nerve compression resulting from rheumatoid arthritis. Painful limitation of motion occurring in trigger fingers of patients with diabetes or rheumatoid arthritis also improves with injection. In this case, the patient has rheumatoid arthritis in the presence of carpal tunnel syndrome. The records document carpal tunnel syndrome that has responded to the injections. As no surgery is being performed, the nerve conduction studies are not necessary and the clinical impression and response to injections is sufficient to make this diagnosis. Based on current medical literature, the requested services are medically indicated. Therefore, bilateral wrist cortisone injections and ancillary procedures 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has been diagnosed with bilateral knee osteoarthritis, and is requesting authorization and coverage for Synvisc injections in both knees.Findings: Medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting pain relief from prior viscosupplementation injections. Furthermore, the patients osteoarthritis is not severe enough to warrant a total knee arthroplasty. The patient has tried and failed treatment with ibuprofen and tramadol. The medical evidence supports the requested services in this clinicals setting. Therefore, Synvisc injections in both knees 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the LINX procedure. Based on the current peer-reviewed medical literature, the LINX device should be an option available to patients for the management of medically refractory gastroesophageal reflux disease (GERD). However, in this patients case, the available records do not support an indication for LINX implantation in lieu of maximized medical therapy and improved lifestyle and diet aimed at GERD management. The provider noted that the patient has GERD based on pH testing. The records support an absence of advanced esophagitis and normal lower esophageal sphincter (LES) function that does not require augmentation. In addition, the patient has reportedly achieved substantial benefit from acid suppression treatment. As such, she is not considered refractory to medical therapy nor is her acid suppression treatment ineffective or poorly tolerated. Moreover, the available records support at least intermittent dysphagia in the absence of dysmotility, warranting clinical caution before embarking on LINX implantation. Given these findings, the LINX procedure was not 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 LINX procedure was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with left knee osteoarthritis. The provider noted the patient has a remote history of left knee medial meniscus arthroscopic surgery. The provider noted the patient has been treated with a platelet rich plasma injection and physical therapy. The patient reported a prior Monovisc injection administered in September 2019 provided several months of pain relief. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted the patient has been treated with a triamcinolone acetonide injection, Motrin, and physical therapy, with minimal relief. The patient has requested authorization and coverage for a Monovisc 88 mg/4 mL injection for the left knee. The Health Plan denied the request and reported that the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Monovisc 88 mg/4 mL injection for the left knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of pain relief from a prior viscosupplementation injection with Monovisc in September 2019, which provided several months of pain relief. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, such as corticosteroid injections, Motrin, and physical therapy. The medical evidence supports the requested service in this clinical setting. Therefore, a Monovisc 88 mg/4 mL injection for the left knee 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet 5/325 mg two tablets every four hours. The U.S. Centers for Disease Control and Prevention (CDC) guidelines for determining when to initiate opioids for chronic pain state, Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. For the responsible, safe, and effective prescribing of opioids for chronic pain, Researchers recommend providers, establish appropriate physical diagnosis and psychological diagnosis if availableconsider appropriate imaging, physical diagnosis, and psychological status to collaborate with subjective complaints and establish medical necessity based on average moderate to severe (greater than or equal to 4 on a scale of 0  10) pain and/or disability. In this case, the patient has chronic pelvic pain. She has tried duloxetine, ibuprofen and naproxen. Depo-Provera was effective but led to weight gain, and gabapentin caused unwanted side effects. The patient has been referred for pelvic floor physical therapy and has an outstanding referral to pain management. Given that this patient has not yet started physical therapy or been seen by pain management, she does not meet the recommendation under current guidelines that patients exhaust non-pharmacological and non-opioid treatment options before considering a trial of chronic opioid therapy. Therefore, Percocet 5/325 mg two tablets every four hours 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 anesthesiology with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Management of radiation therapy patients with cardiac defibrillator or pacemaker is a common clinical scenario. The standard of care for treatment in this setting is intensity modulated radiation therapy with interrogation of the pacemaker after treatment to ensure the pacemaker has not been adversely affected. Current medical literature does not suggest that proton beam radiation therapy offers a clinical benefit compared to conventional photon radiation therapy for patients with lung cancer. Researchers preformed a randomized trial comparing outcomes of proton therapy and photon therapy. The authors noted that proton therapy did not improve dose-volume indices for the lung, but did for the heart. No benefit was noted in radiation pneumonitis and local failure after proton therapy. There is insufficient data to suggest proton radiation therapy techniques would significantly improve the sparing of the surrounding normal structures compared to standard photon techniques. Therefore, proton beam radiation therapy 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 radiation oncology 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: An enrollee has requested authorization and coverage for Xyosted 75 mg/0.5 mL auto-injector.Researchers have explained that the goal of testosterone replacement therapy is to return serum testosterone levels to within physiologic range and improve symptoms in hypogonadal men. Some of the symptoms aimed to improve upon include decreased libido, erectile dysfunction, infertility, hot flashes, depressed mood, and loss of muscle mass or hair. Currently the routes of delivery approved for use by the United States Food and Drug Administration encompasses buccal, nasal, subdermal, transdermal, and intramuscular (IM). Many factors must be considered when a clinician is choosing the most correct formulation for a patient. As this decision depends highly on the patient, active patient participation is important for effective selection. In this case, the patient has diagnoses of hypogonadism with decreased testosterone and energy levels. The patient has failed clomiphene and topical testosterone gel (AndroGel Pump 20.25MG/ACT, 1.62%), and he has only oral testosterone or injectables/implantables left for therapy. The patients reported needle phobia makes the requested Xyosted 75 mg/0.5 mL auto-injector a rational choice for ongoing therapy. Under these circumstances, the requested medication Xyosted 75 mg/0.5 mL auto-injector is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for in-person evaluation and treatment by a neurologist at the skilled nursing facility (SNF). Patients in vegetative states can show behaviors such as spontaneous eye opening, but may still fail to demonstrate behavioral signs of consciousness. Findings of even minimal awareness may favorably alter prognosis and influence management such as pain management and rehabilitation interventions. Early signs of recovery of consciousness include visual pursuit and automatic movements, which requires assessment measures sensitive to these findings. Potentially confounding conditions should be ruled out and interventions to optimize arousal are appropriate for patients in persistent vegetative states. Neurologists or rehabilitation specialists generally best conduct this evaluation and management. The records reviewed do not provide an adequate clinical rationale for the requested neurology consultation for this patient. The records suggest that the provider at the subacute or long-term care facility has requested this visit based on a request made by the patients family member. There is no documented clinical question regarding diagnosis, treatment or prognosis requiring a neurologists consultation. The records indicate that the patient has undergone thorough work-up for assessment and appropriate treatment for the patients condition is in progress. Moreover, there is a lack of support for an in-person neurologist consultation rather than completion of a consultation on an outpatient basis. For these reasons, the requested in-person evaluation and treatment by a neurologist at the SNF is not medically necessary for 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) (Gamunex-C or Gammagard) 25-gram infusion every month. Epilepsy and seizure related disorders are due to a wide variety of symptoms including antibody-mediated etiologies. Various antibodies have been identified which target key components to neuronal stability. The presence of these antibodies mitigate seizure threshold and are established causes of epilepsy. Due to their autoimmune nature, therapeutic approaches differ from the standard antiepileptic regimen approach of other epilepsy disorders. Frequently such patients require immunomodulatory therapy to address the underlying etiology in addition to standard antiepileptic medications. This patient has evidence of voltage gated potassium channel antibodies, which are known in the epilepsy disease process. In addition to topiramate, the patient has tried and failed treatment with steroids. IVIG is an accepted therapy for patients with antibody-mediated epilepsy and is the next logical step for this patient, who is no longer responding to steroids. For these reasons, the requested IVIG (Gamunex-C or Gammagard) 25-gram infusion every month 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 IVIG (Gamunex-C or Gammagard) 25-gram infusion every month 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 reviewers 1, 2, and 3 are board certified in neurology 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.