Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest wearable cardioverter defibrillator. Findings:  The physician reviewer found that wearable defibrillator is a vest-like device worn under the clothing that continuously monitors heart rhythm, automatically delivers an electric shock when ventricular tachycardia (VT) or ventricular fibrillation (VF) is detected and is meant to be worn 24-hours a day except when bathing. The U.S. Food and Drug Administration (FDA) approves the use of a wearable automated external defibrillator for patients at risk for sudden arrhythmic death who are not candidates for an implantable defibrillator. While some clinical studies have observed the efficacy of the WD, there is a lack of data from randomized clinical studies, particularly in the management of recently diagnosed cardiomyopathy, as in this patients case. Therefore, Zoll LifeVest wearable cardioverter defibrillator was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Zoll LifeVest wearable cardioverter defibrillator was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in 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 30 treatments (two hours per treatment) of hyperbaric oxygen therapy (HBOT) in a multi chamber. The records provided for review indicate that this patient is status post liposuction body contouring and injectable fat grafting to each breast on 8/19/21. The provider did not report any significant post-operative healing problems. The provider charted that there were no findings concerning for compromised healing of the liposuction or the fat grafted areas or of threatened or compromised surgical grafts. The patient underwent treatment with HBOT to improve post-operative wound healing. However, in this clinical setting, the peer-reviewed medical literature does not support the use of HBOT in the management of patients status post injectable fat grafting. Fife and colleagues noted that, The U.S. Food and Drug Administration defers to the Undersea and Hyperbaric Medical Society (UHMS) to establish the list of indications for which HBOT has sufficient evidence to support its use. HBOT chambers are Class II medical devices. The U.S. Food and Drug Administration clears them for marketing and use in 13 indications, including Compromised (ischemic) skin grafts and flaps. The authors also commented that, HBOT is ineffective when it is provided to patients who could heal without it (inappropriate). Overall, the studies do not recommend routine use of HBOT in the post-operative management of patients who have undergone liposuction body contouring and/or injectable fat grafting. All told, the 30 treatments (two hours per treatment) of HBOT in a multi chamber were not medically necessary for this patients medical condition.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 plastic 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 Rexulti 0.25 mg (30) with 12 refills. This patient presents with a history of bipolar disorder, current episode depressed. The records reviewed document that the patient has been treated with Abilify and three other atypical antipsychotics without adequate symptomatic improvement. Moreover, the patient experienced severe side effects with each of the attempted atypical antipsychotics. The patients provider has recommended treatment with Rexulti. The patient is responding to Rexulti, which is less likely to cause EPS than aripiprazole (Stahl). According to Citrome and colleagues, clinical trials of Rexulti have demonstrated its efficacy for use as an antidepressant in patients demonstrating inadequate responses to psychopharmacology management. Given these findings, the requested Rexulti 0.25 mg (30) with 12 refills is medically necessary for 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 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 (1) two physical therapy evaluations, (2) eight physical therapy visits, (3) eight LVN visits, and (4) two skilled services evaluations by a registered nurse. Findings:  The physician reviewer found that Bowles and colleagues report that risk factors for poor outcomes and rehospitalization in sepsis survivors may include septic shock and associated acute organ system dysfunction. Prescott and Angus note that early hospital care for sepsis focuses on prompt recognition, treatment with broad-spectrum antibiotics, elimination of infectious sources, and resuscitation with intravenous fluids and vasopressors when appropriate. In this case, the records indicate that the patient was hospitalized with sepsis. The records did not document septic shock or any associated acute organ system disfunction. The patient was medically stabilized with antibiotics and supportive care, and underwent inpatient rehabilitation, improving to a supervision level for mobility when she was discharged back to the community. In this case, the records support physical therapy to address specific mobility issues in the home, such as mobility up and down stairs, the use of gait implements at home, the potential for weaning her off of full-time walker use, and the potential for weaning down her supervision level for household level mobility, such as going to the bathroom. In this case, while one physical therapy evaluation is medically indicated, a second physical therapy evaluation is not medically indicated. The patient should be assessed and treated over a series of intermittent physical therapy visits, with ongoing recommendations made to the patient and her family/caregivers regarding the support and help she should be getting at home and in the community. Therefore, (1) one physical therapy evaluation and (2) eight physical therapy visits are medically necessary for the evaluation and treatment of this patient. The records do not include a clinical rationale for skilled nursing visits by a registered nurse or licensed vocational nurse in the home, given that there are no indications that the requires ongoing skilled care that could not be provided on an ambulatory basis with respect to her medical needs. Therefore, (3) eight LVN visits, and (4) two skilled services evaluations by a registered nurse are not medically necessary for the evaluation and treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment and evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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 Xeljanz 5 mg tablets. The records provided for review document that this patient presents with a diagnosis of vitiligo. Rosmarin and colleagues noted that, Vitiligo is a chronic autoimmune disease resulting in skin depigmentation and reduced quality of life. Per the available documentation, the patient has undergone treatment with topical steroids, topical calcineurin inhibitors, and excimer laser without substantial symptomatic improvement. The patients provider has recommended treatment with Xeljanz, which is a Janus kinase (JAK) inhibitor. Chapman and colleagues found that, Clinical trials and other studies have demonstrated the efficacy of JAK inhibitors in the treatment of a variety of dermatologic conditions. Phan and colleagues reported on a systematic review and meta-analysis of nine studies evaluating the safety and efficacy of JAK inhibitors in the treatment of patients with vitiligo. The authors concluded that more than 50% of patients experienced a good response and 22% of patients reported a partial response. Based on the mechanisms of action and efficacy of JAK inhibition in vitiligo, Xeljanz systemic therapy is an appropriate treatment option to address this patients extensive and refractory vitiligo. For these reasons, the requested Xeljanz 5 mg tablets are medically necessary for 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for four additional home health visits. Game and colleagues note that the most important principles of wound and wound-bed management are regular inspection, cleansing, removal of surface debris, and protection of the regenerating tissue from the environment. In this case, the records note that the patient is receiving skilled care for an abdominal wound, which is being treated with cleansing and application of topical wound cream. The records did not indicate that the patient had a feeding tube, parenteral medications, recent medication changes or hospitalizations, or a recent decline in function. Given that the records do not reflect that the wound is infected or complex in nature and as the patient appears to be medically stable, the requested service may be performed by a layperson and does not require skilled services. Therefore, four additional home health visits 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Octagam intravenous immune globulin (IVIG) 120 gm, divided over three to five days as the loading dose, then 60 gm divided over one to two days every three to four weeks. Oaklander and colleagues describe chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) as a chronic progressive or relapsing and remitting disease that usually causes weakness and sensory loss, with symptoms due to autoimmune inflammation of peripheral nerves. The authors further note that CIDP usually responds to treatments that reduce inflammation. IVIG and corticosteroids remain first line treatments for CIDP. Doneddu and colleague report that there are several CIDP variants, including purely sensory CIDP, or chronic inflammatory sensory neuropathy (CISP), a condition that presents with sensory neuropathy, ataxia, and normal nerve conduction from selective sensory nerve root inflammatory demyelination. The American Academy of Neurology guidelines on IVIG in the treatment of neuromuscular disorders lists IVIG as an effective, long-term treatment for CIDP. In this case, the patient has a diagnosis of CISP, a sensory variant of CIDP, that is progressive and affects activities of daily living. Given that current medical literature supports the efficacy of IVIG therapy in patients with sensory CIDP, the requested medication is medically indicated. Therefore, Octagam IVIG 120 gm, divided over three to five days as the loading dose, then 60 gm divided over one to two days every three to four weeks, 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left hip surgery (total hip arthroplasty or replacement  CPT 27130). York and colleagues reported that the benefits of the direct anterior technique include enhanced post-operative recovery and respect for all the innervation and vascularization territories. The records provided for review document that this patient is being treated for severe hip pain due to labral tear and unilateral primary osteoarthritis of the left hip. The provider charted that the patient presented with left hip pain that is moderate to severe, depending on activities in intensity and sharp and stabbing in quality. The patients provider has recommended left hip total arthroplasty. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures including any formal physical therapy. Additionally, the magnetic resonance imaging (MRI) of the left hip reported left hip anterior superior labral tear and mild left hip degenerative changes. The records do not document the presence of severely advanced arthritis to support the requested total hip arthroplasty. Therefore, the requested left hip surgery (total hip arthroplasty or replacement  CPT 27130) 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Monovisc) injections. 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 routine 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 patient has a history of 18 months of relief with prior viscosupplementation of both knees. As such, the recurrent pain is likely to be benefitted from repeat viscosupplementation with Monovisc injections of both knees. All told, the requested hyaluronan (Monovisc) injections to bilateral knees are 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 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 authorization and coverage for radiofrequency ablation of genicular nerve of the left knee. Arden and colleagues note that in the management of knee osteoarthritis, clinical practice guidelines recommend education, structured exercise, and weight loss as core treatments, topical nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatments and oral NSAIDs and intra-articular injections for persistent pain. The American College of Rheumatology (ACR) and the Arthritis Foundation recommendations for the management of hand, hip, and knee osteoarthritis include strong recommendations for exercise, weight loss in patients who are overweight or obese, self-efficacy and self-management programs, cane use, tibiofemoral bracing for tibiofemoral knee osteoarthritis, topical NSAIDs, oral NSAIDs, and intraarticular glucocorticoid injections. The guidelines noted that while there were some studies demonstrating potential analgesic benefits with various ablation techniques, due to the heterogeneity of techniques and controls used, as well as the lack of long-term safety data, a recommendation on its use was conditional. Overall, there are insufficient published high-grade data at this time to establish that a genicular nerve block or a genicular nerve ablation is a clinically effective procedure that provides benefits beyond a placebo effect in the setting of knee osteoarthropathy. Therefore, radiofrequency ablation of genicular nerve of the left knee is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested radiofrequency ablation of genicular nerve of the left knee is 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 service is 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for weekly occupational therapy (as opposed to occupational therapy every other week). The American Academy of Pediatrics (AAP) describe that, Children with ASD may have low muscle tone or a developmental coordination disorder. The AAP noted that, Occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. Monz and colleagues noted that, The American Academy of Child and Adolescent Psychiatry recommends the use of multiple treatment modalities in ASD. Although occupational therapy is generally accepted for the treatment of patients with ASD, evidence is lacking in the published literature to support optimal intensity and dosage of occupational therapy for children. Gee and colleagues published a meta-analysis evaluating the available studies on occupational therapy for children with ASD. The authors found that, evidence is lacking within the published literature to adequately guide occupational therapy dosage decisions. Further research related to dosage in pediatric occupational therapy practice is needed. At present, there is inadequate evidence to support that one session of occupational therapy per week in lieu of one session every two weeks for treatment of this patient. Reports provided by the patients provider indicate that the patient was at an age-appropriate level on the Pediatric Evaluation of Disability Inventory (PEDI). The patient was making progress with goals with the current treatment plan. Moreover, the requested occupational therapy every week is not medically necessary to treat the patients condition or to prevent disease, disability and other health conditions or their progression, to prolong life, to promote physical and mental health and efficiency, or to correct or ameliorate any physical or behavioral conditions. All told, the requested weekly occupational therapy (as opposed to occupational therapy every other week) 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.