Persius/hicric huggingface dataset:
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 Norditropin Flexpro and/or Nutropin AQ Nuspin. This patient has idiopathic short stature, defined as height less than 2.25 standard deviations (SDs) below the norm for age and gender, without the presence of GH deficiency. The U.S. Food and Drug Administration (FDA) has approved growth hormone (GH) therapy for patients with idiopathic short stature. This patient had poor growth velocity prior to receiving GH, which is consistent with abnormal growth. The patients growth velocity improved after a GH trial, which suggests he will benefit from further treatment with GH therapy. This patient has a mid-parental target height of 170 cm, which is significantly above his extreme short stature, indicating he will not reach his genetic potential without GH therapy. The records document that his estimated adult height is 158 cm, which is significantly below his mid-parental target height of 170 cm. Given these findings, both of the requested agents, Norditropin Flexpro and Nutropin AQ Nuspin, are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 pediatrics with subspecialty certification in pediatric endocrinology 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 Zolgensma. Zolgensma was developed for the treatment of pediatric patients younger than two years of age with SMA and bi-allelic mutations in the SMN1 gene. Zolgensma was designed to deliver a functional copy of the human survival motor neuron (SMN) gene to the motor neuron cells of patients with SMA. The U.S. Food and Drug Administration (FDA) has approved Zolgensma as the first gene therapy used in the treatment of patients with SMA. This patient has SMA type 1 and is under two years of age. Given the support in the medical literature, Zolgensma 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 upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet. The American Society of Interventional Pain Physicians (ASIPP) state that, to establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations. The Centers for Disease Control and Prevention (CDC) guidelines for the treatment of non-cancer pain state that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. In this case, the patient has complaints of chronic low back pain. CT imaging did not reveal any acute abnormalities or focal neurological deficits suggestive of high-grade spinal nerve impingement. Currently there are no significant findings on physical examination or imaging findings to support the use of chronic opioid therapy. The patients records do not document that she has tried and failed conservative treatments such as physical therapy or comprehensive pain management program as recommended by the CDC guidelines. The CDC guidelines recommend a non-opioid approach to chronic pain management before resorting to opioid therapy. For these reasons, the requested Percocet is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested Percocet 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 subspecialty certification in pain management 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 Tesla magnetic resonance imaging (3T MRI) of the prostate. Active surveillance, a management strategy involving serial PSA testing and biopsies, allows safe monitoring of disease progression while reducing rates of overtreatment in patients with prostate cancer. The American Urological Association (AUA) guidelines state that, clinicians may consider multiparametric prostate MRI as a component of active surveillance for localized prostate cancer patients. In the medical literature, 3T multiparametric MRI has been shown to have a role to aid in active surveillance protocols and guide clinical decision-making. In the medical literature, 3T MRI is associated with improved detection rates and the study will permit re-biopsy of the abnormal lesion using the electronic tracking method. Importantly, 3T MRI is helpful in selecting appropriate patients for active surveillance. In this patient, 3T MRI is critical for adequate monitoring along with PSA and digital rectal examination based on the medical records provided for review and current AUA guidelines. Therefore, the requested 3T MRI is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Humatrope 12 mg, six cartridges per month. This patient had evidence of significant deterioration on linear growth, as shown on the growth chart, from the 50th to the 10th percentile, prior to initiation of growth hormone therapy. The patient demonstrated no growth. She did not have a bone age delay based on an average bone age. The estimated predicted adult height prior to therapy is significantly below the patients mid-parental target height of 64 inches and is the lowest cut-off value for normal height for an adult female. The patients growth rate and bone age prediction improved after starting treatment with growth hormone therapy. Given these findings, the requested Humatrope 12 mg, six cartridges per month is medically necessary for treatment of this patients medical condition.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 pediatrics with subspecialty certification in pediatric endocrinology 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 been diagnosed with Crohns disease. The provider noted that the patient had been treated with Remicade, Humira, Cimzia, Entyvio, and azathioprine. The provider noted the patient was status post small bowel resections and had failed treatment with Entyvio and Stelara 90 mg every eight weeks. The provider noted that the patient was taking Stelara 90 mg every four weeks. The patient reported that her symptoms, including diarrhea, had significantly improved. The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 90 mg every four weeks is medically necessary for the treatment of the patients medical condition. Researchers demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate to severe Crohns disease that were resistant to anti-tumor necrosis factor (TNF) therapy. Researchers also performed a retrospective open-label study. The authors reported, The results of our study provide further evidence that subcutaneous ustekinumab treatment is associated with a sustained clinical response in the majority of anti-TNF resistant Crohns disease patients. In a study Patients received 90 mg of ustekinumab subcutaneously at weeks zero, one, and two during induction and 90 mg every four or eight weeks during maintenance. In this case, the patient has failed multiple biologic and conventional alternatives, and failed Stelara every eight weeks. She did have a response to Stelara every four weeks. Current medical literature supports Stelara 90 mg every four weeks in this clinical setting. Therefore, Stelara 90 mg every 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 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 Gazyva 1,000 mg intravenous infusion, every 15 days, for 2 doses.Medical literature does not support that the requested medication is medically necessary to treat the patients medical condition. At this time, Gazyva (obinutuzumab) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic lymphocytic leukemia and follicular lymphoma. Gazyva is not presently approved for minimal change disease (MCD) or nephrotic syndrome. Gazyva has not been shown to be effective in the adult population for the treatment of nephrotic syndrome. In this case, the patient has had a recurrence of MCD that was accompanied by acute kidney injury (AKI) and the need for dialysis therapy. At this time, the medical literature does not support the use of Gazyva to treat the patients medical condition. Accordingly, Gazyva 1,000 mg intravenous infusion every 15 days, for two (2) doses, is not medically necessary to treat the patients medical condition.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 subspecialty certification in nephrology, 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 been diagnosed with obstructive sleep apnea. The patient reported difficulty sleeping, congestion, shortness of breath, and anxiety at night. The patient also reported loud snoring, pauses in breathing, and gasping arousals. A sleep study performed revealed mild obstructive sleep apnea, with a respiratory disturbance index (RDI) score of 7.1. The patient has requested reimbursement for a continuous positive airway pressure (CPAP) device (CPT E0601). The Health Plan denied the request and reported the device at issue was not medically necessary for the treatment of this patient. At issue in this case is whether a continuous positive airway pressure (CPAP) device (CPT E0601) that was provided was medically necessary for the treatment of the patients medical condition. Researchers reported obstructive sleep apnea (OSA) is the most common type of sleep apnea and caused by upper airway obstructions. Clinically, patients with OSA characteristically experience intermittent nocturnal hypoxemia and impaired sleep quality. Studies reported that CPAP treatment may help to improve physical symptoms of OSA. In this case, the patient has a history of snoring and apnea/gasping for air. A sleep study revealed mild obstructive sleep apnea with RDI of 7.1. The medical evidence supports the device at issue in this clinical setting. Therefore, a continuous positive airway pressure (CPAP) device (CPT E0601) that was provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device was 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The provider noted that the patient has been treated with bilateral arthroscopic knee surgery, naproxen, and Flexeril. The provider noted that weight bearing x-rays of the right knee revealed end-stage arthritis of the lateral compartment. The patient reported right knee lateral joint line pain. The provider noted the patient was being treated with physical therapy. A right knee steroid injection was administered. The patient reported that the right knee steroid injection provided pain relief until one week prior. Physical examination findings included right knee valgus alignment. The patient has requested authorization and coverage for a Synvisc-One injection in the right 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 Synvisc-One injection in the right 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. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in 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 patients options are limited. He has tried and failed other conservative treatments, including a corticosteroid injection and physical therapy, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the right 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary osteoarthritis of both knees. The patient reported bilateral knee pain. He reported excellent pain relief from the most recent series of Orthovisc injections administered. Tenderness was noted over bilateral knee joint lines, and patellofemoral grinding was present in both knees. The provider noted that bilateral knee x-rays revealed osteoarthritis of both knees. The patient has requested authorization and coverage for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 excellent response to viscosupplementation in the past, with the last series of Orthovisc injections providing excellent pain relief. Furthermore, the patients options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, bilateral knee Orthovisc injections 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Dexcom continuous glucose monitoring system (CGMS) (CPT codes A9276, A9277, and A9278). The Dexcom CGMS is one of several U.S. Food and Drug Administration (FDA) approved devices that record a patients blood sugar levels at repeated intervals throughout the day and night. The advantages of a Dexcom CGMS includes identification of fluctuations, improved hemoglobin A1C levels, and prevention of episodes of hyperglycemia and hypoglycemia. The requested device alerts patients to high blood sugar levels between meals and early morning spikes in blood sugar. Moreover, this device evaluates how diet and exercise affect an individual patients blood sugar levels. This patient has poorly controlled diabetes with episodic hypoglycemia. Use of a CGMS is appropriate for this patient to improve his hemoglobin A1C levels and avoid episodes of hypoglycemia. All told, the requested Dexcom CGMS (CPT codes A9276, A9277, and A9278) is medically necessary for treatment of this patient.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 internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 50 minutes of occupational therapy once per week for 20 weeks and 50 minutes of speech therapy once per week for 20 weeks. In a review of the evaluation and treatment of children with autism spectrum disorder, Baumer and Spence noted that optimal treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Researchers concluded that, evidence of the effectiveness of social skills programs is strong for children requiring services at the intensive level (e.g., those with autism spectrum disorder, diagnosed mental illness, serious behavior disorders) to improve social behavior and self-management. This patient has a central auditory processing disorder, sensory processing disorder, delayed expressive and receptive language, and disorder of pragmatic language. The provision of occupational therapy and speech therapy is the standard of care in this clinical setting. Therefore, the requested 50 minutes of occupational therapy once per week for 20 weeks and 50 minutes of speech therapy once per week for 20 weeks 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 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.