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

Nature of Statutory Criteria/Case Summary: The patient is a male with diagnoses of cerebral palsy, epilepsy with intractable complex partial seizures, mental retardation, expressive aphasia, gastroesophageal reflux disorder (GERD), subconjunctival hemorrhage of the right eye, H pylori infection, and constipation. An assessment done for a semi-electric hospital bed states the patients hospital bed is in good condition, but the head no longer elevates. The patients mother indicated that the patient has trouble breathing when positioned less than 30 degrees. The durable medical equipment (DME) assessment stated that the bed could be repaired in order for the patient to sleep safely. The assessment also noted that the patients shower chair was in good condition. Physical examination revealed normal respiration and no decubitus. The patient was capable of weight shifting independently. He required minimal assistance for bed mobility, sit to stand, and stand to sit, as well as chair to bed, and bed to chair transfers. His sitting balance was intact. The provider noted that the patient had an old hospital bed. The rails did not go up or down and the head of the bed could not be raised. He stated the patients head needs to be elevated to prevent aspiration and choking.  Based on the available documentation, the requested shower chair is not medically necessary. A shower chair is indicated for daily activities related to health and personal hygiene. However, this patients DME evaluation states that the patient has a shower chair that is four to five years old, in good condition, and there is no indication that it is unable to meet the patients hygiene needs. In addition, the semi-electric hospital bed is not medically necessary. The patient does not have a heart or a lung problem that requires head of the bed positioning. There is no need for a frequent or immediate position change. There is documentation that the patient is at risk of aspiration, however, the records do not support that the patients body positioning could not be obtained with wedges or support pillows. The documentation states that the patients current hospital bed can be repaired per the DME evaluation. Therefore, the request for a new bed exceeds the patient's medical needs. Therefore, the requested shower chair and semi-electric hospital bed are not medically necessary for treatment of this patients medical condition. 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 a licensed M.D. board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 The records indicate the patient has failed first-line therapies with high potency topical steroids, Humira, and methotrexate. Additional treatment has included triamcinolone and clobetasol. Psoriasis was noted to cover 10 percent of his body surface area. The patient began taking Otezla on 6/25/18 and was noted to have good therapeutic effect. The patient has requested coverage for Otezla 30mg. The Health Plan denied the requested and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Otezla 30mg is medically necessary for treatment of this patients medical condition. Psoriasis is a chronic inflammatory skin disease that presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Approximately 20 percent of patients require treatment with systemic drugs and up to 30 percent of psoriatic patients develop psoriatic arthritis. The long-term use of traditional systemic therapies is not recommended due to renal, hepatic, pulmonary toxicity and limited efficacy. Moreover, traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, as well as anti-tumor necrosis factor (anti-TNF) drugs may develop adverse events. Otezla, an oral phosphodiesterase-4 (PDE4) inhibitor, is a U.S. Food and Drug Administration (FDA) approved therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Adequate data from the first phase III study demonstrated the efficacy of Otezla in patients with plaque psoriasis (Papp, et al; Gottileb, et al.; Crowley, et al.). Otezla demonstrated significant improvements in mean percentage change in psoriasis area, severity index (PASI) score, and in pruritus. Furthermore, PASI response was maintained over 52 weeks with continued Otezla treatment (Gottileb, et al.). The records indicate that this patient has failed first-line therapies with high potency topical steroids, Humira, and methotrexate, in addition to triamcinolone and clobetasol. Given the support in the medical literature, Otezla 30mg 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with multiple sclerosis (MS), fatty liver, type two diabetes, and obstructive sleep apnea. The patient also has a history of depression, fatigue, and dizziness. On 10/16/18, the patient reported cognitive difficulties, fatigue after exercise, and numbness in the extremities. The patient has been treated with Vyvanse, Glucophage, Invokana, Tysabri, Valium, fish oil, and vitamin D3 5000 units per day. Physical examination findings on 10/16/18 included a slight tremor in the left upper extremity and decreased vibratory threshold bilaterally. A laboratory report dated 10/17/18 showed a vitamin D level of 37.5. The patient has requested reimbursement for a vitamin D screening test on 10/16/18. The Health Plan denied the request and reported the service at issue was not medically necessary for the evaluation of this patient. At issue in this case is whether the requested vitamin D screening test on 10/16/18 was medically necessary for evaluation of the patients medical condition. Vitamin D has a role in calcium physiology and bone health, but also has numerous potential extra-bone actions such as cardiovascular system protection, anti-infectious properties, anti-inflammatory properties, and immunomodulatory effects involved in autoimmune diseases such as type one diabetes and MS. Immunological and genetic studies in MS patients have suggested that abnormalities involving vitamin D metabolism are related to the risk of the disease. Most patients with MS have vitamin D insufficiency, including in the earliest stages of the disease. In the case of insufficiency, vitamin D supplementation should be undertaken in order to raise the vitamin D serum level up to the physiological range and maintain it within this range. In this case, the patient was diagnosed with MS and has a history of vitamin D deficiency. The medical evidence indicates an association of vitamin deficiency and MS. Vitamin D supplementation to optimal values must be achieved in patients with MS to improve neuronal function due to immunomodulatory effects. The level of vitamin D is important to measure and should be kept above 30 ng/ml range. Therefore, the vitamin D screening test that was performed on 10/16/18 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee has requested reimbursement for the advanced lipoprotein testing that was received. The Health Plan has denied the services at issue as investigational for evaluation of the enrollees hyperlipidemia.Findings:  Three physician reviewers found that the records provided for review document that this patient has a history of hyperlipidemia and was previously treated with a statin. Recurring lipid profiles along with lipoprotein subfractions, apolipoproteins and lipoprotein (A) every weeks and dietary supplements were ordered by the treating provider. Elevations of these subfractions are associated with slightly increased cardiovascular risk, but no specific treatment has been proven effective in a randomized clinical trial. Therefore, the advanced lipoprotein testing that was received was not likely to have been more beneficial than any other available standard evaluation for this patients medical condition.Final Result: The reviewers determined that the requested testing was 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

At issue is whether the 4Kscore protein biomarker testing that was performed was likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The enrollee has a history of an elevated prostate specific (PSA) antigen level. He was diagnosed with benign prostatic hyperplasia, elevated prostate specific antigen, and a family history of malignant neoplasm of the prostate.Three out of three medical experts decided that the 4Kscore protein biomarker testing performed was not likely to have been more beneficial for you than any available standard therapy. The National Comprehensive Cancer Network (NCCN), European Association of Urology (EAU), and American Urological Association (AUA) guidelines recommend considering a 4Kscore protein biomarker for certain patients.  The guidelines do not consider the test as a standard of care for all patients with elevated PSA. There is insufficient data on clinical outcomes to currently support routine use in screening men for prostate cancer.Final Result: The reviewers determined that the requested test was 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 urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma genetic testing that was performed. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees melanoma.Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The DecisionDx-Melanoma gene testing was performed to assess the metastatic risk of the patients melanoma of at least 0.8 mm Breslow depth on the right upper calf in 2015. The patient was treated with immunotherapy via a clinical trial in 2016, but treatment was discontinued due to Grade 3 hepatitis. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. As such, the DecisionDx-Melanoma genetic testing performed was not likely to have been more beneficial than any other available standard therapy for this patients melanoma.Final Result: The reviewers determined that the requested testing was 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 dermatology 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 a history of osteoarthritis of both knees, currently more symptomatic on the left. There is a history of a fall in the past, but no recent mechanical symptoms. Previous examination revealed medial and lateral joint line tenderness. Later, a magnetic resonance imaging (MRI) scan of the left knee revealed tricompartmental osteoarthritis with several full thickness cartilage defects of the medial femoral condyle, moderate- to high-grade thinning of the articular cartilage of the lateral compartment, and moderate osteoarthritis of the patellofemoral joint. There was also a flap tear of the lateral meniscus noted. Evidence of old trauma with chronic sprains was documented. Examination later reported the patient presented with left knee pain. The provider reported the patient had Orthovisc several times in the past which helped. The patient reported a recent cortisone shot only lasted three weeks. The patient has had Orthovisc injections in multiple past years. The patient has requested authorization and coverage for Orthovisc injections in the left knee. Current medical literature reveals mixed results regarding viscosupplementation. Randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. Current evidence is limited, and guidelines from organizations such as the American Academy of Orthopaedic Surgeons indicate that the evidence is not conclusive. As such, the American Academy of Orthopaedic Surgeons does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this case, the patient has had lasting benefit from prior Orthovisc injections. Therefore, Orthovisc injections in the left knee 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 enrollee requested vortioxetine (Trintellix). Findings: The physician reviewer found that the medication requested is medically necessary. Based on a review of the record, the reviewer found that this patient has been treated with Zoloft and Viibryd, but experienced side effects with both medications. As noted in the medical literature, Trintellix is efficacious in reducing depressive and anxiety symptoms in patients with major depressive disorder and high levels of anxiety and the current clinical trial data is suggestive of a benefit of vortioxetine in generalized anxiety disorder. Given the support in the medical literature and reported benefit by the patient, Trintellix, is medically necessary for the treatment of this patients depressive disorder and anxiety.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 visited her podiatrist complaining of bilateral heel pain. Prior treatment has included three corticosteroid injections to the right heel, two injections to the left heel, meloxicam, weight loss, icing, and post exercise stretching. On physical examination, pain is noted upon palpation to the plantar medial heels bilaterally. Her diagnosis includes plantar fasciitis, recalcitrant. The provider recommended the patient continue icing, begin diclofenac daily, and continue Superfeet over-the-counter arch support orthotics. The patient reported improved pain. The patient is exercising and has lost 10 pounds, and continues to ice and stretch daily. The patient continues to exhibit pain to the medial calcaneal tubercle bilateral heels. The treatment plan included custom molded foot orthotics.The progress notes advised that patient has tried and failed numerous conservative treatments for bilateral heel pain. These treatments include oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), local corticosteroid injections, stretching, icing, weight loss, and Superfeet over- the-counter arch supports. Custom molded foot orthotics are a mainstay in the treatment of plantar fasciitis. Studies advise that certain foot structures will respond better to a custom molded insert and allow for dramatic healing of plantar fasciitis. Therefore, the requested custom molded foot orthotics that were provided were 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 doctor of podiatry, 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 patients language skills as assessed by the Clinical Evaluation of Language fundamentals-5 were within the typical range of development. An assessment of fluency was also within the typical range of development, although monitoring was suggested. The primary area of concern was speech sound development. Testing that utilized the Goldman Fristoe Test of Articulation-3 noted errors that included the following sounds: /r/; vocalic /r/; /th/, /dz/, as well as some idiosyncratic errors on /t/ and /b/. He also had a rapid rate of speech, which decreased intelligibility. Progress reports documented limited progress in the acquisition of the /r/ and vocalic /r/ sounds, and noted improvement in the production of multisyllabic words /th/ sound and reduction of the rate of speech. Daily notes documented that in many sessions he was unable to produce an approximation of the /r/ and vocalic /r/ sounds. Based on current medical literature and the American Speech-Language-Hearing Association, this patient does not meet the criteria for speech and language therapy. There is no updated standardized testing with a qualifying score that substantiates the need for continued speech therapy services. The last testing completed was over one year old. Additionally, this patient has made little progress in the acquisition of the /r/ and vocalic /r/ sounds. This is likely because these are inappropriate targets for this patients age. The acquisition of the /r/ and vocalic /r/ sounds are typically the last sounds acquired as they require the highest integrity of the tongue muscles. Moreover, the patient does not have an illness or injury to support an indication for services. The target sounds are inappropriate for his age. Therefore, speech and language therapy sessions are not medically necessary for treatment of this patients medical conditionFinal 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 Ph.D. with certificate of clinical competence in speech-language pathology, 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.