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 hip surgery arthroscopy hip with femoroplasty and arthroscopy hip with labral repair. Findings:  The physician reviewer found that Hip arthroscopy appears to be a safe and efficacious treatment for labral tears and femoroacetabular impingement (FAI) in older patients who do not have significant underlying degenerative changes. However, in this population, there is a significant proportion of patients who eventually require hip arthroplasty. Outcomes may be affected by type of treatment (i.e. labral debridement versus repair). Additional high-quality studies are needed to understand how these factors affect outcomes. Khan and colleagues report, Arthroscopic intervention results in improvements in functional outcomes at both the short-term and midterm for patients with symptomatic FAI in the absence of significant existing degenerative changes. Labral repair may result in improvements over labral debridement. In this case, the patient has a left hip labrum tear and history of bilateral hip pain and coccydynia. The patient reports persistent pain despite participation in physical therapy and home exercise. An examination of the left hip showed a painful range of motion with a hip extension of zero degrees, flexion of 100 degrees, internal rotation of ten degrees, external rotation of 45 degrees, hip strength at five out of five, and a positive FABIR test. While the provider noted FAI, this was not supported by imaging studies. Therefore, hip arthroscopy with labral repair (CPT 29916) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital services at Los Robles Regional Medical Center. Findings:  The physician reviewer found that the patient was admitted with a history of gastroesophageal reflux disease (GERD) and ongoing chest and neck discomfort. He had normal electrocardiogram (EKG) results, negative troponins, and diagnostic imaging did not show aortic dissection. The patient was treated for gastrointestinal symptoms and hypertension, with symptoms improving rapidly, and he was ready for discharge the following day. In this clinical setting, the patients low cardiac risk could have been managed at a lower level of care.    Therefore, inpatient hospital services at Los Robles Regional Medical Center were not medical necessary for the treatment of this patient.Final Result: The reviewer determined that 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a continuous positive airway pressure (CPAP) machine and supplies. Findings:  The physician reviewer found that the use of CPAP therapy for ongoing treatment of obstructive sleep apnea (OSA) in adults. In this case, the patient has a diagnosis of OSA. The records noted that she was using and benefiting from a CPAP machine and was symptomatic when not using it. Given that OSA is a chronic disease requiring treatment, and that CPAP is the first line of treatment for OSA, the equipment at issue was medically indicated. Therefore, CPAP machine and supplies were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue 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 sub-specialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Current medical literature supports the use of TMS for the treatment of refractory and chronic depression. McClintock and colleagues note that there is an abundance of data pertaining to the safety and efficacy of TMS for individuals with major depressive disorder. The American Psychiatric Association (APA) guideline for the treatment of major depressive disorder recognizes the safety and efficacy of TMS in the treatment of patients with a prolonged course of depression. Kisely and colleagues report that deep brain stimulation shows promise for treatment-resistant depression. In this case, the patient has a long history of refractory depression, with continued significant neurovegetative symptoms. The records document numerous medication trials and difficulty tolerating most medications due to adverse effects and limited efficacy. The patient has been in evidence-based therapy with limited improvement. In this clinical setting, the requested service is medically indicated. In this patients case, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS is 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 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: An enrollee has requested authorization and coverage for Tandem T:Slim X2 Insulin Pump.Insulin pump technologies have advanced dramatically in the last several years to integrate with continuous glucose monitors (CGM) and incorporate control algorithms. The Medtronic MiniMed 670G system was the first commercially available hybrid closed-loop system (HCL). It uses the MiniMed 670G insulin pump, the Guardian 3 CGM glucose sensor, and a modified proportionalintegralderivative (PID) algorithm called SmartGuard technology. According to Saunders and colleagues, the MiniMed 670G system responds to the sensor glucose value and automatically adjusts basal insulin delivery every five minutes by either increasing, decreasing, or suspending insulin delivery. The T:Slim, unlike the 670G, is a newer closed loop system which uses the Control-IQ system to incorporate a factory-calibrated CGM and automated correction boluses, in addition to automated basal delivery, to improve benefit and reduce burden. A recent study by Brown and colleagues demonstrated lower glycemic variability and greater percentage of time in target range for patients using this system versus a hybrid closed loop. In this case, the patient has had extreme glycemic variability with his current insulin pump and sensor. Therefore, Tandem T:Slim X2 Insulin Pump is medically necessary for the treatment of the patients medical condition.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 sub-specialty certification in endocrinology, diabetes, 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 patient has requested authorization and coverage for Velphoro (sucroferric oxyhydroxide). Researchers note that a prescription of sucroferric oxyhydroxide as monotherapy to phosphate binder (PB) naive patients, or in addition to existing PB therapy, is associated with significant improvements in serum phosphate control and a low daily pill burden. In this case, the patient has failed conventional therapy with sevelamer, and calcium binders are contraindicated due to his borderline hypercalcemia. In this clinical setting, the requested medication is medically indicated for management of secondary hyperparathyroidism in this case. Therefore, Velphoro (sucroferric oxyhydroxide) 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 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: An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules. Findings:  The physician reviewer found that gastroesophageal reflux disease (GERD) and esophagitis are at least partially caused by mechanical defects in esophageal motility. Scarpignato and colleagues indicate that since proton pump inhibitors (PPIs) do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Usai and colleagues state that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barrett's esophagus. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no significant difference in control and healing of gastroesophageal reflux disease. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. In a study by Fass and colleagues, a significant majority of patients (88%) requiring other PPIs twice daily were able to control symptoms on Dexilant once daily. Dexilant is also more effective to treat heartburn than alternatives such as esomeprazole. American College of Gastroenterology guidelines for the treatment of GERD do recommend proton pump inhibitor therapy, especially in patients with complications such as esophagitis. In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole. Although additional similar proton pump inhibitors have not been attempted, they are unlikely to be effective after failure of omeprazole and pantoprazole. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant (dexlansoprazole) 60 mg delayed-release capsules are medically necessary for the treatment of the 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 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 computed tomography (CT) scan with contrast of the chest. Findings:  The physician reviewer found that For patients with pulmonary embolism (PE) that is unprovoked or in which risk factors cannot be reversed, lifelong anticoagulation is recommended. Follow-up imaging is not recommended, as resolution of the PE would not lead to a recommendation for discontinuation of anticoagulation as the threat of another life-threatening PE still exists. Guidelines do not endorse imaging in this clinical setting. In this case, the patient incurred an unprovoked saddle PE in August 2020. On 9/03/20, the pulmonologist recommended lifelong anticoagulation. Therefore, the requested CT scan with contrast of the chest is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: An enrollee has requested authorization and coverage for Stelara injections every 4 weeks.Findings: Current medical literature supports dose escalation of Stelara every four weeks in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. A study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications. In another study, dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Additionally, multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has failed alternative medications (such as Remicade and Humira), and required budesonide to control disease symptoms while on Stelara every 8 weeks. The patients tested Stelara level was unlikely to be sufficient to control Crohns disease. Continued use of Stelara every eight weeks or a change to another medication may result in worsening disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization or need for surgery. Therefore, the requested Stelara injections every 4 weeks are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication regimen 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esomeprazole magnesium DR 40 mg capsule.Researchers state that GERD is at least partially caused by mechanical defects in esophageal motility. According to researchers, since proton pump inhibitors do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Moreover, medical literature indicate that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barretts esophagus. Multiple studies show superior healing of erosive esophagitis with 40 mg daily dosing of proton pump inhibitor rather than 20 mg. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no difference in the control and healing of gastroesophageal reflux disease. In this case, the patient has had GERD symptoms requiring treatment, and endoscopic biopsies revealed esophagitis. Records indicate that the patient did not have sufficient control with multiple proton pump inhibitors (pantoprazole, omeprazole, lansoprazole, and Dexilant). Although the formulary alternative rabeprazole has not been attempted, it is unlikely to be effective after failure of multiple other proton pump inhibitors. Alternatively, esomeprazole 40 mg daily has been effective. Therefore, esomeprazole magnesium DR 40 mg capsule is medically necessary for the treatment of the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for speech therapy twice a week. The records provided for review document that this patient demonstrated inadequate progress in her speech and language skills during the last evaluation period, as her therapy transitioned to telehealth due to the pandemic. The patient has regressed in her receptive language but has made some progress in expressive language. She has also made progress in articulation. As noted in the medical literature, children with autism spectrum disorder frequently have difficulty attending to telehealth therapy, and loss of skills during the pandemic has been a significant issue for children with developmental disabilities, especially autism spectrum disorder. Manning and colleagues described stress around therapeutic service disruption in families of children with autism spectrum disorder due to the pandemic. The authors noted that the provision of speech therapy to children with autism spectrum disorder is considered the standard of care. Baumer and Spence reported that the treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech and language, occupational, and physical therapies. Moreover, the American Academy of Pediatrics (AAP) recommends speech therapy as a standard of care, stating that Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder (Hyman, et al.). Since this patient met one-third of her goals and made moderate progress towards her other two goals even with her transition to telehealth, she should continue to receive speech therapy services to address her remaining goals and prevent regression of newly acquired skills. The requested services are in accordance with the generally accepted standards of mental health care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested speech therapy twice a week is 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.