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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological services. ADHD is the most common neurobehavioral disorder in children. Per the American Academy of Pediatrics (AAP), there is evidence that appropriate diagnosis can be accomplished in the primary care setting for children and adolescents. To make a diagnosis of ADHD, the primary care clinician should determine that DSM-5 criteria have been met, including documentation of symptoms and impairment in more than 1 major setting, with information obtained primarily from reports from parents or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescents care. The AAP does not recommend neuropsychological testing as an initial evaluation for possible ADHD. An evaluation of a young patient for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patients school or day care functioning, evaluation for comorbid psychiatric disorders, and review of the patients medical, social, and family histories. The records provided for review do not document a history suggestive of low cognitive ability or low achievement in language or mathematics relative to the patients intellectual ability. In addition, there is a lack of documentation that the patient has any underlying medical or psychiatric disorders which might confound the diagnosis of ADHD, such as significant head trauma, brain tumor or symptoms suggestive of neurogenerative disorder. Moreover, there is no evidence of developmental delays. Given these findings, the neuropsychological services  were not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for services at a tertiary level of care. Ehlers-Danlos syndrome is an inherited collection of disorders of connective tissue, with signs and symptoms involving hyperextensibility of the skin, hypermobility of joints, and tissue fragility. Arthrochalasia-type Ehlers-Danlos syndrome is characterized by frequent dislocations of major joints, hypermobility, and in some cases, genetic intractable nausea and vomiting. These signs and symptoms are consistent with this patients presentation. Pain is a significant issue in these patients because of tissue damage, joint damage, dislocations, and previous surgeries. This patient initially presented to his provider with abdominal pain, constipation, and nausea. As he got older, his symptoms became more severe, so that he now experiences near-continuous nausea with vomiting. He has since received a diagnosis of arthrochalasia-type Ehlers-Danlos syndrome. His symptoms were well-managed in the past by his pediatric gastroenterologist. Despite his diagnoses of autism and attention-deficit/hyperactivity disorder (ADHD), the provider was able to connect with the patient and they developed a good working relationship. Now that his symptoms are debilitating, it is even more important to have a good working relationship with his provider, taking into consideration all of his medical problems and mental health diagnoses. Given these findings, the requested services at a tertiary level of care 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 pediatrics with subspecialty certification in pediatric critical care 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 referral to a hematologist. Macrocytosis without anemia may be related to specific drugs, including metformin, excessive alcohol intake, non-alcoholic liver disease, or nutritional deficiencies, including vitamin B12 and folate. With regard to B12 deficiency, Pavlov and colleagues note that vitamin B12 deficiency most significantly affects functions of blood, nervous system and inflammatory response. In this case, the patient has a history of polyneuropathy and is taking vitamin B supplements, which appear to be helping. She also has type 2 diabetes, which may be contributing to her painful neuropathy. Laboratory testing demonstrated increased mean corpuscular volume (MCV) suggestive of mild macrocytosis. Additionally, this testing demonstrated normal B12 and folate levels. The patient is also on metformin, which is associated with macrocytosis. The noted macrocytosis was not noted on prior hemograms. Based on a mildly abnormal MCV on one hemogram without anemia, a referral to hematology is not medically indicated at this time. Therefore, the requested referral to a hematologist is not medically necessary for the evaluation of this patient. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT 84999 and 83520). The records provided for review document that this patient presented with Crohns disease while on treatment with vedolizumab. The patient underwent testing with Prometheus Biosciences Anser VDZ, which revealed detectable serum vedolizumab and undetectable antibodies to vedolizumab. Although therapeutic drug monitoring has the potential to improve the outcome parameters of vedolizumab treated patients with Crohns disease, the peer-reviewed medical literature has not demonstrated a clinically meaningful antibody level for vedolizumab. In addition, immunogenicity to vedolizumab is found approximately fewer than 1% of patients with persistently positive anti-vedolizumab antibodies. The low immunogenicity of vedolizumab limits the utility of determining vedolizumab antibody levels to direct treatment planning. For these reasons, the laboratory testing (CPT 84999 and 83520) not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the laboratory testing (CPT 84999 and 83520) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for transcranial magnetic stimulation (TMS) treatment. Carmi and colleagues describe obsessive-compulsive disorder (OCD) as a chronic and disabling disorder with poor response to pharmacological treatments. Using the Yale-Brown-Obsessive-Compulsive Scale (YBOCS) to measure clinical response to treatment, the authors found that treatment-resistant OCD participants treated with high-frequency deep TMS experienced an alleviation in OCD symptoms. The U.S. Food and Drug Administration (FDA) has approved the use of TMS for the treatment of OCD. In this case, the patient has undergone multiple treatment trials, without response. Therefore, TMS treatment is likely to be more beneficial for treatment of this patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcranial magnetic stimulation (TMS) treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Advair 500/50. Advair is the combination of fluticasone, an inhaled corticosteroid (ICS), and salmeterol, a long-acting B2 agonist (LABA). The National Institutes of Health Guidelines from the National Asthma Education and Prevention Program note that treatment of asthma involves a sequence of steps up or down based upon the patients response and severity of the disease. The recommended initial treatment for mild intermittent asthma, less that two episodes weekly, is a short-acting beta agonist (SABA) which can be stepped up to combination therapy with an ICS and a LABA. Options for combination ICS and LABA therapy include Advair and generic versions, Symbicort, Flutiform, Seretide metered dose inhaler (MDI) versus Accuhaler, Dulera and Breo Ellipta. Longphre and colleagues note a clinical bioequivalence of Advair Diskus to its generic version. In this case, the patient has mild intermittent asthma that is well controlled and would benefit from treatment with a combination ICS and LABA therapy. Current medical literature does not endorse brand-name Advair over generic alternatives. Therefore, Advair 500/50 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Researchers note the possibility that the sedentary nature of power wheelchair usage results in a decline of physical functionality and therefore reduced capabilities in their users. In this case, the patient has a diagnosis of paraplegia. His upper extremities were weak from deconditioning, but were neurologically unaffected by his lower extremity paraplegia and with the appropriate therapy program were expected to improve. The records do not show evidence of a recent therapy program for the upper extremities to strengthen and condition for manual wheelchair use, or of a concrete discharge plan at this time. While a manual wheelchair with tilt in space may be appropriate in the future when the patient is able to self-propel, a power wheelchair is not currently indicated. Therefore, a power wheelchair is not medically necessary to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with an orthopedic surgeon. Current evidence-based peer-reviewed medical literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. Ganglion cysts may arise in any location in the hand and wrist but are usually adjacent to joints, tendons, or bones. Observation is acceptable in most instances. Indications for operative treatment includes pain, interference with activity, nerve compression, and ulceration of the mucous cysts. This patient reports a large cyst on her index finger that is painful and disfiguring. She reports that her condition interferes with the use of her hand. The submitted medical records document a ganglion cyst on her small finger with a request for orthopedic consultation. The records do not document that the patients primary care provider has examined the cyst or that initial conservative management has been attempted. There is a lack of compelling rationale to support a referral to an orthopedic specialist when the patients primary care provider should perform initial evaluation and management of these complaints. Therefore, the requested consultation with an orthopedic surgeon is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of breasts (CPT 77049). The clinical documents provided for review indicate that this patient has heterogeneously dense breast tissue. In addition, the records report that the patients breast malignancy was not visualized on mammogram or ultrasound performed either before or after MRI. However, the, MRI detected the patients breast abnormality. Given this, surveillance MRI in this clinical setting is consistent with National Comprehensive Cancer Network (NCCN) recommendations (Gradishar, et al.). The MRI was helpful for surveillance and to identify in-breast tumor recurrence at the earliest possible timepoint, which  gives the patient the best chances for improved long-term survival. All told, the MRI of breasts (CPT 77049) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the MRI of breasts (CPT 77049) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an appointment with a psychiatrist that specializes in obsessive compulsive disorder (OCD) at least once per month. The American Academy of Child and Adolescent Psychiatry (AACAP) guidelines recommend starting treatment for OCD with cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI). The American Academy of Child and Adolescent Psychiatry (AACAP) noted that combined treatment is more effective than monotherapy for patients with severe OCD. For patients who do not respond, options include raising SSRI dosage, switching to clomipramine, and pursuing various augmentation strategies such as second generation antipsychotics. The appropriate frequency of CBT depends on the severity of the patients symptoms, whether suicidal ideation is present, and the complexities introduced by co-occurring conditions. One specific type of CBT called exposure and response prevention (ERP) has the strongest evidence supporting its use in the treatment of OCD. This type of therapy should be delivered on an outpatient basis weekly or twice weekly depending on the severity of the problem. The records suggest that the patients psychiatric treatment has been consistent with practice guidelines. There is a lack of documentation to support a change in treatment with a psychiatrist that specializes in OCD. Therefore, the requested appointment with a psychiatrist that specializes in OCD at least once per month is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent 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 the medication Rituxan.Neuromyelitis optica (NMO) is a severe demyelinating disease that predominantly affects the optic nerve and spinal cord. Prophylactic treatment of NMO recurrence must be immediately performed when NMO is identified, because the progression of NMO disability is related to the severity of attacks. Researchers noted in their meta-analysis that Rituxan is used as a prophylactic first-line treatment because it can reduce the severity of disease recurrence. Rituxan has acceptable tolerance, reduces the relapse frequency, and improves disability in most patients with NMO. Researchers noted that B cell depletion with Rituxan has been demonstrated as effective in the treatment of NMO. Rituxan is now increasingly also used in treatment-naive NMO patients with high disease activity. Researchers compared the efficacy and tolerability of azathioprine, mycophenolate mofetil and lower dosages of rituximab among patients with neuromyelitis optica spectrum disorder (NMOSD). They concluded that all are effective in reducing annualized relapse rate and improving the clinical symptoms of patients with NMOSD. Lower dosages of rituximab are more effective than the others in decreasing the CD19 B-cell counts. Mycophenolate mofetil and reduced rituximab decrease AQP-4-IgG titers more and cause fewer adverse events than azathioprine. In this case, the patient has seropositive neuromyelitis optica. Based on the above-referenced studies, Rituxan is recommended as first-line treatment and is effective in the prevention of disease recurrence. There is also evidence that Rituxan may be more effective and cause fewer adverse events than azathiorpine. Accordingly, the requested Rituxan is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.