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

Nature of Statutory Criteria/Case Summary: A 65-year-old male enrollee has requested reimbursement for skilled nursing home care services provided for five (5) days at the end of September 2018. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees osteomyelitis.At issue in this case is whether the skilled nursing home care services at issue, provided from for five (5) days at the end of September 2018, were medically necessary for treatment of the enrollees medical condition.Per Hakkarainen and colleagues the surgical population is aging, and greater numbers of surgical patients are being discharged to skilled nursing facilities. Post-acute care is a poorly understood but very important aspect of our healthcare system. The role of the care setting and care delivery in contributing to outcomes has not been well studied, and no strong conclusions can be made.  The progress note from the patients podiatrist dated mid-September 2018 advises extremely good healing of the right forefoot with a small Wagner grade 1 superficial ulceration. It is noted that the left toe amputation is completely healed. During this visit the podiatrist recommended continued skilled nursing facility stay for dressing changes and bed rest. It is further noted that the dressing orders were changed to a simple normal saline pat dry, apply medical honey with dry dressing daily. It was recommended that the patient be discharged to home. Taking into account the physical exam and recommendations from both the podiatrist and the nursing staff, the patient could have been transitioned home in the end of September of 2018. Therefore, skilled nursing home care services were not medically necessary for five (5) days at the end of September 2018.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for the medication OxyContin 80mg tablet, quantity 360 tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain. At issue in this case is whether the requested OxyContin 80mg tablet, quantity 360 tablets is medically necessary for treatment of the enrollees medical condition.The CDC Opioid Guidelines recommend less than 90mg morphine equivalents per day. The patient has a history of severe chronic neck pain that has been refractory to multiple conservative measures including physical therapy; aquatic therapy; multiple cervical fusions; cervical rhizotomies; and over 25 epidural injections to the cervical spine. The prior medication trials are not outlined. Despite these treatments, the patient continues to report severe pain. However, the request for OxyContin 80mg quantity 360, 3 tabs by mouth every 6 hours is beyond the norm for treatment of non-malignant chronic pain. This dose is much greater than the CDC recommendation for opioids and therefore not medically necessary.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment for Lyme disease with a specialist who is a certified. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees Lyme disease. A review of the records indicates that the enrollee has been diagnosed with chronic fatigue syndrome. The records indicate the enrollee had complained of fatigue, digestive problems, and occasional rashes. The enrollee wanted to be treated for Lyme disease. The enrollees provider has recommended treatment for Lyme disease with a specialist who is a certified. The patient does not have Lyme disease. Even if she did, she would be most effectively managed with a simple course of oral antibiotics. This therapy would best be delivered by an infectious diseases specialist. The ILADS physicians typically treat for extended periods use a variety of unproven herbal remedies and have no evidence base for their therapy. Therefore, the requested treatment is not medically necessary.Final Result: The reviewer determined that the requested treatment 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 infectious 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for bioimpedance spectroscopy. Measurements of arm circumference and arm volume are common ways to identify lymphedema at an early stage following treatment for breast cancer. Bioimpedance spectroscopy is a newer method of determining whether a patient may develop lymphedema. Given these findings, the bioimpedance spectroscopy services were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the bioimpedance spectroscopy services were and are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not and are 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: One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three 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 parent of an enrollee has requested authorization and coverage for the medication Vyvanse. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees autism and Attention Deficit Hyperactivity Disorder (ADHD). At issue in this case is whether the requested medication Vyvanse is medically necessary for treatment of the enrollees medical condition. Treatment guidelines and literature on ADHD for preschool age children indicate that: When the clinician and parents agree that medication is warranted for a preschool child, we suggest methylphenidate rather than amphetamines or nonstimulant medication. Overall there is minimal literature and studies on the use of stimulants in preschool age children and Controlled studies comparing methylphenidate with other medications for preschool children are lacking. The majority of literature and practice guidelines for children of the patients age recommend trials of methylphenidate as a first-line treatment. Methylphenidate comes in chewable, patch and liquid formulations. The requested medication Vyvanse is not approved for the patients age group and the records and do not indicate that the patient has tried or failed any methylphenidate formulations. Therefore, the requested medication, Vyvanse, is not medically necessary.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the Synagis vaccine. At issue in this case is whether the requested Synagis vaccine is medically necessary for treatment of the enrollees medical condition. In 2014, the American Academy of Pediatrics issued new guidelines for the administration of Synagis for respiratory syncytial virus (RSV) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease. The following groups of patients are considered at highest risk, with recommendations for administration of Synagis: infants born before 29 weeks gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger with hemodynamically significant congenital heart disease (excluding those with lesions adequately corrected by surgery unless medication is necessary for ongoing congestive heart failure); consideration for infants 12 months of age or younger with anatomic pulmonary abnormalities or neuromuscular disorders that have difficulty clearing secretions; consideration for infants less than 24 months of age that are profoundly immunocompromised; and consideration for infants with Down syndrome or cystic fibrosis that have evidence of other risk factors such as chronic lung disease or congenital heart disease. Researcher found, the current literature supports and substantiates the changes in administration guidelines made by the American Academy of Pediatrics. Based on the current American Academy of Pediatrics guidelines, Synagis is not medically necessary for this patient for the 2018-19 RSV season.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 pediatrics with subspecialty certification in pediatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom molded shoe inserts. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees pain. At issue in this case is whether the requested equipment, custom molded shoe inserts, is medically necessary for treatment of the enrollees medical condition.Researchers note that the potential of foot orthotics for reducing pain and injuries is convincing. The current study provides valuable information about the role of specific structural components of foot orthotics and contributes to the knowledge about the mechanism underlying the effect of foot orthotics in running. It is well established in the progress notes that patient suffers with bilateral ankle pain and knee pain. Patient also demonstrates osteoarthritic changes to the first metacarpophalangeal joint bilaterally. Physical examination also reveals flat feet bilaterally with a valgus heel position and pronation bilaterally. Custom orthotics are standard of care in the treatment of overpronation with a valgus heel deformity. These devices maintain the correct alignment of the foot (neutral position), allowing for reduction in stress and strain to both the medial and lateral aspects of the ankle. It is also noted that reduction in pronation of the subtalar joint reduces strain to the medial knee. The patient is extremely active and in need of biomechanical correction of the feet. Therefore, the requested custom molded shoe inserts are medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a high frequency chest wall oscillation (HFCWO) system. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees bronchiectasis.At issue in this case is whether the requested high frequency chest wall oscillation system is medically necessary for treatment of the enrollees medical condition.Bronchiectasis is a disease where the airways become inflamed and dilated, thus creating a fertile breeding ground for bacterial infections. Patients with bronchiectasis typically have a chronic cough and recurrent infections. Treatment for this includes antibiotics, hyperosmolar agents, anti-inflammatory agents and chest physical therapy. The goals of treatment are to reduce the number of exacerbations and to improve the patients quality of life.Researchers concluded that the HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physical therapy. This patient, based on the medical records, has obviously benefited from using HFCWO. It was documented the patient had a cough of two years duration prior to starting chest physiotherapy.  Patients with bronchiectasis have very thick mucous and difficulty clearing mucous. Chest wall oscillation therapy greatly improves the ability to do so. The benefits of the therapy are proven. Additionally, using HFCWO vests allows patients to be independent and provide therapy themselves, at their convenience. This is especially important when patients do not have other family around to provide traditional chest physical therapy. The medical records support the medical necessity of the requested high frequency chest wall oscillation system for this patient.Final Result: The reviewer determined that the requested device 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 pulmonary 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: An enrollee has requested authorization and coverage for Aimovig auto injections 70mg-ml.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine headaches. At issue in this case is whether the requested medication, Aimovig auto injections 70mg/ml, is medically necessary for treatment of the enrollees medical condition.Aimovig showed efficacy for chronic migraine headaches. two Phase II trials (one for episodic migraine and one for chronic migraine) and two Phase III trials for episodic migraine have been published demonstrating the efficacy and safety of erenumab in the prevention of migraine.Aimovig is Food and Drug Administration indicated for the treatment of chronic migraine headache that has failed two or more preventive medications.  The records indicate the presence of chronic migraine headache condition (more than 15 headache days per month).  The patient has reportedly failed 11 preventive agents.  Therefore, the medication Aimovig is medically necessary.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in  pain 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the corneal collagen cross-linking. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen over time. Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant, which places patients at risk for significant complications. Corneal collagen cross-linking has been studied extensively and is now considered part of the standard of care for patients with progressing keratoconus. As compared to a corneal transplant, corneal collagen cross-linking has little to no risk. In this patients circumstance, the use of corneal collagen cross-linking was indicated to address the patients progressive condition. Accordingly, the corneal collagen cross-linking was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the corneal collagen cross-linking was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in ophthalmology and is actively practicing. One Reviewer is board certified in ophthalmology and is actively practicing.  One Reviewer is board certified in ophthalmology and is actively practicing.  All three 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: enrollee has requested reimbursement for wound product (stem cell injections). The submitted documentation fails to demonstrate the superior efficacy of the services at issue. Stem cell implantation has been utilized successfully for the treatment of diabetic wounds and burns. There is research demonstrating some efficacy of stem cells in the treatment of osteoarthritis and regeneration of cartilage. However, the research is relatively new, and small studies have demonstrated minor effectiveness. Cheilectomies have been performed for many years to the first metatarsophalangeal for the successful treatment of hallux limitus/rigidness. In this particular case, the records do not demonstrate that the addition of the stem cells would be more beneficial than the standard surgical treatment alone. Therefore, wound product (stem cell injections) was not likely to have been of greater benefit than other treatment options. Findings:  Three medical professional reviewers found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in podiatry 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.