Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for power wheelchair accessories including sit to stand features. This patient presents with relapsing remitting multiple sclerosis. Per the provider, the patients condition has progressed, and she is unstable for transfers. The provider has recommended a power wheelchair with elevation seat system and power stander to enable her to safely perform activities of daily living and improve bilateral lower extremity swelling. There is a lack of evidence demonstrating that use of a power stander feature equipped on a power wheelchair provides clinically significant benefits with respect to health or functional outcomes in the setting of neurological weakness due to multiple sclerosis or other conditions impairing the active ability to stand. Overall, use of a power stander has not been demonstrated to improve muscle function, skin integrity, bony health, respiratory function, or digestive function in a significant manner in this patient population. With respect to wounds, the standing feature could mitigate risk in some areas, but would also introduce new areas that would be at higher-risk for pressure ulcer development. Power seat elevation can be an appropriate component for a power wheelchair in order to improve a patients independence with transfers. However, this patients records do not document that the patient is dependent on a mechanical transfer device for her transfers to support an indication for power seat elevation. Overall, there is a lack of documentation that the requested equipment will provide this patient with improved health or functional mobility. All told, the requested power wheelchair accessories, including sit to stand features, are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested power wheelchair accessories, including sit to stand features, are not 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 equipment is 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is 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 right eyelid ptosis repair. The records provided for review document that this patient sustained a right upper eyelid laceration and superior orbital roof fracture. The medical literature favors observation during the first 6 to 12 months after most injuries in this clinical setting to determine the need for surgery as well as the method and extent of repair. In this case, the providers advised the patient to delay ptosis repair surgery due to the proximity of the initial injury. There is a lack of evidence in the medical records that the requested surgery would be safe and beneficial for the patients condition. Therefore, the requested right eyelid ptosis repair is not medically necessary for treatment of 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 ophthalmology 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 and prospective authorization and coverage for partial hospital program (PHP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk of harm, due to intermittent suicidal ideation. In terms of functional status, the records support a score of 3. The documentation moderate impairment due to significant eating disorder.With regard to comorbidity, the records support a score of 3. The records documented the presence of tachycardia and orthostatic hypotension as a result of food restricting. She is at high risk of metabolic abnormalities and has lost weight since admission to PHP.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due to living with a roommate who is recovering from an eating disorder, but reported a supportive family. With regard to level of support of the recovery environment, the records support a score of 2 as the patient had a supportive recovery environment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment, reporting several admissions at varying levels of care over the past several years.With regard to treatment acceptance and engagement, the records support a score of 3. The patient had been adherent with treatment although she struggled with her eating plan. Thus, the patient had a total score of 21. In this case, the recommended level of care is Level 4, medically monitored non-residential care. Therefore, PHP services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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: The patients parent has requested authorization and coverage for Nourish formula. Dodrill and Gosa note that swallowing difficulties in pediatric populations can have a detrimental effect on dietary intake and, thus, growth and development. In this case, the patient depends on gastrostomy tube feedings for nutrition and fluid requirements. She has tried and failed multiple formulas, including Pediasure and Pediasure with fiber. The records show she has tolerated Nourish formula. Given that continued use of Nourish formula prevents malnutrition and unwanted side effects, it is medically indicated for this patient. Therefore, Nourish formula is medically necessary to promote physical and mental health and efficiency for this patient.Final Result: The reviewer determined that the requested formula is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued acute inpatient care. Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Anaplastic astrocytomas and glioblastoma multiforme are high-grade tumors that are best treated with resection, radiation therapy, and chemotherapy. This patient has experienced multiple complications from her brain tumor such as edema, mass effect, and stroke. The providers have documented that the patient has been nonverbal for many of her evaluations. According to the available medical records, the patient was clinically stable for discharge. Therefore, the continued acute inpatient care was not and is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 internal medicine with subspecialty certifications in medical oncology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued speech therapy, preferably for a period of at least six months. The benefits of speech therapy for children with autism spectrum are well established. However, published studies have not demonstrated positive outcomes of continued speech therapy in adults with autism spectrum disorder (Mulhern, et al.). Wilson and colleagues reported on a meta-analysis of published studies evaluating speech therapy in adults with autism spectrum disorder. The authors included 22 studies, which showed a wide range of effects from near-zero to large effects. Differences in intervention strategies and durations, as well as in patient characteristics and outcome measures, presented barriers to aggregation. The authors concluded that there is a need for increased high-quality research examining interventions targeting expressive communication in adults with autism spectrum disorder. The records provided for review do not document that this patient has made substantial progress over the past two years in speech therapy. A review of his most recent evaluation from 8/3/20 indicates that he met 0/3 individual speech therapy goals and 0/3 group speech therapy goals. Given the current medical literature and this patients lack of progress, continued speech therapy, for a period of at least six months, is not medically necessary for treatment of 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated carbon dioxide (CO2) laser to the bilateral face, scalp, chest, abdomen, left shoulder, and groin with topical application of 5-fluorouracil (5FU). Intralesional injection with triamcinolone acetonide (TAC) represents the gold standard in the treatment of keloids, with the fastest response. Fractionated CO2 has been demonstrated to be as efficient, and possibly more effective, than TAC for some patients. Given the severe symptoms associated with this patients disease including infection and purulent drainage, he would most likely benefit from TAC combined with fractionated CO2. However, the medical literature does not support the long-term safety and efficacy of 5FU for the treatment of keloids. Based on these findings, initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated CO2 laser to the bilateral face, scalp, chest, abdomen, left shoulder, and groin are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the topical application of 5FU is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated CO2 laser are likely to be more beneficial for treatment of the patients condition than any available standard therapy, while the topical application of 5FU is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Humira (adalimumab). Currently, the peer-reviewed medical literature lacks randomized controlled trials demonstrating long-term health improvement with Humira for the treatment of folliculitis decalvans. Researchers reported on 60 patients with a minimum follow-up of five years. The authors found that of the 21 patients with folliculitis decalvans treated with clindamycin and rifampicin, 91% achieved a response, which was a greater than 75% improvement in symptoms and inflammatory signs as compared to standard therapies. This patient presents with a diagnosis of folliculitis decalvans treated with doxycycline, tetracycline, intralesional Kenalog, prednisone, and isotretinoin. Data supports the use of rifampicin with clindamycin as compared with Humira for this patient. The patients records do not include evidence that the patient has failed treatment with  rifampicin with clindamycin. For these reasons, the requested Humira (adalimumab) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Humira (adalimumab) is not 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 medication is 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 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 requested authorization and coverage for any or all of ten (10) treatment sessions of transcranial magnetic stimulation (TMS) (CPT 90868). Perera and colleagues note that daily left prefrontal TMS therapy has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Benadhira and colleagues found that repetitive TMS (rTMS) could represent a novel strategy for preventing relapse in patients with treatment resistant depression who respond to rTMS treatment. In this case, given that the patients test scores show she is still experiencing symptoms consistent with the acute phase of severe depression, the requested services are medically indicated. Therefore, all ten (10) treatment sessions of TMS (CPT 90868) 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 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: An enrollee has requested authorization and coverage for removal of C5 to C7 hardware, conversion to C5, C6-7 artificial disk replacement, as well as C4-5 artificial disk replacement.Lanman and CuEllar have published a case report involving five patients in which they describe the technique and outcomes of the conversion of prior anterior cervical discectomy and fusion (ACDF) with pseudarthrosis to an artificial disc replacement (ADR). They concluded that the reversal of ACDF and conversion to an artificial disc replacement is feasible and achieves postoperative range of motion that is similar to that achieved when performed in a segment not previously fused. Spinelli and colleagues published a case report in which they presented a conversion from an anterior cervical discectomy and fusion (ACDF) to cervical arthroplasty in a 40-year-old, and performed a review of the literature. They found that revision of ACDF to arthroplasty is an exceedingly rare procedure with only two cases reported in the literature. They also concluded that when facet joint degeneration or ankylosis is absent, restoration of motion can successfully, and safely, be achieved. These case reports reflect that a patient who has a pseudoarthrosis may possibly be eligible for conversion to artificial disc.In this case, the patient is a 42-year-old who previously underwent C5-7 ACDF. The patient is now being proposed to have conversion to C5 to C7 artificial disk, removal of C5 to C7 hardware, and an artificial disk at C4-5 level. Apparently, there is a pseudoarthrosis. However, there is no indication that flexion extension x-rays have been performed to see if this is a stable pseudoarthrosis or not. When considering the proposed procedure, it is important that normal facet joints are present, and there is no mention of this in the patients work up. Under these circumstances, the requested removal of C5 to C7 hardware, conversion to C5, C6-7 artificial disk replacement, as well as C4-5 artificial disk replacement are not medically necessary for the patients condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patient's 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for budesonide EC 3 mg CAPDR  ER is medically necessary for treatment of this patient. In this case, the patients celiac disease has not responded to attempts at a gluten-free diet. Biopsies have shown ongoing infiltration with intraepithelial lymphocytes consistent with persistent disease activity (Rubio-Tapia, et al.; Husby, et al.). The American College of Gastroenterology (ACG) guidelines recommend consideration of treatment with medication as an adjunct to gluten-free diet in this clinical setting (Rubio-Tapia, et al.). Patients attempting a strict gluten-free diet often experience accidental gluten exposure (Therrien, et al). The standard option for the treatment of refractory celiac disease is open-capsule budesonide, which has demonstrated clinical and histologic improvement in celiac disease refractory to other measures (Mukewar, et al.; Therrien, et al.). In this case, the patient has attempted a gluten-free diet for over one year, with persistent histologic celiac disease. For these reasons, the requested budesonide EC 3 mg CAPDR  ER is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.