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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiac computerized tomography (CT) scan for calcium scoring. Findings: Based on current medical literature, coronary artery calcium (CAC) scoring has been shown to be of benefit in those with intermediate risk, defined as a ten-year risk of coronary artery disease of at least 7.5% and in some cases as low as 5%. In this case, the American College of Cardiology calculated ten-year coronary artery disease risk score is less than 2% for this patient. Given that the patient has a very low ten-year risk for coronary artery disease, and as bicuspid aortic valve is not an established risk factor for coronary artery disease but rather a risk factor for aortopathy and aortic stenosis, the requested service is not medically indicated. Therefore, cardiac CT scan for calcium scoring is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for intraosseous basivertebral nerve ablation (Intracept procedure). Current medical literature supports the use of the requested procedure in leading to statistically significant improvement over standard therapies including physical modalities and injections. Truumees and colleagues report that in patients with chronic low back pain and Modic type 1 or type 2 vertebral endplate changes, treatment with minimally invasive radiofrequency ablation of the basivertebral nerve resulted in significant improvement in pain and function. The referenced articles do also indicate this procedure is not recommended in cases with radiculopathy present. In this case, the patient reports persistent non-radiating low back pain despite prior maximal conservative treatment. However, there is no recent physical examination presented within the last 12 months to document the absence of radiculopathy findings which would make the procedure contraindicated.  In this clinical setting, intraosseous basivertebral nerve ablation (Intracept procedure) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested intraosseous basivertebral nerve ablation (Intracept procedure) 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 service 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power stand module (for tilt only) and/or eight-way rocker (multi-function electronics) for the authorized Group 4 power wheelchair. Findings: This patients records support a history of cerebral palsy, which is a nonprogressive condition due to a brain injury or lesion acquired in the antenatal, perinatal or early postnatal period. The patient independently uses a power wheelchair as their primary means of mobility in the home and community. The patient was authorized for a Group 4 power wheelchair, which is appropriate given the age and state of disrepair of her current wheelchair. However, the requested power stand module (for tilt only) and eight-way rocker (multi-function electronics) are not medically necessary for treatment of this patient. As noted in the medical literature, regular passive standing with use of a power standing feature equipped on a power wheelchair, has not been demonstrated to provide clinically significant benefits with respect to health or functional outcomes in patients with severe neurological weakness causing tetraplegia such as spastic tetraplegic cerebral palsy, with an inability to actively stand. Overall, there is a lack of high-grade evidence that use of a power stand module improves muscle, respiratory, urinary, or digestive function in this patient population, or that skin integrity or bony health are improved with their use. Power recline is routinely used to provide relief from discomfort in patients who use power wheelchairs as their primary means of mobility but do not have the means to independently reposition themselves without assistance. With respect to function, the patients home environment can be adapted to meet the patients accessibility needs for hand hygiene, preparing meals, and other activities of daily living. Use of the requested power stand module is not expected to improve the patients functional course in the long-term with respect to transfers. Moreover, there is a lack clinical rationale to support the requested eight-way rocker system in the available documentation or medical literature. For these reasons, the requested power stand module (for tilt only) and eight-way rocker (multi-function electronics) for the authorized Group 4 power wheelchair are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is 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 physical medicine and rehabilitation 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 magnetic resonance angiogram (MRA). Fibromuscular dysplasia is a disease of the arteries which predisposes aneurysm formation and dissection. In a review of the U.S. Registry for Fibromuscular Dysplasia, incidence of dissection was noted in approximately 25% of patients (Kadian-Dodov, et al.). Given the high incidence of aneurysms and dissections as well as subsequent hemorrhagic and ischemic complications, the authors recommend baseline imaging in all patients with fibromuscular dysplasia. In this case, the patient underwent cervical vessel imaging because she was symptomatic with headaches and pulsatile tinnitus. A computed tomography angiography (CTA) six months ago revealed internal carotid artery vessel dissections and vessel narrowing. The patient was placed on antiplatelet therapy for the prevention of dissection propagation and stroke. At this time, it is unknown whether the patients dissections have improved, remained stable, or worsened since her initial diagnosis. OConnor and Gornik noted that considering the risk of complication, imaging surveillance is required, although the exact timeline of imaging has not been determined. In this clinical setting, the patients provider is an interventional neuroradiologist subspecialized in the care of the vessels of the head and neck. The patients provider has recommended a six month interval for follow-up after diagnosis and initiation of treatment. On follow-up, the provider recommended further evaluation with an MRA. Per the American College of Radiology (ACR), MRA is appropriate for the initial and follow-up evaluation of this patients cervical vessel anomaly. Therefore, the requested MRA is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neuroradiology with subspecialty certification in diagnostic radiology 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 authorization and coverage for computed tomography (CT) scan of the heart, without contrast, with quantitative evaluation of coronary calcium. In this case, the patient has increased coronary risk. The ACC and American Heart Association (AHA) clinical practice guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary calcium quantification, coronary CT scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. While the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data from controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable with treatment based on standard risk factor profiling and basic lipid analysis. Therefore, CT scan of the heart, without contrast, with quantitative evaluation of coronary calcium is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested CT scan of the heart, without contrast, with quantitative evaluation of coronary calcium 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 service 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 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Breg Vista multi-post cervical collar. There is a paucity of evidence in current medical literature to support the use of cervical collars in general in the treatment of neck pain. When considering recommendations for the management of spinal disorders including neck pain, Chou and colleagues concluded, Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction. In a clinical practice guideline for physical therapists addressing the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, Bier and colleagues specify, The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar. In a systematic review of the effectiveness of conservative treatment for patients with cervical radiculopathy, Thoomes and colleagues found, There is low-level evidence that a collar is no more effective than physiotherapy at short-term follow-up and very low-level evidence that a collar is no more effective than traction. The authors further concluded, On the basis of low-level to very low-level evidence, no one intervention seems to be superior or consistently more effective than other interventions. In this case, the patient is undergoing treatment for cervical radiculopathy. Notes reported that the patient is experiencing neck and arm pain. While the provider has recommended the use of a cervical collar, given the lack of evidence in current medical literature supporting the use of cervical collars in the management of chronic neck pain, the requested equipment is not medically indicated. Therefore, a Breg Vista multi-post cervical collar is not medically necessary for the treatment of this patient.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.
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 office visits and hyperbaric oxygen therapy (HBOT) services. The records provided for review indicate that the patient is status post bilateral modified mastectomies with advancement flaps and free nipple grafting as part of gender confirmation procedures. The patient underwent treatment with HBOT to help prevent graft failure. On review of the peer-reviewed medical literature, HBOT has not been shown to have prophylactic value in preventing graft or flap failure. Current data suggests that HBOT can be effective in the treatment of patients with failing flaps and graft. However, there is a lack of support for use of HBOT as an adjunctive therapy to prevent graft failure. There is a paucity of clinical studies showing benefit in routine adjunctive use of HBOT in the management of graft healing following nipple grafts. Researchers found that for patients with foot ulcers due to diabetes, HBOT significantly improved the ulcers healed in the short-term but not the long-term and the trials had various flaws in design and/or reporting that means we are not confident in the results. The authors concluded that, More trials are needed to properly evaluate HBOT in people with chronic wounds. All told, the office visits and HBOT services were not and are 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 preventive medicine, critical care medicine, and undersea and hyperbaric 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for next generation sequencing (NGS) and comprehensive genetic testing. Per the National Comprehensive Cancer Network (NCCN) guidelines, molecular diagnostic studies, such as next generation sequencing (NGS), is considered the standard of care for the evaluation of patients with non-small cell lung cancer (NSCLC). As noted in the medical literature, numerous gene alterations have been identified that impact therapy selection (Jordan, et al.; Robson, et al.). The NCCN strongly recommends broader molecular profiling with the goal of identifying rare driver mutations for which effective therapies may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. As noted in the medical literature, testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with Tempus is appropriate for this patient, who presents with a history of metastatic NSCLC. Previous testing with Tempus and Guardant360 do not obviate the need for additional NGS testing. Therefore, the requested NGS testing and comprehensive genetic testing is 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 requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for physical therapy, occupational therapy, and speech therapy provided at a skilled nursing facility (SNF). Functional impairments due to a cerebral stroke can be severe to profound. Functional recovery may be amenable to natural recovery processes and rehabilitative measures. However, the extent of initial injury generally determines the patients capability of engaging in recovery (Alawieh, et al.). Most of a patients significant neurological and functional recovery following a stroke occurs in the early stages after stroke, such as in the first 30 days, and gains are slower in the subsequent stages (Kubis). There is a general consensus that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes, but there is a lack of data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages (Belagaje; Gittler and Davis; Stinear, et al.). In the present case, the patient sustained a stroke in February 2022 following CABG surgery. The patient has undergone extensive rehabilitation efforts with therapy, but he has remained at a low level of function and continues to require maximum to total assistance for most basic self-care and mobility. The records indicate that the patients persistent left-sided hemiplegia has been a barrier to progress. The patient has remained at a custodial level of care and there is a lack of support for the requested therapy services in a SNF treatment setting. Therefore, the requested physical therapy, occupational therapy, and speech therapy provided at a SNF are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech therapy. Capone Singleton reports that a wait and see approach to delaying speech therapy services for children with developmental speech and language disorder may place late talking children who do not receive professional intervention at risk for life-long disability. Liu and colleagues explain, The ability to communicate effectively with others is central to children's development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. OHare and Bremner emphasize the need for comprehensive speech and language assessment, and for speech therapy, for children with speech and language difficulty. In this case, the patient has developmental speech and language disorder. The records note at a chronological age of 31 months, the patients cognitive ability was assessed as being equivalent to 24 months. While the records note that the patient has a vocabulary of approximately 25 words, the expected vocabulary for the patient's chronological age is between 50 to 100 words. Given the patients significant expressive language delay, and as speech delays will put the patient at a definite disadvantage both socially and academically, the requested services are medically indicated. Therefore, speech therapy 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.
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 physical therapy and occupational therapy at a skilled nursing facility (SNF). The records provided for review document that this patient presents with recent right-sided hemiparesis, difficulty walking, and hypertensive heart failure. The patient was admitted to a SNF and has been treated with physical therapy and occupational therapy. Hemiparesis is usually caused by stroke, but other potential causes include post-ictal hemiparesis, hemiplegic migraine, and psychiatric disorders (Fernandes, et al.; Terrin, et al.). The available charts indicate that by the date of denial, the patient made progress sufficient for community reintegration with home health services and custodial level assistance for management of her right-sided weakness with an unspecified etiology. There is a lack of support for ongoing physical therapy or occupational therapy services in the SNF treatment setting after the date of denial. By this date, the patient was a candidate for an alternative custodial level caregiver to assist her in the community. Therefore, the physical therapy and occupational therapy services at a SNF were not and are 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 physical medicine and rehabilitation 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.