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 knee scooter. The documentation indicates that the patient was recently evaluated and has no change in her neurovascular status. The patient was advised to weight bear as tolerated. The provider reports that the patient is ambulatory with crutches, which does not suggest that the patient requires a knee scooter for mobility. There is no medical indication on examination or imaging that prohibits weightbearing as recommended by her providers. The providers recent office notes document complaints of back pain with burning and tingling at the ankle up the back of the leg. These symptoms are not likely consistent with her ankle injury alone and may be suggestive of a possible alternate etiology that would not be alleviated with a knee scooter. The current medical literature reports concern regarding the higher incidence of falls associated with knee scooters. For these reasons, the requested knee scooter is not medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MitraClip procedure (transcatheter mitral valve repair). This patient has symptomatic severe mitral insufficiency, atrial fibrillation, and severe prolapse of the mitral valve. She remains significantly symptomatic on medical therapy. Based on her symptoms and her specific clinical situation, she has an indication for mitral repair. Given her comorbid conditions of poor wound healing and extremely low body weight as well as chronic treatment with steroids and immunosuppressive therapy, she is deemed too high-risk for open surgical repair of the mitral valve. She was evaluated for MitraClip therapy given her clinical features in the setting of a high operative risk. As she has multiple high-risk features for open surgical repair, MitraClip repair is likely to provide improved functional status as compared to standard available interventions. This patient meets published criteria for the MitraClip procedure, which is U.S. Food and Drug Administration (FDA) approved for this indication. Given these findings, the requested MitraClip procedure (transcatheter mitral valve repair) is 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 MitraClip procedure (transcatheter mitral valve repair) 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 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 overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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 requested Hymovis injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient had tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services were medically indicated. Therefore, Hymovis injections were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 Linzess 290 mcg capsule. Love and colleagues noted that Linzess has a novel mechanism of action, resulting in accelerated intestinal transit and is indicated for treatment of chronic constipation. Furnari and colleagues noted that linaclotide may be recommended for step-up management of chronic constibation. Lembo and colleagues reported that linaclotide therapy was associated with few adverse events and produced rapid and sustained improvement of bowel habits, abdominal symptoms, global relief, and quality of life in patients with chronic constipation. In this case, the patient has tried and failed Miralax and diet modifications to treat her chronic constipation. In this clinical setting, the requested medication is medically indicated. Therefore, Linzess 290 mcg capsule is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for risedronate sodium 35 mg. A study noted that bisphosphonates and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures, while teriparatide reduces the risk of nonvertebral and vertebral fractures. In this case, the patient has osteoporosis of the bilateral hips. Given that the patient requires an osteoporosis agent that reduces risk of hip, nonvertebral, and vertebral fractures, the requested medication is medically indicated. Therefore, risedronate sodium 35 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 Annovera. Kerns and Darney note, Combined (estrogen-progestin) hormonal contraception is available as an oral pill, transdermal patch, or vaginal ring and is highly effective when used consistently and correctly. Commonly available combined hormonal contraceptive rings include the etonogestrel/ethinyl estradiol ring (NuvaRing) and the segesterone acetate/ethinyl estradiol ring (Annovera). The hormonal contraceptive vaginal rings offer the same benefits as the other estrogen-progestin combined methods but have the advantage that daily or weekly user compliance is not required.` The U.S. Food and Drug Administration (FDA) notes that dosage for both the NuvaRing and Annovera systems are continuous for three weeks, followed by a one-week system-free interval. There is a lack of evidence in current medical literature supporting differences between the two systems in terms of weight gain, acne, mood changes, or efficacy in pregnancy prevention. Given that the patient reported significant side-effects with NuvaRing, another ring system is not medically indicated. Therefore, Annovera 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 obstetrics and gynecology 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 fecal analysis laboratory test for gastrointestinal pathogens (CPT 0097U). The Enteric Pathogen Panel is an automated test that is able to identify multiple enteric pathogens in stool during one run via polymerase chain reaction (PCR). When available, the Enteric Pathogen Panel is accepted as standard practice for rapid identification as cause of diarrhea in patients who have symptoms for more than seven days, no history of international travel, and are not immunocompromised. This patients records demonstrate that she met these criteria for testing. The patient was tested for acute diarrhea given her presentation of leukocytosis and fever with more than seven days of symptoms with prior risk factors for Clostridium difficile including antibiotic use. The Enteric Pathogen Panel successfully identified the cause of her illness as Clostridium difficile and she was then successfully treated. In this case, the Enteric Pathogen Panel was the most efficient means to identify the cause of the patients illness, fever, leukocytosis, and diarrhea. Given this support, the fecal analysis laboratory test for gastrointestinal pathogens (CPT 0097U) 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 fecal analysis laboratory test for gastrointestinal pathogens (CPT 0097U) 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 internal medicine with subspecialty certification in infectious disease 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 continued care at a skilled nursing facility (SNF), including continued physical therapy and occupational therapy. Functional impairments due to acquired brain insults such as stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery (Alawieh, et al.). Most of the 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 to come in the subsequent stages (Kubis). There is a general consensus that initiating rehabilitative measures earlier in the post-stroke course enhances outcomes, but there are generally poor data guiding optimal practices regarding dose, manner and venue of stroke rehabilitation in the more subacute and chronic stages (Belagaje, et al.). Comorbidities, especially controlled diabetes, are associated with poorer outcomes after stroke (Desilles, et al.). In this case, the patient sustained a stroke in early August 2020 that had profound functional impacts on her cognition, speech, motor activity on her dominant side, self-care ability, and basic mobility. Despite multiple bouts of inpatient multidisciplinary rehabilitation, she has made minimal meaningful functional progress. She continues to require maximum to total assistance for her self-care and mobility. Barriers to progress include severe weakness, pain with any type of passive stretch of the stroke affected limbs, apraxia, and problem solving impairments. Based on the records available for review, there is reasonable expectation of benefit with further skilled therapy services. There are no other issues requiring inpatient level skilled nursing services or medical care. For these reasons, the requested continued care at a SNF, including continued physical therapy and occupational therapy, 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 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 four chiropractic services a month. In a systematic review and meta-analysis of 47 randomized controlled trials on the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain, Rubinstein and colleagues reported that SMT produced similar effects to recommended therapies for chronic low back pain, and appeared better than non-recommended interventions for the improvement in function in the short term. Coulter and colleagues concluded that there is moderate quality evidence that both manipulation and mobilization appeared safe and were likely to reduce pain and improve function for patients with chronic low back pain, with manipulation appearing to produce a larger effect than mobilization. In this case, the patient has chronic low back pain. She reports functionality and relief with four chiropractic sessions a month. Given that the patient is unable to function without the requested services and that her provider recommends continued chiropractic services, the requested services are medically indicated. Therefore, four chiropractic services a month 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 chiropractic 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 proton beam therapy. Currently, there is inadequate clinical data supporting that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, the authors observed that IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities. Yu and colleagues found that there was a statistically significant decrease in genitourinary toxicity at six months with proton therapy, but this difference disappeared by one year, and there were no other significant differences in toxicity between the two techniques. Further, the American Society of Radiation Oncology (ASTRO) stated that, the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO. This patients receipt of high-dose rate brachytherapy does not necessitate the use of proton therapy. The patients prostate would not undergo reirradiation, as the pelvis requires treatment which did not undergo radiation from the brachytherapy procedure. Treatment of the pelvis after brachytherapy is routinely performed with photons with standard IMRT technique. For these reasons, the requested proton beam therapy 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 radiation oncology 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 a Trelegy Ellipta inhaler. Researchers note that treatment with an inhaled glucocorticoid, a long-acting muscarinic antagonist (LAMA), and a long-acting 2-agonist (LABA) have been studied as the cornerstone of effective, evidence-based management of chronic obstructive pulmonary disease (COPD). The authors found that triple therapy at two glucocorticoid doses resulted in a lower rate of moderate or severe COPD exacerbations than glycopyrrolate-formoterol or budesonide-formoterol. Given that the patient has responded well to Trelegy in the past, the requested medication is medically indicated. Therefore, a Trelegy Ellipta inhaler is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: The patient has requested authorization and coverage for a Xiidra 5% droperette. Donnenfeld and colleagues describe lifitegrast ophthalmic solution 5.0% as the first medication approved in the U.S. for the treatment of the signs and symptoms of dry eye disease (DED). Haber and colleagues report that lifitegrast has a novel mechanism of action and is safe and effective for the treatment of DED. In this case, the patient has a diagnoses of dry eye syndrome. In this clinical setting, the requested medication is medically indicated. Therefore, a Xiidra 5% droperette is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.