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 (1) testing body biofeedback, (2) non-invasive vagus nerve stimulation, (3) electrical stimulation, and (4) vestibular rehabilitation. Findings:  The physician reviewer found that the patient has multiple psychiatric diagnoses, but presents predominantly with somatic symptoms and without insight into his psychiatric diagnoses. While the patient has been evaluated for treatment-resistant depression, his presentation, based on the clinical documentation, appears to be most consistent with a primary psychotic disorder. In this case, as is quite common in the early treatment of psychosis, particularly for patients predominantly with somatic delusions as in this case, the patients psychotic symptoms and agitation have not yet been adequately treated, due in large part to the patients refusal of treatment and poor insight into his need for treatment of psychotic symptoms. The records do not note support from any provider in any specialty for the treatments that the patient has requested. In this case, the records do not document that the patient has first failed standard treatments for his current symptoms and presenting diagnosis of a primary psychotic disorder, delusional disorder. Camacho-Conde and colleagues report that brain stimulation may be a powerful tool in the remedy against neurological diseases. While treatments such as brain stimulation, biofeedback, vestibular rehabilitation, and non-invasive vagus nerve stimulation may hold promise for the treatment of neurologic disorders, in this case, the patient is not diagnosed with neurologic disorders. There is a lack of evidence supporting the use of these modalities in the treatment of psychiatric diagnoses, and more studies are needed to establish which of these treatments may hold more promise and be used in regular clinical practice in the future. Given that that this patient is requesting non-evidence based treatments for his clinical presentation, the requested services are not medically indicated. Therefore, (1) testing body biofeedback, (2) non-invasive vagus nerve stimulation, (3) electrical stimulation, and (4) vestibular rehabilitation are not medically necessary for the 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 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 patient has requested reimbursement for neurofeedback of the quantitative electroencephalogram brain scan. Findings:  The physician reviewer found that Electroencephalographic neurofeedback involves a real-time electroencephalogram (EEG) signal measurement, immediate data processing with the extraction of the parameter(s) of interest, and feedback to the individual in real-time. Using such a feedback loop, the individual may gain better control over the neurophysiological parameters by inducing changes in brain functioning and, consequently, behavior. Current medical literature supports its use as a complementary treatment for a variety of neuropsychological disorders and improvement of cognitive capabilities. In this case, given that this patient has several psychiatric diagnoses, the use of neurofeedback as a supplement to other psychiatric interventions was medically indicated. Therefore, neurofeedback of the quantitative electroencephalogram brain scan performed on 6/7/22 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL every four weeks. Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has severe fistulizing and stricturing Crohn's disease status post multiple surgeries has had disease symptoms. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, the records reported  a low Stelara level of 3.3 ug/mL. Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL every four weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 for diagnostic cardiac catheterization. Findings:  The physician reviewer found that American College of Cardiology (ACC) guidelines for the diagnoses and management of patients with stable ischemic heart disease note that a coronary angiography is considered a Class I recommendation for patients with suspected ischemic heart disease when results of noninvasive testing indicate a high likelihood of severe coronary artery disease. In this case, while nuclear stress test images demonstrated only apical reversible ischemia, the electrocardiographic findings of significant ST-segment depression in five leads are very significant. In a study on the  role of exercise stress test induced ST-segment elevation, Russo and colleagues reported that ST-segment depression in five or more leads was the only independent predictor of left main or proximal left anterior descending coronary disease. In this case, the requested service, prior to elective major orthopedic surgery, to further define his coronary anatomy and risk is medically indicated.  Therefore, diagnostic cardiac catheterization is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with right knee osteoarthritis. The patient has been treated with physical therapy, a corticosteroid injection, bracing, and anti-inflammatory medications that failed to relieve her pain. A physical examination revealed medial joint line tenderness and patellofemoral crepitus. An MRI revealed cartilage loss at the apex of the patella and chondromalacia of the medial compartment. The patient was treated with a Synvisc-One injection (CPT J7325) to the right knee. At issue is whether the Synvisc-One injection (CPT J7325) to the right knee was medically necessary for the treatment of this patient. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has been treated with conservative options including physical therapy, a corticosteroid injection, bracing and anti-inflammatory medications. Therefore, the Synvisc-One injection (CPT J7325) to the right knee was medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 Dupixent solution pen-injector (inject 300 mg pen subcutaneously every other week). The U.S Food and Drug Administration (FDA) approves the use of Dupixent for the treatment of adult patients with moderate-to-severe atopic dermatitis. While topical tacrolimus may be used to treat moderate-to-severe atopic dermatitis, and topical pimecrolimus may be used to treat mild-to-moderate dermatitis, the records noted that topical medications were challenging for the patient to apply and keep on his hands. Deleuran and colleagues report that the safety and efficacy profile from an ongoing, multicenter, open-label extension study supports the role of dupilumab as continuous long-term treatment for patients with moderate-to-severe atopic dermatitis. While the American Academy of Dermatology (AAD) notes that systemic medications such as methotrexate, azathioprine, corticosteroids, mycophenolate, and cyclosporine are used more commonly for the treatment of refractory moderate-to-severe atopic dermatitis not responsive to topical medications, these guidelines were published in 2014, prior to the availability of Dupixent. Methotrexate, azathioprine, corticosteroids, mycophenolate, and cyclosporine cannot be used chronically because of severe potential side effects and may require routing laboratory monitoring. In this case, given that current medical literature supports the use of Dupixent as effective and with fewer side effects than with other systemic medications used to treat moderate-to-severe atopic dermatitis, the requested medication is medically indicated. Therefore, Dupixent solution pen-injector (inject 300 mg pen subcutaneously every other week) 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 dermatology 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 modified duodenal switch weight loss surgery. The requested duodenal switch is a standard procedure for the treatment for morbid obesity. Duodenal switch has the greatest weight loss and improvement of metabolic outcomes, with durability of greater than ten years, and the least weight regain of any bariatric operation, far less than gastric bypass. In this case, the patient meets all accepted criteria for bariatric surgery including a body mass index (BMI) that is at least 40 kg/m2 and failure of conservative weight loss efforts. A pre-bariatric surgery psychological assessment did not reveal psychological contraindications, and completion of a multidisciplinary evaluation did not reveal dietary contraindications. Therefore, modified duodenal switch weight loss surgery (CPT 43845) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Twho of the three physician reviewers found the requested modified duodenal switch weight loss surgery 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in general surgery 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for lumbar surgery (L4-5 decompression supplemented by an instrumented fusion using autograft/allograft, a bilateral pedicle screw/rod construct and possible interbody fusion device). Spinal fusion may benefit individuals with spinal instability and chronic low back pain without response to any conservative measures, among other conditions. In this case, the records do not demonstrate evidence of spinal instability or that the patient has exhausted conservative options of at least twelve weeks in duration for the treatment of chronic low back pain. The patient has significant comorbidities, making the patient a high risk for elective spinal surgery, and is non-compliant with simple care instructions such as taking Xarelto for hypercoagulable state. The patient's severe osteoporosis makes the likelihood of a successful fusion doubtful. The submitted records suggest that ongoing back pain is not chronic in nature. While the patient reported prior back pain, similar recent symptoms are insufficient to establish a causal relationship between the two. A radiographic finding of disc desiccation is insufficient to establish a causal connection between this finding and the patients symptoms. Additionally, the requested fusion level does not appear to correlate with the radicular findings. Given that the records do not demonstrate trial and failure of conservative options or that the patients pain is chronic in nature, and given the patients comorbidities, the requested service is not medically indicated. Therefore, lumbar surgery (L4-5 decompression supplemented by an instrumented fusion using autograft/allograft, a bilateral pedicle screw/rod construct and possible interbody fusion device) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested reimbursement and prospective authorization and coverage for Trintellix (vortioxetine) 10 mg tablets taken once per day. Although the current peer-reviewed medical literature on the safety and efficacy of Trintellix in adolescent patients is limited, there are data to support its use in this patients clinical setting. Findling and colleagues evaluated the safety and efficacy of Trintellix in child and adolescent patients. The authors concluded that the dosages of Trintellix from 5-20 mg as approved for treatment in adults and the up-titration schedule used are appropriate for pediatric efficacy. Trintellix has a unique pharmacology which makes it distinct from other antidepressants. For this patient, Trintellix has been effective while other medications have not provided the same symptomatic relief. The records document that the patient has failed previous trials on duloxetine, citalopram, and escitalopram. A critical aspect of this case is the patients significant improvement since starting on Trintellix. There are detailed reports from the patient, the patient's parent, and the patients providers documenting a robust response including remission of previous chronic suicidality, self-injury, depressive symptoms, anxiety, insomnia, and substance abuse since starting Trintellix. Given the patients positive response to Trintellix with lack of reported side effects, continued treatment with this medication is consistent with the findings in the medical literature. Therefore, the Trintellix (vortioxetine) 10 mg tablets taken once per day was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for pelvic floor program consisting of (rectal balloon biofeedback therapy) three times a day for one week, and twice a day for a second week. The records document that this patient presents with pelvic dyssynergia and possible anal fistula. Treatment has included surgery, but the patient reports continued symptoms. As noted in the medical literature, symptomatic constipation, anorectal inflammation, and pelvic dyssynergia may require surgery when scarring renders Botox and pelvic floor therapy ineffective. Once diagnostic evaluation reveals no anatomic impediment to biofeedback and medical management, this is considered the mainstay of treatment for this patient population. Mazor and colleagues assessed 138 patients with chronic constipation and symptoms of functional defecatory disorder who were treated with biofeedback. The authors concluded that following biofeedback, 89% of patients in the high group reduced their rectal pressure to normal. Parker and colleagues found that the overall response rate with biofeedback in patients with chronic constipation and fecal incontinence secondary to pelvic floor neuromuscular sensory or motor dysfunction was 76.2%. Given this support, the requested pelvic floor program consisting of (rectal balloon biofeedback therapy) three times a day for one week, and twice a day for a second week is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in urology 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 medical ventilator, ventilator supplies, and portable oxygen concentrator provided by Apria Healthcare. The management of this patient with noninvasive nocturnal ventilation is supported as medically necessary (Rand, et al.). Patients with congenital hypoventilation syndrome are at very high risk of not breathing adequately at night, leading to hypoventilation, respiratory acidosis, and respiratory arrest. As noted by the National Organization for Rare Disorders (NORD) of patients with congenital central hypoventilation syndrome (CCHS), Adequate ventilation is essential to ensure optimal growth and development of CCHS patients. The NORD guideline noted further that, Ventilation can be managed with a mechanical ventilator via tracheostomy or masks or using phrenic pacemakers. Monitoring both oxygen saturations and CO2 using end-tidal capnography at home helps ensure adequate ventilation in all conditions (sleep, awake, during illness and growth spurts). Thus, ventilatory support at night is imperative to safely management this patient. As such, all equipment necessary to provide adequate non-invasive nocturnal ventilation including the medical ventilator, ventilator supplies, and portable oxygen concentrator are appropriate. Therefore, the medical ventilator, ventilator supplies, and portable oxygen concentrator provided by Apria Healthcare were and are medically necessary for treatment of 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 internal medicine with subspecialty certifications in pulmonary diseases and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.