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+{"answers": {"text": ["The patient has requested authorization and coverage for oxycodone 5 mg.", "The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended", "oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action."], "answer_start": [43, 961, 1209]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 5 mg. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and non-opioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Washington Agency Medical Directors Group Interagency guidelines state that providers should reserve opioids for acute pain resulting from severe injuries or medical conditions, surgical procedures, or when alternatives (non-opioid options) are ineffective or contraindicated. If opioids are prescribed, it should be at the lowest necessary dose and for the shortest duration (usually less than 14 days). The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended an appropriate amount of oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action. For these reasons, the requested oxycodone 5 mg is not medically necessary for 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "3e234439f0724adcba3df6076697c1b5", "question": "What is the background context in this case summary?", "title": "3e234439f0724adcba3df6076697c1b5", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). All told, the requested Ozempic 1 mg 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 endocrinology, diabetes, and metabolism 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. ", "id": "44ccd4b606654c8d9b5d7eef456ad303", "question": "What is the background context in this case summary?", "title": "44ccd4b606654c8d9b5d7eef456ad303", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement for DecisionDx-Melanoma test."], "answer_start": [45]}, "context": "Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma test. In reviewing the NCCN guidelines, the recommended therapy for patients with stage I cutaneous melanoma includes review of history, physical examination, and imaging to evaluate certain signs and symptoms. The NCCN indicates that category 1A treatment includes wide excision of the melanoma and consideration of sentinel lymph node biopsy. Furthermore, the NCCN guidelines state that for stage IB melanoma, the probability of a positive sentinel lymph node is greater than 10%. The NCCN guidelines do not endorse use of a gene expression assay to determine the course of treatment for patients with stage I melanoma. Marchetti and colleagues concluded that the prognostic ability of gene expression profiling tests among patients with localized melanoma have been found to be poor at correctly identifying recurrence in patients with stage I disease, suggesting limited potential for clinical utility in these patients. Given these findings, the DecisionDx-Melanoma test was not 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 services at issue were not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. ", "id": "c128f02e456d430fa6b84ad998e55c70", "question": "What is the background context in this case summary?", "title": "c128f02e456d430fa6b84ad998e55c70", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has requested reimbursement for general anesthesia services.", "this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction.", "The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2.", "the patients preoperative blood pressure was charted as 148/89"], "answer_start": [43, 1192, 1662, 1962]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. The American Dental Association (ADA) recommends moderate sedation for patients with American Society of Anesthesiologists (ASA) score of III or IV, and obesity, especially when associated with airway associated morbidity. The ADA also reports that deep sedation or general anesthesia may be appropriate for mentally or physically challenged patients. The American Academy of Pediatric Dentistry (AAPD) states that general anesthesia may be indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability;  patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring significant surgical procedures;  patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and  patients requiring immediate, comprehensive oral/dental care (Cote, et al.). The records provided for review document that this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction. However, there is a lack of documentation that this patient has an anesthesia classification score ASA of 3 or 4, or evidence of a difficult airway. The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2. The diagnosis of attention deficit disorder (ADD) is not considered a developmental disability that prevents a patient from undergoing a tooth extraction without sedation or general anesthesia. Moreover, the patients preoperative blood pressure was charted as 148/89, which does not constitute a hypertensive urgency or emergency. The providers records do not include sufficient documentation to support an indication for general anesthesia for the tooth extraction. Therefore, the general anesthesia services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "f4072624c7ba47e8b63a660f2bda598f", "question": "What is the background context in this case summary?", "title": "f4072624c7ba47e8b63a660f2bda598f", "sufficiency_score": 4}
+{"answers": {"text": ["The patients parent has requested authorization and coverage for intensive in-home family treatment.", "The patient has a significant risk of harm, due to a history  multiple suicide attempts, and ongoing suicidal ideation and self-harm behaviors.", "The documentation notes moderate functional impairment as evidenced by multiple visits to the emergency department and several inpatient hospitalizations, which has likely interfered with her schooling. The patient endorses depressive symptoms and is noted as being unable to function in the social setting.", "The patient does not have comorbidities.", "The patient has a moderately stressful environment as the patient had made allegations of abuse in the home resulting in investigation. The patient reports not having friends and being lonely. She has minimal coping skills and it appears that role expectations exceed the patients capacity to cope.", "the records suggest that the patients parents may have difficulty setting appropriate limits for their daughter. The family has limited ability to respond appropriately to the patients developmental needs and/or problems, as the patients parents have declined various levels of care, indicating that they may not be consistently following treatment recommendations.", "The patient has poor response to treatment and recovery management as prior treatment has included outpatient treatment including dialectical behavior therapy (DBT), multiple medication trials, intensive outpatient program (IOP), partial hospitalization program (PHP), crisis residential treatment, and at least two inpatient psychiatric hospitalizations.", "The records suggest that the patient has refused to engage in recommended treatment in the past and struggles to utilize coping skills. She is noted as lacking motivation."], "answer_start": [43, 1273, 1482, 1852, 1984, 2380, 2826, 3268]}, "context": "Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intensive in-home family treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; 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 has a significant risk of harm, due to a history  multiple suicide attempts, and ongoing suicidal ideation and self-harm behaviors. In terms of functional status, the records support a score of 3. The documentation notes moderate functional impairment as evidenced by multiple visits to the emergency department and several inpatient hospitalizations, which has likely interfered with her schooling. The patient endorses depressive symptoms and is noted as being unable to function in the social setting. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment as the patient had made allegations of abuse in the home resulting in investigation. The patient reports not having friends and being lonely. She has minimal coping skills and it appears that role expectations exceed the patients capacity to cope. With regard to level of support of the recovery environment, the records support a score of 3 as the records suggest that the patients parents may have difficulty setting appropriate limits for their daughter. The family has limited ability to respond appropriately to the patients developmental needs and/or problems, as the patients parents have declined various levels of care, indicating that they may not be consistently following treatment recommendations. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as prior treatment has included outpatient treatment including dialectical behavior therapy (DBT), multiple medication trials, intensive outpatient program (IOP), partial hospitalization program (PHP), crisis residential treatment, and at least two inpatient psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The records suggest that the patient has refused to engage in recommended treatment in the past and struggles to utilize coping skills. She is noted as lacking motivation. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is a higher level of care than the requested intensive in-home family treatment. In this patients case, intensive in-home family treatment is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, intensive in-home family treatment 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "1336cb965dfb444eba53308dcbb1d77d", "question": "What is the background context in this case summary?", "title": "1336cb965dfb444eba53308dcbb1d77d", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled clinical trials on the treatment of patients with IBS-D (Schoenfeld, et al.). In addition, the American College of Gastroenterology (ACG) guidelines for the treatment of IBS state that Xifaxan has been shown to be safe and effective for use in this patients clinical setting (Ford, et al.; Cangemi, et al.). The clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days. For these reasons, the requested Xifaxan 550 mg tablet (three tablets a day for 14 days) 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. ", "id": "87dc2a2f1c974a9dadd023a707cd51a8", "question": "What is the background context in this case summary?", "title": "87dc2a2f1c974a9dadd023a707cd51a8", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has requested authorization and coverage for Taltz.", "The medical records state that the patients psoriasis is well controlled while on Taltz."], "answer_start": [43, 313]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. There is a lack of documentation regarding the extent of this patients psoriasis in terms of body surface area (BSA) involvement or prior disease severity to support an indication for treatment with Taltz. The medical records state that the patients psoriasis is well controlled while on Taltz. However, biologic medications including Taltz are not recommended for mild disease in the absence of extenuating factors such as difficult to treat areas. The U.S. Food and Drug Administration (FDA) has approved Taltz for the treatment of patients with moderate-to-severe plaque psoriasis, as defined by a BSA greater than 3%, or a psoriasis area and severity index (PASI) greater than 10 (Menter, et al.; Gordon, et al.). Similarly, the peer-reviewed medical literature recommends treatment with Taltz for patients with moderate-to-severe plaque psoriasis, which is not reported in the records provided for review. All told, the requested Taltz is not medically necessary for 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 dermatology with subspecialty certification in dermatopathology 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. ", "id": "7eb14ded6f024d5ba08e48ffc3eb89e0", "question": "What is the background context in this case summary?", "title": "7eb14ded6f024d5ba08e48ffc3eb89e0", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for platelet rich plasma (PRP) treatment (CPT 0232T).", "This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections."], "answer_start": [43, 195]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) treatment (CPT 0232T). Findings:  The physician reviewer found that This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections. On review of the peer-reviewed medical literature, the data on PRP injections remains mixed with regard to efficacy in the treatment of patients with ankle arthritis. Fukawa and colleagues concluded that intra-articular PRP injections resulted in no serious adverse effects, while it reduced pain in the patients with ankle osteoarthritis. Paget and colleagues concluded among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. However, there is a paucity of large-scale, peer-reviewed literature demonstrating the long-term safety and efficacy of PRP injection in the treatment of patients with ankle osteoarthritis. For these reasons, the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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. ", "id": "78e7b903202b4f9a87429bfc4b1b6578", "question": "What is the background context in this case summary?", "title": "78e7b903202b4f9a87429bfc4b1b6578", "sufficiency_score": 4}
+{"answers": {"text": ["The patients parent has requested authorization and coverage for Motegrity (2 mg tablets, 30 tablets per 30 days)."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Motegrity (2 mg tablets, 30 tablets per 30 days). Motegrity is a medication that is U.S. Food and Drug Administration (FDA) approved for the treatment of motility in the gastrointestinal tract in patients 18 years of age and older. In an open-label pilot study, Motegrity demonstrated a favorable effect on stool frequency, stool consistency, and fecal incontinence frequency in children with functional constipation (Winter, et al.). However, in a multicenter randomized controlled clinical trial including 213 children with functional constipation, Motegrity was found to be less effective in increasing stool frequency and decreasing fecal incontinence frequency when compared to placebo (Mugie, et al.). Overall, there is a lack of data demonstrating the safety and efficacy of Motegrity in the pediatric patient population. Thus, Motegrity is not expected to decrease this patients likelihood of having obstructive symptoms. All told, the requested Motegrity (2 mg tablets, 30 tablets per 30 days) is not medically necessary for 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 pediatrics with subspecialty certification in pediatric 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. ", "id": "66e0a65ee56d42cdb62b299cec552d0c", "question": "What is the background context in this case summary?", "title": "66e0a65ee56d42cdb62b299cec552d0c", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested reimbursement for myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D. The American College of Cardiology guidelines on the appropriate indications for myocardial strain imaging include patients prior to and following exposure to potentially cardiotoxic agents or for patients with suspected hypertrophic cardiomyopathy. In this case, the records do not reflect that the patient meets either of these indications. Therefore, myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D., was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided M.D., at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation 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 internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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. ", "id": "55efa702c8eb4b8abc7863b1421daf92", "question": "What is the background context in this case summary?", "title": "55efa702c8eb4b8abc7863b1421daf92", "sufficiency_score": 2}
+{"answers": {"text": ["The patients parent has requested authorization and coverage for weekly individual mental health therapy services.", "The patient had some risk for harm due to passive suicidal ideation and mild substance use", "The patient had moderate functional impairment, due to the presence of symptoms of depression, anxiety, and panic. The records noted that the patient still looked forward to some activities and saw some friends but had withdrawn socially.", "The patient had minor comorbidity due to some substance use, depression, and anxiety.", "The patient had a mildly stressful environment due to a stable home with a mother involved in her care but with the patient reporting some frustration and discomfort.", "The patient had moderate or equivocal response to treatment as she appeared to have some response to therapy but continued to have symptoms.", "The patient appears able to develop a trusting, positive relationship with clinicians and other care providers"], "answer_start": [43, 1287, 1443, 1745, 1922, 2317, 2544]}, "context": "Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly individual mental health therapy services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; 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 2. The patient had some risk for harm due to passive suicidal ideation and mild substance use.In terms of functional status, the records support a score of 3. The patient had moderate functional impairment, due to the presence of symptoms of depression, anxiety, and panic. The records noted that the patient still looked forward to some activities and saw some friends but had withdrawn socially.  With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to some substance use, depression, and anxiety. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to a stable home with a mother involved in her care but with the patient reporting some frustration and discomfort. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients mother participating in her care. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as she appeared to have some response to therapy but continued to have symptoms. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appears able to develop a trusting, positive relationship with clinicians and other care providers.Thus, the patient has a total score of 16. This is consistent with low intensity community-based services. In this patients case, weekly individual mental health therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, weekly individual mental health therapy services 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "27a2025bfdaf4112bab2a306ab686c7e", "question": "What is the background context in this case summary?", "title": "27a2025bfdaf4112bab2a306ab686c7e", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for durable medical equipment - Bioness L300 GO functional electric stimulator (FES) and supplies."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment - Bioness L300 GO functional electric stimulator (FES) and supplies. Findings:  The physician reviewer found that a lack of evidence in current medical literature demonstrating that exposure to lower limb orthotic devices employing functional electrical stimulation (FES) improves gait in persons with central neurological weakness. In a comprehensive review of the literature comparing FES-aided lower limb orthoses and conventional or mechanical orthoses, Johnston and colleagues reported that studies that directly compared ankle-foot orthotics (AFO) and FES did not indicate overall superiority of one over the other. The authors further noted that the evidence on AFO and FES improving gait kinematics was weak. While there are some potential benefits to exogenously stimulating lower limb effector muscles that have lost effective connections with the central nervous system, it is not evident that the potential benefits of FES-aided orthoses, such as a lighter weight and the potential of a decreased likelihood of skin breakdown, outweigh their disadvantages, such as a lack of stabilizing support during stance phase and potential for mechanical or technological complications including lead misapplication, lead failure or dislodgement, battery drainage or failure, and device failure. Given the lack of data supporting the use of the requested equipment as favorably altering neurological recovery, the requested equipment and supplies are not medically indicated. Therefore, durable medical equipment - Bioness L300 GO FES and supplies are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies 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. ", "id": "403608c9cbdc45029fe667195c1e4803", "question": "What is the background context in this case summary?", "title": "403608c9cbdc45029fe667195c1e4803", "sufficiency_score": 2}
+{"answers": {"text": ["The patient has requested authorization and coverage for a consultation for proton beam radiation therapy."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation for proton beam radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of breast cancer  do not endorse the routine use of proton therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of breast cancer. In a majority of cases, an acceptable cardiac and lung dose may be achieved using intensity modulated radiation or three-dimensional conformal techniques, along with the use of deep inspiratory breath holds during treatment, moving the heart away from the chest wall. Therefore, a consultation for proton beam radiation therapy 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.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. ", "id": "a5ae766d6348427a9d9207a108cf1257", "question": "What is the background context in this case summary?", "title": "a5ae766d6348427a9d9207a108cf1257", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast.", "This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high"], "answer_start": [43, 737]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast. The current peer-reviewed medical literature and guidelines recommend biopsy for a palpable breast mass, even in the setting of negative mammogram and ultrasound findings. However, MRI is indicated for the screening of high risk patients. This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high, which supports an indication for MRI screening as the appropriate modality. Based on these findings, the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral breast MRI with and without contrast (CPT 77049) is 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. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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. ", "id": "b162c2c13d7043b9b0675030d0b8ffc0", "question": "What is the background context in this case summary?", "title": "b162c2c13d7043b9b0675030d0b8ffc0", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for hyaluronic acid injection", "The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis."], "answer_start": [44, 1074]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for hyaluronic acid injection.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 patients options are limited. The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis. Therefore, the requested hyaluronic acid injection is medically necessary for the treatment of the patients medical condition.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 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. ", "id": "aaf8b12a039b43f1a7f4e24e6a4ed4dd", "question": "What is the background context in this case summary?", "title": "aaf8b12a039b43f1a7f4e24e6a4ed4dd", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for cancer vaccine", "This patient has advanced neuroblastoma."], "answer_start": [44, 283]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for cancer vaccine.Findings: Two out of three physician reviewers found that the requested cancer vaccine is not likely to be more beneficial for you than any available standard therapy.This patient has advanced neuroblastoma. There is insufficient evidence demonstrating the efficacy and safety of neuroblastoma vaccine for the treatment of advanced neuroblastoma. The current National Cancer Institute (NCI) guidelines do not support the use of a neuroblastoma vaccine as an accepted treatment option for advanced neuroblastoma. The current literature indicates that further studies are still needed to establish the efficacy and safety of the vaccine. Therefore, the requested cancer vaccine is not likely to be more beneficial than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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.  ", "id": "9f3a8d3f79db49f28a8397d41bec465d", "question": "What is the background context in this case summary?", "title": "9f3a8d3f79db49f28a8397d41bec465d", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Euflexxa injections in both knees (HCPCS code J7323)", "In this case, there is a history of good extended response to prior viscosupplementation.", "The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties."], "answer_start": [44, 1053, 1190]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections in both knees (HCPCS code J7323).An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of good extended response to prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Therefore, Euflexxa injections in both knees (HCPCS code J7323) are medically necessary for treatment of the patients medical condition.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 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. ", "id": "972fd486cfa74b44a9e95e40d45e6696", "question": "What is the background context in this case summary?", "title": "972fd486cfa74b44a9e95e40d45e6696", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides. According to Kwo and colleagues, a workup for underlying liver disease is appropriate given the risk of eventual cirrhosis with untreated metabolic liver disease, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. However, the patient does not have an indication for consideration of liver transplantation, and there is no evidence of liver disease on extensive laboratory testing. For these reasons, the requested blood tests are medically necessary for the evaluation of the patients medical condition. However, the consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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. ", "id": "a9c25849d6fd4c36bc3b485ee580d585", "question": "What is the background context in this case summary?", "title": "a9c25849d6fd4c36bc3b485ee580d585", "sufficiency_score": 4}
+{"answers": {"text": ["The patients parent has requested authorization and coverage for Nutropin AQ.", "In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth."], "answer_start": [43, 364]}, "context": "Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. The patients recent growth pattern indicates that catch-up growth is unlikely without somatotropin (brand name Nutropin AQ) therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nutropin AQ 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 pediatrics with sub-specialty certification in pediatric endocrinology 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. ", "id": "ae9ed57c31664098855bedc8ee16cf2d", "question": "What is the background context in this case summary?", "title": "ae9ed57c31664098855bedc8ee16cf2d", "sufficiency_score": 4}
+{"answers": {"text": ["The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus.", "In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery."], "answer_start": [43, 456]}, "context": "Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus. There is sufficient support for the services at issue in this clinical setting. CT scanning is the standard method of evaluating the sinuses. Moreover, Che and colleagues stated, Analyzing the CT features of bone changes in unilateral chronic maxillary sinusitis can improve the accuracy of disease diagnosis. In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery. Therefore, the CT scan of the maxillofacial/sinus was medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 otolaryngology 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. ", "id": "71cf557ae81e497084f1b67cc8114d45", "question": "What is the background context in this case summary?", "title": "71cf557ae81e497084f1b67cc8114d45", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease", "He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe", "was unsuccessful. He was", "prescribed Repatha, which lowered his LDL level to goal without side effects."], "answer_start": [43, 425, 769, 808]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease and should be managed with intensive risk factor modification per American College of Cardiology/American Heart Association (ACC/AHA) guidelines. He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe, which would be the only other option to get him to goal along with lifestyle modifications, was unsuccessful. He was appropriately prescribed Repatha, which lowered his LDL level to goal without side effects. The patient meets published ACC/AHA guidelines for Repatha use. Therefore, Repatha 140 mg/mL SureClick is medically necessary for the treatment of the patients medical condition.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 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. ", "id": "58538a99e63a4262b9ce1b6e75e39932", "question": "What is the background context in this case summary?", "title": "58538a99e63a4262b9ce1b6e75e39932", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules.", "In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole.", "additional similar proton pump inhibitors have not been attempted", "Dexilant, unlike alternatives, has been effective in this case."], "answer_start": [43, 1652, 1786, 1933]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules. Findings:  The physician reviewer found that gastroesophageal reflux disease (GERD) and esophagitis are at least partially caused by mechanical defects in esophageal motility. Scarpignato and colleagues indicate that since proton pump inhibitors (PPIs) do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Usai and colleagues state that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barrett's esophagus. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no significant difference in control and healing of gastroesophageal reflux disease. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. In a study by Fass and colleagues, a significant majority of patients (88%) requiring other PPIs twice daily were able to control symptoms on Dexilant once daily. Dexilant is also more effective to treat heartburn than alternatives such as esomeprazole. American College of Gastroenterology guidelines for the treatment of GERD do recommend proton pump inhibitor therapy, especially in patients with complications such as esophagitis. In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole. Although additional similar proton pump inhibitors have not been attempted, they are unlikely to be effective after failure of omeprazole and pantoprazole. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant (dexlansoprazole) 60 mg delayed-release capsules are medically necessary for the treatment of the patients medical condition.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. ", "id": "489a9f6375cd48f782f3d3612b873b89", "question": "What is the background context in this case summary?", "title": "489a9f6375cd48f782f3d3612b873b89", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen"], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen. Given that the patient was medically stable, without advanced procedures or monitoring, and without complications or unstable comorbidities, the services at issue were not and are not medically indicated. Therefore, inpatient care services at Providence St. Joseph Medical Center were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 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. ", "id": "1ce73feba8954d129eaa39da821afd7f", "question": "What is the background context in this case summary?", "title": "1ce73feba8954d129eaa39da821afd7f", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization. Researchers concluded that geniculate artery embolization is a safe and effective treatment approach for the management of recurrent hemarthrosis of the knee following arthroplasty and should be considered first-line treatment following failure of conservative management. Researchers reported that, Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following total knee arthroplasty. However, there is a lack of large-scale, long-term studies documenting the safety and efficacy of the geniculate artery embolization outside of recurrent hemarthrosis post arthroplasty. This patients records do not document any prior knee arthroplasty to support an indication for geniculate artery embolization. Therefore, the requested geniculate artery embolization of the right knee 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 requested geniculate artery embolization of the right knee 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 services are 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 orthopedic 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. ", "id": "c89f4d026f644dc09e576238f4f3a00d", "question": "What is the background context in this case summary?", "title": "c89f4d026f644dc09e576238f4f3a00d", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility", "In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case."], "answer_start": [43, 808]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility.At issue is whether the requested referral for an otolaryngology office visit at a tertiary care facility is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.There is sufficient support for the requested services in this clinical setting. Audiometry follow-up and evaluation of the tympanic membrane after myringotomy and tube placement is part of the standard of care in caring for patients with tubes. In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case. A tertiary care facility is the most appropriate site for follow-up evaluation, which would include speech, audiology, otolaryngology, and pediatric neurology evaluations. Therefore, the requested otolaryngology office visit at a tertiary care facility is medically necessary to prevent disease, disability, and other health conditions or their progression.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 otolaryngology 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. ", "id": "0517b5c8744e4ba794532ef202052d6d", "question": "What is the background context in this case summary?", "title": "0517b5c8744e4ba794532ef202052d6d", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294)."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294). Accelerated partial breast irradiation (APBI) may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy (IORT). IORT to perform APBI is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria per current National Comprehensive Cancer Network (NCCN) guidelines. Researchers reported that at four-year follow-up, local control rates between IORT and external beam whole breast radiotherapy were largely equivalent. A study concluded that, Important radiation-related quality of life parameters after IORT were superior to external beam radiation therapy. Per the authors, toxicity may also be slightly improved with IORT. This patient meets ABPI criteria set by the American Society of Breast Surgeons (ASBS), given her age and the presence of a tumor measuring less than 3 cm. All told, the requested IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) is 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 IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) 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 radiation oncology 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. ", "id": "941072b64acf4fe2a27620e28a4da796", "question": "What is the background context in this case summary?", "title": "941072b64acf4fe2a27620e28a4da796", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested reimbursement for dual diagnosis residential substance misuse treatment", "The patient had been sober from alcohol for 75 days", "Records indicate that the patient had a history of cerebrovascular accidents with left sided weakness, hypertension and gastritis.", "The patient was diagnosed with major depressive disorder and was suicidal upon admission. He experienced frequent suicidal ideation that was exacerbated by drinking. He had two prior attempts and was admitted for suicidal ideation on three days prior to his admission at the residential treatment center. He initially endorsed multiple symptoms of depression including hopelessness, worthlessness, anhedonia, depressed mood, poor sleep and appetite.", "The patient was also assessed as not posing a risk to self or others.", "The patient admitted himself voluntarily and participated actively in treatment. He recognized the effects of alcohol on his health and relationships. The patient acknowledged the existence of a substance use problem, and he recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change.", "The patient had been drinking heavily for 30 years and most recently relapsed after he had three strokes. He made significant progress in addressing his relapse triggers, and he was actively working on transitioning to the community with the assistance of his daughter. He was not able to return to the camper that he was residing in due to his disability from the cerebrovascular accidents. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community.", "The patient had been technically homeless, as he was living alone in a camper and going from campsite to campsite. He was socially isolated and had been experiencing frequent bouts of suicidal ideation with severe depression. He had been unable to cope with his physical disabilities after having three strokes. He is not able to reside alone due to disabilities from his strokes.", "the patient was noted to be able to identify triggers and coping skills. He was described as engaged, positive, focused and motivated, and he was described as having taken on a leadership role. His depressed mood had stabilized, and he no longer needed staff support to maintain engagement in his recovery program.", "the patient was noted to have changed his mind regarding his original discharge plan, as he reconciled with his significant other and intends to move in with her rather than his daughter, which had been the patients earlier discharge plan."], "answer_start": [43, 547, 822, 1091, 1853, 1961, 2468, 3025, 4576, 5032]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dual diagnosis residential substance misuse treatment.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.1 criteria for residential treatment center services provided during the first 25 days of the services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient had been sober from alcohol for 75 days, and he did not have a significant Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score. The patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had a history of cerebrovascular accidents with left sided weakness, hypertension and gastritis. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depressive disorder and was suicidal upon admission. He experienced frequent suicidal ideation that was exacerbated by drinking. He had two prior attempts and was admitted for suicidal ideation on three days prior to his admission at the residential treatment center. He initially endorsed multiple symptoms of depression including hopelessness, worthlessness, anhedonia, depressed mood, poor sleep and appetite. The patients mental status permitted participation. His psychiatric condition was stable and his anxiety and depression could be related to substance use problems or to a stable co-occurring emotional condition with imminent likelihood of relapse with dangerous consequences outside of a structured environment. The patient was also assessed as not posing a risk to self or others.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily and participated actively in treatment. He recognized the effects of alcohol on his health and relationships. The patient acknowledged the existence of a substance use problem, and he recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had been drinking heavily for 30 years and most recently relapsed after he had three strokes. He made significant progress in addressing his relapse triggers, and he was actively working on transitioning to the community with the assistance of his daughter. He was not able to return to the camper that he was residing in due to his disability from the cerebrovascular accidents. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community.For dimension 6 - Recovery Environment. The patient had been technically homeless, as he was living alone in a camper and going from campsite to campsite. He was socially isolated and had been experiencing frequent bouts of suicidal ideation with severe depression. He had been unable to cope with his physical disabilities after having three strokes. He is not able to reside alone due to disabilities from his strokes. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. Continued exposure to his living environment, however, made recovery unlikely, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Using the ASAM level 3.1 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.1 treatment during the first 25 days of the services at issue. Accordingly, the dual diagnosis residential substance misuse treatment provided during the first 25 days of the services at issue was medically necessary to treat the patients condition.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient did not meet Level 3.1 criteria for residential treatment center services provided during the next 29 days of the services at issue. Regarding dimension 5 - Relapse, Continued use, or Continued Problem Potential  during this period, the patient was noted to be able to identify triggers and coping skills. He was described as engaged, positive, focused and motivated, and he was described as having taken on a leadership role. His depressed mood had stabilized, and he no longer needed staff support to maintain engagement in his recovery program. Given these status changes, the patient no longer met the dimension 5 criteria for Level 3.1. Regarding dimension 6 - Recovery Environment - the patient was noted to have changed his mind regarding his original discharge plan, as he reconciled with his significant other and intends to move in with her rather than his daughter, which had been the patients earlier discharge plan. Given these status changes, the patient no longer met the dimension 6 criteria for Level 3.1. Accordingly, the dual diagnosis residential substance misuse treatment provided during the next 29 days of the services at issue was not medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were partially medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be partially 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.", "id": "741d9ee85a5c45cab15e855e6a756ec0", "question": "What is the background context in this case summary?", "title": "741d9ee85a5c45cab15e855e6a756ec0", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy. There is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including the efficacy of exercise and physical therapy interventions such as manual therapy and traction. Current treatment guidelines related to the management of cervical radiculopathy are lacking, while higher quality studies are underway. There is a lack of high grade, evidence-based support for prolonged formal physical therapy in this clinical setting. Treatment should include services in the formal therapy setting until transition to an independent program can be made. However, there is a lack of an indication in the available records that this patient has impairments that preclude full transition to an independent program with exercises and modalities that can be applied independently for further improvement in range of motion and symptomatic management. There is no reasonable expectation that her clinical course or outcomes with further formal therapy would be marginally improved over an independent program. The patients documented exercises in the formal therapy setting can be performed independently or substituted with independent exercise. For palliation, the patient can use topical heat, self-massage techniques, and independently applied electrical stimulation pads. All told, the requested physical 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 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. ", "id": "ecae827ab0b242c4bc61f22358c4f23f", "question": "What is the background context in this case summary?", "title": "ecae827ab0b242c4bc61f22358c4f23f", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Laparoscopic Sleeve Gastrectomy", "In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation."], "answer_start": [43, 746]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Laparoscopic Sleeve Gastrectomy.Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity (Mechanick, J., et al.). Mechanick and associates have developed updated clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. These guidelines recommend that all patients should undergo a psychosocial-behavioral evaluation as well as an appropriate nutritional evaluation before any bariatric surgical procedure. In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation. Under these circumstances, the requested Laparoscopic Sleeve Gastrectomy is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.", "id": "e01ea2f79c9745feac42938ad5f7f6f7", "question": "What is the background context in this case summary?", "title": "e01ea2f79c9745feac42938ad5f7f6f7", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for Xifaxan.", "In this case, the patient has diagnoses of IBS with constipation and SIBO."], "answer_start": [43, 576]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. A study notes that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Another study found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of irritable bowel syndrome (IBS) by possibly counteracting SIBO. An additional study notes that rifaximin plus neomycin is superior to neomycin alone in improving multiple constipation-predominant IBS symptoms. In this case, the patient has diagnoses of IBS with constipation and SIBO. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablets 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. ", "id": "d5675e55f2744d8da324be7f06f84983", "question": "What is the background context in this case summary?", "title": "d5675e55f2744d8da324be7f06f84983", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) for a minimum of 90 days.", "the patient was admitted to RTC after completing a 10-day detoxification at a different facility. She continued to have withdrawal symptoms including agitation, anxiety, hallucinations, and gastrointestinal upset.", "the patient does not have any medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring.", "the patient has significant difficulties with acute PTSD, anxiety, and an eating disorder. She participated in groups and was described by the providers as constantly anxious. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable, and he was assessed as having minimal problems in this area as evidenced by anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment. In addition, the patient was assessed as not posing a risk of harm to self or others.", "the patient admitted herself for treatment after a four-day binge on methamphetamine and experiencing a psychotic episode that resulted in her arrest. She has tried on several occasions to stop using alcohol and Xanax and has been unable to do so despite negative consequences. She expressed a desire to remain clean and abstinent and was able to identify negative consequences of her addiction. The patient acknowledged the existence of a psychiatric condition and substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change.", "the patient endorsed drinking alcohol in combination with Xanax for several years. She is also on 16 mg of suboxone daily. She started using methamphetamine and experienced psychotic episodes with dangerous behaviors. She also used methamphetamine on the day between her 10-day detoxification and admission to the RTC. The patient demonstrated limited coping skills to address relapse triggers and urges.", "the patient was living with her boyfriend who also uses substances, and she was unable to return to that apartment. She was unemployed due to her substance usage and she had difficulty accepting responsibility for her actions. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities."], "answer_start": [43, 665, 979, 1138, 1861, 2581, 3143]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) for a minimum of 90 days. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was admitted to RTC after completing a 10-day detoxification at a different facility. She continued to have withdrawal symptoms including agitation, anxiety, hallucinations, and gastrointestinal upset. The patients withdrawal needs could have been safely managed in Level 3.1 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient has significant difficulties with acute PTSD, anxiety, and an eating disorder. She participated in groups and was described by the providers as constantly anxious. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable, and he was assessed as having minimal problems in this area as evidenced by anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment. In addition, the patient was assessed as not posing a risk of harm to self or others. For dimension 4, the patient admitted herself for treatment after a four-day binge on methamphetamine and experiencing a psychotic episode that resulted in her arrest. She has tried on several occasions to stop using alcohol and Xanax and has been unable to do so despite negative consequences. She expressed a desire to remain clean and abstinent and was able to identify negative consequences of her addiction. The patient acknowledged the existence of a psychiatric condition and substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed drinking alcohol in combination with Xanax for several years. She is also on 16 mg of suboxone daily. She started using methamphetamine and experienced psychotic episodes with dangerous behaviors. She also used methamphetamine on the day between her 10-day detoxification and admission to the RTC. The patient demonstrated limited coping skills to address relapse triggers and urges. She was in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient was living with her boyfriend who also uses substances, and she was unable to return to that apartment. She was unemployed due to her substance usage and she had difficulty accepting responsibility for her actions. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment made recovery unlikely and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services, for a total treatment plan of a minimum of 90 days were and are medically necessary for 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 with subspecialty certification in addiction 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. ", "id": "628c01c1fa544ea3880e29987e843ffb", "question": "What is the background context in this case summary?", "title": "628c01c1fa544ea3880e29987e843ffb", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for positron emission tomography (PET) scan.", "this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable."], "answer_start": [43, 232]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan. Findings:  The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan. The National Comprehensive Cancer Network (NCCN) guidelines do not support routine use of PET scans for the surveillance of patients with triple negative breast cancer. Current data have reported that PET imaging has high false-negative rates in the detection of lesions that are smaller than 1 cm or are low grade. For these reasons, the requested PET scan is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 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. ", "id": "3984049c4c7449e69597186d713b9432", "question": "What is the background context in this case summary?", "title": "3984049c4c7449e69597186d713b9432", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for bilateral upper lid blepharoplasties.", "dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids.", "In this case, a physical examination and photographs show that the patient has"], "answer_start": [43, 394, 303]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral upper lid blepharoplasties. Findings:  The physician reviewer found that Hahn and colleagues note that upper lid blepharoplasty is a common procedure that can be performed safely and reliably. In this case, a physical examination and photographs show that the patient has significant dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids. In this clinical setting, the requested services are medically indicated. Therefore, bilateral upper lid blepharoplasties 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 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. ", "id": "b6965c17d0d8434dbb8450de1db40e7f", "question": "What is the background context in this case summary?", "title": "b6965c17d0d8434dbb8450de1db40e7f", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg.", "the documentation shows that the patient has tried and failed multiple TNF inhibitors", "In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq."], "answer_start": [43, 299, 199]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg. Findings:  The physician reviewer found that In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq. Given that the documentation shows that the patient has tried and failed multiple TNF inhibitors, a trial of another TNF inhibitor when she has had good response to another class of medications is not medically indicated. Therefore, Rinvoq (upadacitinib) extended 24-hour release 15 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. ", "id": "777b1a87ca60480cbdf5b7fb4574f812", "question": "What is the background context in this case summary?", "title": "777b1a87ca60480cbdf5b7fb4574f812", "sufficiency_score": 4}
+{"answers": {"text": ["The patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro.", "This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature."], "answer_start": [43, 259]}, "context": "Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro. The U.S. Food and Drug Administration (FDA) has approved GH therapy for patients with idiopathic short stature. This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature. Somatotropin therapy is indicated to help the patient attain a final adult height z-score above -2 SDs for North American women. However, this patients records lack documentation to meet the criteria for treatment with GH therapy. Specifically, there is no record of karyotype testing to exclude mosaic Turner syndrome, or brain MRI with and without gadolinium contrast obtained either before or after initiation of somatotropin. In the absence of this data, the requested Brand medication, Norditropin FlexPro is not medically necessary for 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 board certified in pediatrics with subspecialty certification in pediatric endocrinology 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. ", "id": "1998773393f94f42ba38cda53a716c0a", "question": "What is the background context in this case summary?", "title": "1998773393f94f42ba38cda53a716c0a", "sufficiency_score": 4}
+{"answers": {"text": ["The patients parent has requested authorization and coverage for residential treatment center (RTC) services.", "The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness.", "The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.", "The patient was motived and participated in treatment.", "The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis.", "The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service.", "The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization."], "answer_start": [43, 1164, 1522, 1839, 945, 600, 416]}, "context": "Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motived and participated in treatment.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored residence-based services, due to the serious risk of harm score of 4. This is consistent with the RTC level of care. Therefore, RTC services are 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 overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "e1239d48a07042dcb84de33d241f487d", "question": "What is the background context in this case summary?", "title": "e1239d48a07042dcb84de33d241f487d", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for a short-stem resurfacing procedure for the right shoulder", "In this case, the patient presents with complaints of bilateral shoulder pain, right greater than left, and decreased range of motion. The patients functional limitations are noted in activities of daily living. Her clinical exam findings are reported consistent with imaging evidence of severe glenohumeral osteoarthritis with effusion, moderate tendinopathy of the long head of the biceps tendon, moderate-severe acromioclavicular joint arthrosis, and rotator cuff tendinopathy with at least partial-thickness tearing of the supraspinatus. There is radiographic evidence of bone-on-bone glenohumeral osteoarthritis. The patient has requested authorization for a resurfacing procedure of the right shoulder."], "answer_start": [43, 1629]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a short-stem resurfacing procedure for the right shoulder.Researchers indicate that the potential advantages of humeral resurfacing, as compared with conventional shoulder arthroplasty, are: (1) no osteotomy is performed (and thus the head-shaft angle does not have to be addressed); (2) minimal bone resection; (3) a short operative time; (4) a low prevalence of humeral periprosthetic fractures; and (5) ease of revision to a conventional total shoulder replacement, if needed. Outcomes of surface replacement arthroplasty have been comparable with those of arthroplasties with a stemmed prosthesis in numerous short and mid-term follow-up studies. Future studies are required to assess the long-term outcomes of humeral resurfacing and to evaluate alternative surface bearing materials, especially on the glenoid side. Resurfacing appears to be a viable option for shoulder replacement, especially in young patients. Medical literature concluded that the indications for glenoid resurfacing are controversial. Advantages of glenoid resurfacing include decreased glenoid pain from metal-on-bone articulation, increased stability provided by the conforming glenoid component in the presence of asymmetric glenoid wear, and lateralization of the joint line providing for improved range of motion and strength. Patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock should be treated with hemiarthroplasty alone because glenoid resurfacing is associated with early loosening and failure.In this case, the patient presents with complaints of bilateral shoulder pain, right greater than left, and decreased range of motion. The patients functional limitations are noted in activities of daily living. Her clinical exam findings are reported consistent with imaging evidence of severe glenohumeral osteoarthritis with effusion, moderate tendinopathy of the long head of the biceps tendon, moderate-severe acromioclavicular joint arthrosis, and rotator cuff tendinopathy with at least partial-thickness tearing of the supraspinatus. There is radiographic evidence of bone-on-bone glenohumeral osteoarthritis. The patient has requested authorization for a resurfacing procedure of the right shoulder. Current evidence based medical literature indicates that resurfacing appeared to be a viable option for shoulder replacement, especially in younger patients. Glenoid resurfacing is associated with early loosening and failure in patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock. In this case, there is no consensus between the physicians on the surgical treatment plan. However, the active patients age, deficient rotator cuff, shoulder osteoarthritis, knowledge and positive experience with resurfacing supports the requested procedure. The short stem resurfacing procedure represents a reasonable alternative to ongoing non-operative and more invasive shoulder replacement. Therefore, a short-stem resurfacing procedure for the right shoulder is medically necessary for treatment of the patients medical condition (right shoulder osteoarthritis and tears in the rotator cuff).Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient's 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.", "id": "da167c521fb845bb85c56c5df880d1cc", "question": "What is the background context in this case summary?", "title": "da167c521fb845bb85c56c5df880d1cc", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics."], "answer_start": [0]}, "context": "The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics. There is a lack of clinical indication for the patient to remain admitted to the hospital in order to complete her antibiotic dosing. Such medications can be safely administered in a long-term care setting such a skilled nursing facility or another long-term care facility. Moreover, prolonged hospitalization increases this immunocompromised patients risk to other infections. As such, an infection such as a UTI is treated without inpatient care in an outpatient setting when possible. For these reasons, the requested continued hospitalization until her course of antibiotics is complete for her infection and her heart rate is stabilized is not medically necessary for treatment of this patient.", "id": "8550644acc434345b281ec8d5e8c8a75", "question": "What is the background context in this case summary?", "title": "8550644acc434345b281ec8d5e8c8a75", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of the patient has requested authorization and coverage for speech therapy services.", "In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued."], "answer_start": [43, 1082]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for speech therapy services. The submitted documentation supports the medical necessity of the requested services. Speech therapy is standard of care for children with autism spectrum disorder. Hyman and colleagues stated, All children with autism spectrum disorder (ASD) should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with ASD. Researchers noted the importance of early intervention for children with autism spectrum disorder. Studies concluded that behavioral interventions were evidence based to induce speech among individuals with developmental disabilities. Scientists described treatment for autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued. Therefore, speech therapy services 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 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. ", "id": "0187f75771b648a9a7832182fb1408ad", "question": "What is the background context in this case summary?", "title": "0187f75771b648a9a7832182fb1408ad", "sufficiency_score": 2}
+{"answers": {"text": ["The patient has requested reimbursement for Wide local excision of melanoma in situ.", "The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision."], "answer_start": [43, 403]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Wide local excision of melanoma in situ.  Per Health and Safety Code section 1345(h), health plans are required to cover urgent care services. Per that same provision, urgent care services are defined as, services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision. Based on the definition of urgent care services, the patients melanoma did not require urgent excision on the date of service. The American Academy of Dermatology (AAD) guidelines on the management of melanoma recommend definitive excision within two months of diagnosis. Moreover, current data suggest that there is a paucity of evidence to suggest that a shorter timeline for removal of the tumor changes long-term patient health outcomes. Based on these findings, the procedure could have been performed within the two-month timeframe without urgent excision on the date of service. A wide local excision by a plastic surgeon or dermatologist was reasonable. There was no reasonable expectation of deterioration in the patients health to support an urgent indication for the procedure. Therefore, the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Therefore, the Health Plans denial should be upheld. 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. ", "id": "de2ac8d606f74c45b576bd9832e98451", "question": "What is the background context in this case summary?", "title": "de2ac8d606f74c45b576bd9832e98451", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm."], "answer_start": [0]}, "context": "An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm. Standard options for treatment include hysterectomy, myomectomy, and uterine artery embolization. Radiofrequency ablation procedure is a less invasive alternative treatment for myomas of appropriate size and location. Researchers found that radiofrequency ablation of uterine fibroids reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates. Based on the peer-reviewed medical literature, the requested laparoscopic radiofrequency ablation of fibroids 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 obstetrics and gynecology 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.", "id": "4e18be4c2d9b461aaa2a276467496837", "question": "What is the background context in this case summary?", "title": "4e18be4c2d9b461aaa2a276467496837", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol"], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol without any documented trial or intolerance to higher dose beta-blocker therapy. A recent clinic note did not document any tachycardia or hypotension, at baseline or after standing, despite symptom occurrence. Studies evaluating Corlanor for the treatment of patients with POTS have demonstrated lower heart rate and reduced symptoms in some patients. However, the available studies are small and without comparison control groups. The patient has not reported any tachycardia during symptoms while on low dose carvedilol and there is no documented contraindication to higher dose carvedilol therapy. For these reasons, the requested ivabradine (Corlanor) is not medically necessary for 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 internal medicine with subspecialty 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. ", "id": "2e8ddf014bb4429d901adc4d903421ef", "question": "What is the background context in this case summary?", "title": "2e8ddf014bb4429d901adc4d903421ef", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are", "reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis."], "answer_start": [43, 398]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are anecdotal reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis. No plan for parent training is provided. Under these circumstances, the submitted documentation does not support that Visual Communication Analysis and Self-Determination Theory are medically necessary for the patient. Therefore, Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day) and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week) were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat 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.", "id": "f83c4cc146674640b0f88ab49948d2d2", "question": "What is the background context in this case summary?", "title": "f83c4cc146674640b0f88ab49948d2d2", "sufficiency_score": 4}
+{"answers": {"text": ["The patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric services."], "answer_start": [0]}, "context": "The patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. The patients composite score is consistent with high intensity community based services. This level of care is consistent with the IOP level of care. Given these findings, the IOP psychiatric services were medically necessary for 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "99d547ad060843dd9bf34c2b0b467253", "question": "What is the background context in this case summary?", "title": "99d547ad060843dd9bf34c2b0b467253", "sufficiency_score": 2}
+{"answers": {"text": ["The patient has requested reimbursement for Euflexxa injections in both knees.", "In this case, the patient has a history of significant benefit from prior viscosupplementation injections.", "The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties."], "answer_start": [0, 662, 816]}, "context": "The patient has requested reimbursement for Euflexxa injections in both knees. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of significant benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the services at issue in this clinical setting. Therefore, Euflexxa injections in both knees 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. ", "id": "fae660f5b2a44df7b565aff3693b1b84", "question": "What is the background context in this case summary?", "title": "fae660f5b2a44df7b565aff3693b1b84", "sufficiency_score": 3}
+{"answers": {"text": ["The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse.", "he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior.", "the enrollee demonstrates significant improvement in function following a period of deterioration.", "the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes.", "previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function.", "the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers."], "answer_start": [45, 1019, 1207, 1683, 1901, 2188]}, "context": "Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, as he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior. For functional status the enrollees score is 2, as the enrollee demonstrates significant improvement in function following a period of deterioration. For comorbidity the enrollees score is 2, due to the presence of transient, occasional, stress-related psychiatric symptoms that have no discernable impact on his presenting condition. For recovery environment level of stress, the enrollees score is 3, due to exposure to substance abuse and its effects. For recovery environment level of support, the enrollees score is 2, as the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history the enrollees score is 3, since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function. For acceptance and engagement the enrollees score is 2, as the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers. The enrollees composite CALOCUS score is 17, which correlates with high intensity community-based services, as provided at the intensive outpatient program (IOP) level.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.", "id": "5c2e13f943834abfa88abac8c0de4628", "question": "What is the background context in this case summary?", "title": "5c2e13f943834abfa88abac8c0de4628", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception. The requested D&C is no longer medically necessary. The patient has no heavy bleeding, fever or pain. Proceeding with a D&C would be more harmful than beneficial. Therefore, the requested D&C without general anesthesia is 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 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. ", "id": "9605964677954912acb374f2c067d1ab", "question": "What is the background context in this case summary?", "title": "9605964677954912acb374f2c067d1ab", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen."], "answer_start": [0]}, "context": "An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen. The American College of Medical Genetics and Genomics (ACMGG) recommends offering carrier screening for cystic fibrosis to all female patients using a 23-mutation panel. The American College of Obstetricians and Gynecologists (ACOG) also recommends carrier screening for cystic fibrosis and spinal muscular atrophy to all patients of childbearing age. The expanded carrier screening is efficient, as it includes carrier screening for cystic fibrosis, and spinal muscular atrophy. Given this patients age and family history, the 10 prenatal genetic tests  Foresight Carrier Screen were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the 10 prenatal genetic tests  Foresight Carrier Screen.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 genetics 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.", "id": "196784acabb544938fa532c15b73bb66", "question": "What is the background context in this case summary?", "title": "196784acabb544938fa532c15b73bb66", "sufficiency_score": 2}
+{"answers": {"text": ["The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM).", "In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness."], "answer_start": [0, 910]}, "context": "The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM). The Eversense real time CGM system consists of a subcutaneously inserted sensor, a wearable transmitter, and a smartphone application. The sensor longevity is achieved using multiple approaches, including the chemical structure of the glucose binding polymer, the platinum coating, the dexamethasone acetate eluting ring, and the subcutaneous position in comparison to transcutaneous real time CGM systems. The U.S. Food and Drug Administration (FDA) approved the Eversense CGM in 2018. There are multiple peer-reviewed studies and published literature attesting to the Eversense CGM accuracy, and its superiority to the Dexcom and the Freestyle Libre CGM devices. In a recent study that compared the three CGM systems, the point accuracy of the Eversense was significantly better than two other CGM systems. In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness. The Eversense CGM is implantable subcutaneously, which also supports superior accuracy when compared to Dexcom and Freestyle Libre CGM devices, and helps keep the sensor in place. All told, the requested Eversense CGM is 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 certification in diabetes, endocrinology and metabolism 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. ", "id": "a3fccd861066434c8130e9f78f4e4a39", "question": "What is the background context in this case summary?", "title": "a3fccd861066434c8130e9f78f4e4a39", "sufficiency_score": 3}
+{"answers": {"text": ["The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1.", "The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis."], "answer_start": [45, 562]}, "context": "Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1. This places her in the absent-to-mild fibrosis, low-risk category for significant fibrosis/stenosis. The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis. Professional societies  recommended Zepatier as a treatment for HCV genotype 1a, interferon-experienced persons; but only if they do not have resistance variants.  To utilize this medication regimen, resistance testing needs to be performed.  There was insufficient evidence in the record that resistance testing was performed. Epclusa, an alternative medication, is also a recommended regimen for HCV genotype 1a interferon-experienced patients and does not require resistance testing.   Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.", "id": "8be8915f35ae455db9a6db9004fac653", "question": "What is the background context in this case summary?", "title": "8be8915f35ae455db9a6db9004fac653", "sufficiency_score": 4}
+{"answers": {"text": ["The enrollee is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered a residential treatment center (RTC) for treatment of heroin addiction. The enrollee reported he was mentally exhausted. He started opiates in high school, and heroin at 17-18 years old. Since the start of heroin use, he has accumulated approximately five years of sobriety. He noted his heroin use was due to pain. He was involved in an accident which exacerbated his pre-existing sciatic pain and added significant thoracic and shoulder pain. He had past success with Methadone and Suboxone and remained abstinent when adhering to his medication regimen. This admission is his sixth time in treatment. The discharge recommendation was an intensive outpatient program and sober living. The enrollee reports using two grams of heroin a day for two years. Prior to this, he was sober for a year and a half. The enrollee describes a history of depression and insomnia, but he stated he was never diagnosed. However, he had been prescribed Seroquel and Ativan. He was taking Gabapentin for pain from a motor vehicle accident two years ago. He has no history of suicidal ideation (SI), homicidal ideation (HI), self-harming behaviors, or auditory and visual hallucinations. He denied a history of seizure or blackouts. After admission, he was placed on an opioid withdrawal protocol and was receiving Clonidine, Imodium, Baclofen, Vistaril and Suboxone; when indicated.", "He shows significant deterioration in his ability to fulfill responsibilities and obligations to job, school, self, or significant others; which may be avoided or neglected on some occasions.", "He may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but they are transient and have no discernable impact on the co-existing substance use disorder.", "At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings.", "The enrollee shows some recognition of his personal role in recovery and accepts some responsibility for it."], "answer_start": [45, 2354, 2762, 3601, 3846]}, "context": "Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered a residential treatment center (RTC) for treatment of heroin addiction. The enrollee reported he was mentally exhausted. He started opiates in high school, and heroin at 17-18 years old. Since the start of heroin use, he has accumulated approximately five years of sobriety. He noted his heroin use was due to pain. He was involved in an accident which exacerbated his pre-existing sciatic pain and added significant thoracic and shoulder pain. He had past success with Methadone and Suboxone and remained abstinent when adhering to his medication regimen. This admission is his sixth time in treatment. The discharge recommendation was an intensive outpatient program and sober living. The enrollee reports using two grams of heroin a day for two years. Prior to this, he was sober for a year and a half. The enrollee describes a history of depression and insomnia, but he stated he was never diagnosed. However, he had been prescribed Seroquel and Ativan. He was taking Gabapentin for pain from a motor vehicle accident two years ago. He has no history of suicidal ideation (SI), homicidal ideation (HI), self-harming behaviors, or auditory and visual hallucinations. He denied a history of seizure or blackouts. After admission, he was placed on an opioid withdrawal protocol and was receiving Clonidine, Imodium, Baclofen, Vistaril and Suboxone; when indicated.  The Clinical Opiate Withdrawal Scale (COWS) is used to assess the progress and severity of withdrawal and to guide medication administration. Scores of 5-12 indicate mild withdrawal, 13-24 indicate moderate withdrawal, 25-26 indicate moderately severe withdrawal, and over 36 indicate severe withdrawal. His initial COWS score was 11 and his last was 3. The Level of Care Utilization System (LOCUS), level of care assessment tool, applied in review of this case indicates for risk of harm, the enrollees score is 2, due to substance use without significant episodes of potentially harmful behaviors. For functional status, the enrollees score is 3, due to significant disturbances in vegetative activities such as sleep, eating habits, activity level, or sexual appetite which do not pose a serious threat to health. He shows significant deterioration in his ability to fulfill responsibilities and obligations to job, school, self, or significant others; which may be avoided or neglected on some occasions. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. He may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but they are transient and have no discernable impact on the co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 3, due to a significant transition causing disruption in life circumstances; such as job loss, legal difficulties or change of residence, and easy exposure and access to alcohol and drugs. For recovery environment level of support, the enrollees score is 2, because supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, because previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For engagement and recovery status, the enrollees score is 2, due to willingness to change. The enrollee shows some recognition of his personal role in recovery and accepts some responsibility for it. The enrollees composite LOCUS score is 17, which correlates with high intensity community-based services. Medical evidence does not support the services at issue in this clinical setting. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.", "id": "b7165c60749540b19ada323107ca3070", "question": "What is the background context in this case summary?", "title": "b7165c60749540b19ada323107ca3070", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.", "In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction."], "answer_start": [43, 819]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction. Under these circumstances, the requested double mastectomy with nipple reconstruction is medically necessary to treat the patients medical condition.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.", "id": "9387a37ac4404169a87cd1b781940f56", "question": "What is the background context in this case summary?", "title": "9387a37ac4404169a87cd1b781940f56", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for Radicava", "The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability", "This patient is able to ambulate with the use of assistive devices."], "answer_start": [43, 514, 1036]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Radicava. Radicava is U.S. Food and Drug Administration (FDA) approved to slow decline and loss of physical function in patients with amyotrophic lateral sclerosis (ALS). A study found that medical trials demonstrated beneficial improvement on functional ability and slowing clinical decline in ALS with Radicava. Study extension results published also reflected positive benefit of Radicava for treatment of ALS. The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability. However, the patients ALS Functional Rating Scale (ALSFRS) (ALSFRS) score should reflect a score two for walking ability, not a one, as noted in the records. A score of two is appropriate when a patient can walk with assistance. A score of one denotes only non-ambulatory functional movement. This patient is able to ambulate with the use of assistive devices. As such, all of the elements of the ALSFRS at the time medication was to be started were two or greater, which supports an indication for Radicava. Moreover, the timeframe of diagnosis was less than two years ago, as recommended by the guidelines. As such, the medical records demonstrate that the patient meets the recommendations in the medical literature for the treatment with Radicava. Therefore, treatment with Radicava is medical 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 neurology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "44c4d4ef44a9484c8d076e45e705ad40", "question": "What is the background context in this case summary?", "title": "44c4d4ef44a9484c8d076e45e705ad40", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness.", "the patient is", "insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range."], "answer_start": [43, 674, 699]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness. Moreover, the patient is extremely insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range. 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 certification in diabetes, endocrinology and metabolism 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. ", "id": "a4813127efd14c86a77b9dcc1f4ba3ca", "question": "What is the background context in this case summary?", "title": "a4813127efd14c86a77b9dcc1f4ba3ca", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested Synvisc One injections.", "The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections."], "answer_start": [43, 216]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested Synvisc One injections. Findings: The physician reviewer found that medical evidence supports that Synvisc One injections are medically necessary. The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections. A review of current medical literature pertaining to viscosupplementation reveals mixed results. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Current research reports that intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit for patients with knee osteoarthritis, without major safety concerns. IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, there is evidence of benefit from prior injections. Moreover, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc One injections 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 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. ", "id": "07e5d88a19024a28bdb232d765eaeea5", "question": "What is the background context in this case summary?", "title": "07e5d88a19024a28bdb232d765eaeea5", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for partial hospitalization program services.", "The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times.", "The patients family was involved in her treatment on a regular basis, and she denied illicit substance use."], "answer_start": [43, 397, 589]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not indicate that the patient had active suicidal or homicidal ideation. The records do not demonstrate that the patient was experiencing psychosis. The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times. The progress notes do not indicate that the patient was engaging in aggressive behaviors. The patients family was involved in her treatment on a regular basis, and she denied illicit substance use. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to problems with role performance and ability to maintain some meaningful relationships. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living situation with intermittent interpersonal conflict. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the inpatient and residential treatment levels of care but without complete remission of the eating disorder symptoms. In terms of engagement and recovery status, the records support a score of 2 to 3 due to cooperation in treatment but also hesitation in acceptance of her illness. Thus, the patient has a composite score of 14 to 15. This score correlates with high intensity community based services, or treatment in an intensive outpatient clinic setting. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.", "id": "a89b991a7acc4afcbda45223739b866a", "question": "What is the background context in this case summary?", "title": "a89b991a7acc4afcbda45223739b866a", "sufficiency_score": 2}
+{"answers": {"text": ["The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant.", "the patients records indicated the possibility of a diagnosis of an intracranial aneurysm"], "answer_start": [43, 208]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant. A review of the patients records indicated the possibility of a diagnosis of an intracranial aneurysm, which is common in patients with ADPKD. The risk of bleeding from such an aneurysm is significant. Therefore, any anticoagulation in patients with ADPKD must be undertaken cautiously. Studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Findings:  Two out of three physician reviewers found that studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Final Result: The reviewers determined that the requested tests were likely to have been 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 sub-specialty certification in nephrology, 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.", "id": "c3bfdd433b0b4cca8f86164ae12c86b4", "question": "What is the background context in this case summary?", "title": "c3bfdd433b0b4cca8f86164ae12c86b4", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer.Findings:  Three physician reviewers found that high-intensity focused ultrasound (HIFU) has been widely used for whole gland ablation. The first published results of focal HIFU are promising. The patient's quality of life and potency are well preserved with good early results. Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under five years of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. The U.S. Food and Drug Administration (FDA) has approved HIFU as safe for the treatment of prostate ablation. However, there is no specific indication for the treatment of prostate cancer. Furthermore, the safety and efficacy of chemical or surgical cytoreduction of the prostate remains unproven. The safety and efficacy of HIFU are currently being evaluated. There is a paucity of long-term comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Thus, the HIFU prostate ablation procedure that was performed was 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 procedure was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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.", "id": "1db3f5a8230a43309b8acc78ee68d5bc", "question": "What is the background context in this case summary?", "title": "1db3f5a8230a43309b8acc78ee68d5bc", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily.", "He indicates that he experienced temporary relief with treatments.", "The patient has been referred for surgical management due to the lack of relief of conservative measures."], "answer_start": [43, 1176, 1618]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily. The patient has received sufficient acupuncture treatment to his neck and low back. He has not reportedly made any sustained and significant improvement after 26 total treatments with two different providers. He indicates that he experienced temporary relief with treatments. However, he is not reasonably expected to make further sustained improvement through more treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is only limited evidence for long-term effects. Also, studies show that acupuncture is not clinically more effective than sham-acupuncture or placebo for neck or back pain. The patient has been referred for surgical management due to the lack of relief of conservative measures. Acupuncture is not supported as medically necessary for his condition.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 a board certified chiropractor licensed in oriental 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. ", "id": "ce84b09b6d254438a827ee4b49a7d54e", "question": "What is the background context in this case summary?", "title": "ce84b09b6d254438a827ee4b49a7d54e", "sufficiency_score": 3}
+{"answers": {"text": ["The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that RTC or similar care that is higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In addition, the American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce the risk of relapse. The RTC was in accordance with generally accepted standards of medical practice.This patients risks included her living alone without a support system in place. She required a safe and stable living environment in order to develop her recovery skills, and thus qualified for ASAM Level III treatment, which is consistent with the services provided at the RTC. Therefore, the RTC services provided from 12/12/18 through 12/16/18 were medically necessary to treat the patients behavioral health condition.Final Result: The reviewer determined that the requested services 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 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. ", "id": "f37666edaa7b48f5be58cfbabbaff20c", "question": "What is the background context in this case summary?", "title": "f37666edaa7b48f5be58cfbabbaff20c", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for genetic testing.", "this patient does not have a reported personal or family history of clotting disorders"], "answer_start": [0, 283]}, "context": "An enrollee has requested reimbursement for genetic testing. Although antiphospholipid syndrome has been associated with early pregnancy loss, routine testing for other thrombophilias is not recommended by the American College of Obstetricians and Gynecologists (ACOG). In addition, this patient does not have a reported personal or family history of clotting disorders to warrant testing for thrombophilias. According to the ACOG practice bulletin, no work-up generally is recommended until after the second consecutive clinical early pregnancy loss. Specifically, ACOG noted that maternal or fetal chromosomal analyses or testing for inherited thrombophilias are not recommended routinely after one early pregnancy loss. Further, from the American Society for Reproductive Medicine (ASRM), routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not recommended. Accordingly, the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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.", "id": "2cc45bf915164933b50cc7ab217a6c2d", "question": "What is the background context in this case summary?", "title": "2cc45bf915164933b50cc7ab217a6c2d", "sufficiency_score": 2}
+{"answers": {"text": ["The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services.", "the patient had some potential for risk of harm, for she is noted to have had a history of serious harm to others and suicidal ideation and covert preparation for self-harm or suicide", "the patient had been neglecting her ADLs and had a history of a previous shutdown", "the patient has a significant comorbidity, sensory integration disorder", "The patients recovery environment  level of stress score reflects a highly stressful environment", "The patients recovery environment  level of support score reflects that the patients recovery support was limited", "The patients resilience and treatment history score", "and her acceptance and engagement  child/adolescent score", "were adversely affected by her non-adherence and repeated rejection of therapists, along with multiple relapses. The patients acceptance and engagement  parent/primary caretaker score appeared destructive", "due to their competition."], "answer_start": [43, 932, 1158, 1276, 1361, 1471, 1598, 1662, 1732, 1949]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters 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. Regarding the six CALOCUS dimensions, the patient had some potential for risk of harm, for she is noted to have had a history of serious harm to others and suicidal ideation and covert preparation for self-harm or suicide (score = 3). Regarding functional status, the patient had been neglecting her ADLs and had a history of a previous shutdown (score = 4). Regarding comorbidity, the patient has a significant comorbidity, sensory integration disorder (score = 3). The patients recovery environment  level of stress score reflects a highly stressful environment (score = 4). The patients recovery environment  level of support score reflects that the patients recovery support was limited (score = 4). The patients resilience and treatment history score (score = 4) and her acceptance and engagement  child/adolescent score (score = 4) were adversely affected by her non-adherence and repeated rejection of therapists, along with multiple relapses. The patients acceptance and engagement  parent/primary caretaker score appeared destructive (score = 4) due to their competition. This represents a composite CALOCUS score of 26 at the time of admission to the RTC. The patient therefore met CALOCUS criteria on the date of admission to residential treatment center services. After treatment, however, the patient no longer met CALOCUS criteria for a continued RTC stay. The CALOCUS score after admission was 18, with marked improvement in the patient's daily functioning and engagement and acceptance of treatment; especially her willingness to continue Lexapro, which had improved her mood and anxiety. The patients family appeared much more prepared to continue therapy and to be supportive. Therefore, the RTC services provided during the patients admission were medically necessary for treatment of the patients medical condition. The RTC services following the patients 12th month of admission to the RTC were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that some of requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "de08d0808e1e42728619dcedc14afc54", "question": "What is the background context in this case summary?", "title": "de08d0808e1e42728619dcedc14afc54", "sufficiency_score": 4}
+{"answers": {"text": ["The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg", "In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18."], "answer_start": [11, 680]}, "context": "Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg. The submitted documentation supports the medical necessity of the requested medication. Menstrual migraine is defined as migraine without aura that occurs within days -2 and +3 of the menstrual period on at least 2 of 3 consecutive menstrual cycles (where menstruation onset is defined as day 1). Studies have stated that evidence from frovatriptan studies meets the AAN threshold for a Level A recommendation for short-term use to prevent menstrual migraine. Researchers recommend frovatriptan as effective for menstrual headaches. In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18. Under these circumstances, frovatriptan succinate 2.5mg is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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.", "id": "b5d3f53ab6fb417682cf83d94c001d5a", "question": "What is the background context in this case summary?", "title": "b5d3f53ab6fb417682cf83d94c001d5a", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of an enrollee has requested reimbursement for residential treatment services.", "The medical records indicate that the patient was not actively suicidal during the disputed timeframe, and he did not engage in self-harm behaviors.", "The patient had some issues with level of function prior to residential treatment center placement, but the progress notes indicate significant improvement after a period of deterioration. The progress notes indicate he performed his activities of daily living as well as chores at the treatment center on a regular basis. He was also noted to help peers with their chores.", "The patient had asthma issues which were exacerbated by wildfires in the area near the residential treatment center. The records did not indicate a history of substance use, and he did not have a substance use diagnosis.", "The patient was not noted to have interpersonal conflict with the family members.", "The patients parents were involved in treatment on a regular basis.", "During the dates of service in dispute, the patient showed cooperative behavior and attitude. The progress notes indicated that he was open and honest with regards to his feelings about his peers at the treatment center, who appeared to be his major focus of stress. He did not display aggression towards peers or staff during the disputed timeframe. The patient did not express significant depression or anxiety symptoms. He did not express symptoms of psychosis. He indicated that his medications were working for him, and his focus was good.", "The patient had a good response to a short period in the residential treatment center prior to the disputed dates.  His presentation during the disputed timeframe indicates that he was cooperative in treatment. He had failed prior treatment at the outpatient and partial hospitalization program levels of care.", "The patient participated in therapy actively, and his insight and judgment into his issues with his peer relationships appeared to improve as his treatment progressed.", "The parents worked actively and constructively with clinicians on a regular basis."], "answer_start": [43, 1127, 1345, 1778, 2094, 2268, 230, 2420, 2823, 3079]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the patient showed cooperative behavior and attitude. The progress notes indicated that he was open and honest with regards to his feelings about his peers at the treatment center, who appeared to be his major focus of stress. He did not display aggression towards peers or staff during the disputed timeframe. The patient did not express significant depression or anxiety symptoms. He did not express symptoms of psychosis. He indicated that his medications were working for him, and his focus was good.In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal during the disputed timeframe, and he did not engage in self-harm behaviors. With regards to functional status, the records support a score of 2. The patient had some issues with level of function prior to residential treatment center placement, but the progress notes indicate significant improvement after a period of deterioration. The progress notes indicate he performed his activities of daily living as well as chores at the treatment center on a regular basis. He was also noted to help peers with their chores. In terms of comorbidity, the records support a score of 2. The patient had asthma issues which were exacerbated by wildfires in the area near the residential treatment center. The records did not indicate a history of substance use, and he did not have a substance use diagnosis. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was not noted to have interpersonal conflict with the family members. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center prior to the disputed dates.  His presentation during the disputed timeframe indicates that he was cooperative in treatment. He had failed prior treatment at the outpatient and partial hospitalization program levels of care. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and his insight and judgment into his issues with his peer relationships appeared to improve as his treatment progressed. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with outpatient services. Therefore, residential treatment services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "f7e8bf32fec046a6b71987a8a28cf5c6", "question": "What is the background context in this case summary?", "title": "f7e8bf32fec046a6b71987a8a28cf5c6", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for MRI of silicone breast implants.", "In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years."], "answer_start": [43, 866]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of silicone breast implants. The U.S. Food & Drug Administration (FDA) recommends that persons who have silicone gel-filled breast implants receive MRI screening for silent rupture 3 years after receiving their implant, and every 2 years after that. A study found that MRI is the modality of choice, if it is available. Their study found that the diagnostic accuracy of magnetic resonance imaging was significantly higher than that of ultrasound (94 percent versus 72 percent; p < 0.0001), and states, [M]agnetic resonance imaging should be considered the investigation of choice for implant rupture where the resource is available. However, if magnetic resonance imaging is contraindicated or unavailable, ultrasound can be considered as an alternative method. In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years. Based on the entirety of the medical documentation, MRI of silicone breast implants is medically necessary for treatment of the patients medical condition at this time.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 plastic 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.", "id": "b3f2ff365f8c4c5499180f3f946d9340", "question": "What is the background context in this case summary?", "title": "b3f2ff365f8c4c5499180f3f946d9340", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two."], "answer_start": [0]}, "context": "An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two. The submitted documentation supports the medical necessity of the requested services. While there is a paucity of studies that have specifically compared laser keratoplasty procedure performed at two different sites versus one site, transporting the patient from one site to another during the procedure does add a small risk to the procedure. Therefore, in order to minimize risk of any harm to the patient, the one site procedure is recommended. Thus, the requested corneal transplant with laser to be performed at one location, instead of two, is medically necessary for the treatment of this patient.", "id": "63aa4d59b6d4493888d658a7b0276f04", "question": "What is the background context in this case summary?", "title": "63aa4d59b6d4493888d658a7b0276f04", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra.", "other anticonvulsants are available on the Health Plan formulary"], "answer_start": [43, 286]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra. Although other anticonvulsants are available on the Health Plan formulary, it is unknown whether any other monotherapy or combination antiepileptic drug regimen would control the patient's seizures. In 30-year review of 1795 patients with newly diagnosed epilepsy, colleagues stated that Most patients who attain control do so with the first or second antiepileptic drug. The probability of achieving seizure freedom diminishes substantially with each subsequent antiepileptic drug regimen tried. More than one-third of patients experience epilepsy that remains uncontrolled. Colleagues noted that epilepsy associated with tumors is generally poorly controlled by antiepileptic drugs. Colleagues explained that Aptiom (eslicarbazepine acetate) is effective in the treatment of refractory partial seizures in children, and that it is well tolerated from a neurocognitive and behavioral standpoint. Therefore, Aptiom 800 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 pediatrics and neurology, with special qualification in pediatric 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. ", "id": "bd25c21ffcc54925ba1b2536f23f0007", "question": "What is the background context in this case summary?", "title": "bd25c21ffcc54925ba1b2536f23f0007", "sufficiency_score": 3}
+{"answers": {"text": ["A female enrollee has requested reimbursement for the serological antibody blood test."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the serological antibody blood test. Confirmation of eradication should be performed in patients treated for H. pylori due to increasing antibiotic resistance. Based on the current medical guidelines, eradication can be confirmed with a urea breath test, stool antigen testing, or endoscopy-based testing. The choice of test depends on the need for an upper endoscopy. Tests to confirm eradication should be performed at least four weeks after completion of antibiotic treatment. However, there is a lack of data supporting a role for serologic testing to confirm eradication, as patients may continue to have antibodies after eradication, and this leads to false positive results. Accordingly, the serological antibody blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the serological antibody blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "b1912dba2a2c49bab776fe6f326ac0ee", "question": "What is the background context in this case summary?", "title": "b1912dba2a2c49bab776fe6f326ac0ee", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Orthovisc injections to the right and left knee."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections to the right and left knee. The submitted documentation demonstrates the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. The current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In this patients case, prior viscosupplementation was beneficial. Therefore, the requested Orthovisc injections to the right and left knee 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 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. Findings:  The physician reviewer found that ", "id": "abbf19c31e8d4de49fad1c74af9f3aec", "question": "What is the background context in this case summary?", "title": "abbf19c31e8d4de49fad1c74af9f3aec", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Stelara."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara. Current medical literature supports the use of Stelara in this case. Stelara is U.S. Food and Drug Administration (FDA) approved for Crohns disease. One large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A recent study demonstrated that a majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this patient with primary nonresponse to anti-TNF medication (Humira), a medication with an alternative mechanism of action, such as Stelara, is more appropriate to control disease and to prevent further complications. For these reasons, Stelara is medically necessary for the treatment of this patients Crohns disease.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. ", "id": "ec1532e307fe4859a5c4f8feb20ee10b", "question": "What is the background context in this case summary?", "title": "ec1532e307fe4859a5c4f8feb20ee10b", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Orthovisc injection (hyaluronan) for treatment of knee pain due to osteoarthritis."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection (hyaluronan) for treatment of knee pain due to osteoarthritis. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Researchers have noted that medical guidelines recommend intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption); and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. In addition, other researchers have conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested services are medically necessary.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 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. ", "id": "18719d0968d84602a326391d3e9a7449", "question": "What is the background context in this case summary?", "title": "18719d0968d84602a326391d3e9a7449", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for interferon alfa 2b injections."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for interferon alfa 2b injections. The submitted documentation supports the medical necessity of the requested medication. A large case series of 127 patients by researchers demonstrated an overall 54% response rate with a mean 9 degree improvement in curvature in all patients. The study concluded that intralesional therapy with interferon alfa 2b continues to be a viable treatment option for Peyronies disease with data consistently showing improvements in disease characteristics. The current medical evidence supports intralesional interferon alfa 2b for nonoperative treatment of Peyronies disease. Therefore, interferon alfa 2b injections 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 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.", "id": "824fa32b36364f7a9b47a1172bc63966", "question": "What is the background context in this case summary?", "title": "824fa32b36364f7a9b47a1172bc63966", "sufficiency_score": 2}
+{"answers": {"text": ["The parent of an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG)."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG). Central to the idea of PANDAS is the concept that after Group A beta-hemolytic streptococcal (GABHS) infection, antibodies are generated that cross-react with antigens present in the basal ganglia and related structures. This in turn causes pathologic derangement of poly-synaptic pathways that subserve both cognitive, emotional and motor functions frequently associated with obsessive compulsive disorder and other neuropsychiatric disorders. In the medical literature, researchers reported on a clinical trial that showed no difference between IVIG and placebo in the blinded phase for pediatric patients with a purported diagnosis of PANDAS. All told, the current medical literature does not support the requested IVIG as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and 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. ", "id": "0eca31ea40fa422eb38f97e4882f9107", "question": "What is the background context in this case summary?", "title": "0eca31ea40fa422eb38f97e4882f9107", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Xeljanz 5 mg tablet.", "In this case, the patient has seronegative rheumatoid arthritis, Sjogren's syndrome and a positive ANA. The submitted documentation demonstrates the patient has failed methotrexate and hydroxychloroquine.", "the patient has previously done well with Xeljanz with no evidence of synovitis."], "answer_start": [43, 278, 510]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. Review of the submitted evidence demonstrates that the requested Xeljanz 5 mg tablet is medically necessary for treatment of the patients medical condition. In this case, the patient has seronegative rheumatoid arthritis, Sjogren's syndrome and a positive ANA. The submitted documentation demonstrates the patient has failed methotrexate and hydroxychloroquine. Further, there is evidence the patient has previously done well with Xeljanz with no evidence of synovitis. Given the patients history of positive ANA, a tumor necrosis factor inhibitor (TNFi) such as Enbrel or Humira would not be recommended. Therefore, the requested Xeljanz 5 mg tablet is medically necessary.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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. ", "id": "879454a89679469db4a0867c40850827", "question": "What is the background context in this case summary?", "title": "879454a89679469db4a0867c40850827", "sufficiency_score": 4}
+{"answers": {"text": ["A patient has requested authorization and coverage for Lyrica. The Health Plan has denied this request on the basis that the requested medication is not medically necessary for treatment of the enrollee's foot pain.", "The patient presents with traumatic neuropathy with motor involvement. The submitted records reveal the patient has EMG-confirmed peroneal neuropathy (sensorimotor). He has a history of treatment with gabapentin. Gabapentin is contraindicated in this patient as it caused mental confusion, which is a known side effect of the drug."], "answer_start": [43, 364]}, "context": "Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Lyrica. The Health Plan has denied this request on the basis that the requested medication is not medically necessary for treatment of the enrollee's foot pain. Review of the submitted documentation supports the medical necessity of Lyrica in this clinical setting. The patient presents with traumatic neuropathy with motor involvement. The submitted records reveal the patient has EMG-confirmed peroneal neuropathy (sensorimotor). He has a history of treatment with gabapentin. Gabapentin is contraindicated in this patient as it caused mental confusion, which is a known side effect of the drug. As such, gabapentin is not appropriate for this patient due to well recognized neurologic side effects. Lyrica has been approved by the U.S. Food and Drug Administration for treatment of neuropathic pain. As such, the requested medication is medically reasonable and necessary for treatment of this patients medical condition.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 pain medicine and anesthesiology 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. ", "id": "aec3c18bf5744a6ba84b7f0371507ce3", "question": "What is the background context in this case summary?", "title": "aec3c18bf5744a6ba84b7f0371507ce3", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Depend brand adult diapers.", "the patient is requesting a specific brand of adult briefs or incontinence pads."], "answer_start": [43, 1011]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Depend brand adult diapers. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. There are several types of urinary incontinence, and there is significant overlap in the conditions that cause urinary leakage. The risks for urinary incontinence increase with age, female gender, decrease in estrogen levels at menopause, obesity, smoking, chronic constipation, neurologic disorders and diabetes mellitus.  The diagnosis is mainly based on history and examination. The treatment depends on the etiology of the incontinence. Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. Patients often use incontinence pads when leaking is not controlled by medications or surgical treatments.  In this case, the patient is requesting a specific brand of adult briefs or incontinence pads. However, there is no medical documentation to support that she has had a significant adverse reaction to the pads that are provided by her Health Plan. Therefore, the requested Depend brand adult diapers are 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. Credentials/Qualifications: The reviewer is board certified in internal 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. ", "id": "49c4f9e32aec42e18e9000cf00a866cc", "question": "What is the background context in this case summary?", "title": "49c4f9e32aec42e18e9000cf00a866cc", "sufficiency_score": 3}
+{"answers": {"text": ["A patient has requested authorization and coverage for Saxenda. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients obesity."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Saxenda. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients obesity. The submitted documentation does not support the medical necessity of the requested medication. Saxenda is approved for the treatment of obesity. It is used in adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index greater than 30 kg/m2 or greater than 27 kg/m2 in the presence of at least one weight-related comorbid condition, including hypertension, type II diabetes mellitus, and/or dyslipidemia. Initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention consisting of a combination of diet, exercise, and behavioral modification. Per the medical evidence, patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with an initial body mass index greater than 30 kg/m2 or a body mass index of 27 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction, and increased physical activity to achieve weight loss goals. Additionally, the requested non-formulary drug, Saxenda, would not be more effective than the Health Plans formulary drugs, phentermine, benzphetamine, diethylpropion, and phendimetrazine.  There is a lack of studies that demonstrate that Saxenda is more effective than the listed formulary drugs. Therefore, Saxenda 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 internal 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. ", "id": "404bca941c204500afa74e4ce3a328a0", "question": "What is the background context in this case summary?", "title": "404bca941c204500afa74e4ce3a328a0", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a male enrollee has requested authorization and coverage for immunotherapy with nivolumab (Opdivo). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees grade IV glioblastoma."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for immunotherapy with nivolumab (Opdivo). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees grade IV glioblastoma. Although multiple trials are testing various forms of immunotherapy in patients with glioblastoma, published data remain limited. In a phase I trial investigating the safety of monotherapy or combination therapy with two checkpoint inhibitors, 40 patients received either Opdivo with or without ipilimumab. Overall, monotherapy with Opdivo was better tolerated than combination therapy. However, the authors concluded that further studies are needed to help select patients most likely to respond to checkpoint inhibitor immunotherapy. Available standard therapies include retreatment with temozolomide and low-intensity alternating electric fields, which have more data to support them than Opdivo in this clinical setting. Accordingly, the requested Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "bc52fa1983114ecca2c998cc20275046", "question": "What is the background context in this case summary?", "title": "bc52fa1983114ecca2c998cc20275046", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for platelet-rich plasma injections (CPT 0232T).", "this patient presented with a history of chronic bilateral knee pain. There was imaging evidence of bilateral lateral meniscus tears. Prior hyaluronic acid injections had provided two years of good relief.", "The procedure report documented bilateral knee platelet-rich plasma injections were performed for the diagnoses of bilateral meniscal tears and knee pain."], "answer_start": [43, 186, 524]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT 0232T). Findings:  Two of the three physician reviewers found this patient presented with a history of chronic bilateral knee pain. There was imaging evidence of bilateral lateral meniscus tears. Prior hyaluronic acid injections had provided two years of good relief. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure was not submitted. The procedure report documented bilateral knee platelet-rich plasma injections were performed for the diagnoses of bilateral meniscal tears and knee pain. There is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in knee meniscal and cartilage disorders. The use of platelet-rich plasma injections is not supported in this clinical setting. In this patients case, the evidence does not support the use of platelet-rich plasma injections over other conservative treatment options. In sum, platelet-rich plasma injections were not likely to have been more effective than other treatment modalities. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic 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.", "id": "843e550b4ee74ea4bed1b2d6daf5595e", "question": "What is the background context in this case summary?", "title": "843e550b4ee74ea4bed1b2d6daf5595e", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement for stroller repairs for treatment of the enrollees cerebral palsy.", "The patient is quadriplegic and has cerebral palsy."], "answer_start": [43, 276]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for stroller repairs for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the patients stroller is the primary source of mobility that the patient uses. The patient is quadriplegic and has cerebral palsy. Thus, the use of the stroller is mandatory for proper transport of the patient for activities of daily living (ADLs) and for routine daily travel. Based on the review of the current medical literature, the stroller repairs provided were medically necessary for treatment of this patients medical condition. 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 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. ", "id": "6920de304d3d4c0a904d8a6f6fa2e5ed", "question": "What is the background context in this case summary?", "title": "6920de304d3d4c0a904d8a6f6fa2e5ed", "sufficiency_score": 3}
+{"answers": {"text": ["this patient has been diagnosed with Lyme disease", "An enrollee has requested authorization and coverage for additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of neurologic disorder."], "answer_start": [547, 43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of neurologic disorder. Findings:  The documentation provided does not support the superior efficacy of the requested services. While there is documentation that this patient has been diagnosed with Lyme disease, the available records do not substantiate conclusively the presence of Lyme disease or any other infection in this patient.  However, even if the records support the diagnosis of Lyme disease in this patient, peer reviewed literature supports treatment for no more than four weeks with any antibiotics. This patients request is for intravenous ceftriaxone for a period in excess of four weeks. Based on the documentation provided as well as the medical literature, additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601) is not likely to be of greater benefit when compared to the available standard duration for treatment of this patients medical condition. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  Two reviewers are board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. One reviewer is board certified in internal medicine with expertise in Lyme disease. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "f8950bd84c92494abaa52a0b75ab2ae5", "question": "What is the background context in this case summary?", "title": "f8950bd84c92494abaa52a0b75ab2ae5", "sufficiency_score": 3}
+{"answers": {"text": ["A patient has requested authorization and coverage for testosterone injections.", "The patient has failed therapy with transdermal testosterone."], "answer_start": [43, 901]}, "context": "Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testosterone injections. The submitted documentation supports the medical necessity of the requested medication. Low testosterone can lead to complications such as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment, in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. The patient has failed therapy with transdermal testosterone. The patient will benefit from intramuscular testosterone therapy. Therefore, the requested testosterone injections are medically necessary for 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 endocrinology, diabetes and metabolism 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. ", "id": "18a2c153b13f4befad5620ba1b74c60a", "question": "What is the background context in this case summary?", "title": "18a2c153b13f4befad5620ba1b74c60a", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks.Findings: According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing in genotype 1a patients should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg tablets daily for 12 weeks is medically necessary for this patient.", "id": "c01d12f17ba448e38056010718304155", "question": "What is the background context in this case summary?", "title": "c01d12f17ba448e38056010718304155", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for gene panel testing.", "The records document that this patient underwent screening for spinal muscular atrophy.", "the submitted documentation indicates that CPT code 81401 is in dispute. This code represents a complete gene panel."], "answer_start": [43, 421, 593]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found there is sufficient support for a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that providers offer screening for spinal muscular atrophy to all patients who are considering pregnancy or who are currently pregnant. The records document that this patient underwent screening for spinal muscular atrophy. Thus, the medical evidence supports this testing in this clinical setting. However, the submitted documentation indicates that CPT code 81401 is in dispute. This code represents a complete gene panel. The records did not provide further support for the remaining of the tests which were included in the gene panel testing. In sum, screening for spinal muscular atrophy was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of the remaining tests of the gene panel testing has not been established.Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation 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 obstetrics and gynecology 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.", "id": "1007747a0b7a44da8b7dcec3f52b71e2", "question": "What is the background context in this case summary?", "title": "1007747a0b7a44da8b7dcec3f52b71e2", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Latuda prescription for treatment of the enrollees behavioral health condition."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Latuda prescription for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Lurasidone is an atypical, or second generation, antipsychotic medication initially approved for the treatment of schizophrenia. In mid-2013, lurasidone gained two additional indications, both for the treatment of bipolar illness, and is one of only three U.S. Food and Drug Administration (FDA) approved medications for bipolar depression.  The other two, quetiapine and olanzapine-fluoxetine combinations, are frequently associated with weight gain, glucose intolerance and dyslipidemia.  The medical evidence appears to indicate that lurasidone is associated with fewer metabolic side effects and less weight gain. The Health Plan suggested aripiprazole as an alternative.  However, the data supporting aripiprazole as a monotherapy or in conjunction with lamotrigine in the treatment of bipolar depression are weak when compared to lurasidone. Lurasidone is approved by FDA for this patients condition and is reasonably expected to improve the patients condition and to prevent a more serious episode of illness.  Therefore, Latuda is medically necessary for the treatment of this patients medical condition. 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 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. ", "id": "876721e911da4f438f9fb5c84d2b6da4", "question": "What is the background context in this case summary?", "title": "876721e911da4f438f9fb5c84d2b6da4", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested reimbursement for wireless capsule endoscopy for evaluation of the enrollees abdominal pain.", "this patient has had symptoms and biopsy findings suggestive of possible Crohns disease."], "answer_start": [43, 244]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for evaluation of the enrollees abdominal pain. Findings:  2/3 of the physician reviewers found that the physician reviewer found this patient has had symptoms and biopsy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and has been demonstrated to be superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Per the study by colleagues, the frequency of small intestinal Crohns disease activity found by capsule endoscopy in a consecutive series was approximately double that detected by computed tomography enteroclysis, leading to change in management in a significant number of patients. In this patients case, wireless capsule endoscopy was likely to have been more effective than other available modalities for evaluating this patient.  Final Result: 2/3 of 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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. ", "id": "78e2b4c6dc9341d4ab36dc69807e3c8e", "question": "What is the background context in this case summary?", "title": "78e2b4c6dc9341d4ab36dc69807e3c8e", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing. Findings:  Three physician reviewers found that there is insufficient medical evidence to support the effectiveness of Prometheus Anser ADA diagnostic testing compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control. Additionally, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management.  For these reasons, the superior effectiveness of Prometheus Anser ADA diagnostic testing performed has not been established. Final Result: 3 of 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.", "id": "59475d9addb1477aa0ba161fb23982b6", "question": "What is the background context in this case summary?", "title": "59475d9addb1477aa0ba161fb23982b6", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI).", "This patient has a PSA level in the 14 to 16 range and his PSA has been persistently elevated."], "answer_start": [43, 573]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that there is currently considerable debate about how best to screen for prostate cancer.  The fact that this patients PSA level is stable does not rule out prostate cancer. Prostate cancer is notoriously slow growing, and the lack of progressive elevation does not exclude a malignancy. In general, PSA levels under 4 are not considered abnormal, whereas levels over 4 are regarded as suspicious.  This patient has a PSA level in the 14 to 16 range and his PSA has been persistently elevated. There are many options for therapy (radical prostatectomy, observation and monitoring, brachytherapy, external bean radiation), with no single therapy clearly advantageous, and all therapies having significant risks of complication. Accordingly, MRI has become a common imaging procedure to better evaluate the prostate. The American College of Radiology (ACR) provides recommendations to help guide clinicians as to the most efficient and efficacious means to evaluate various clinical entities. In their publication concerning patients who are clinically suspected with prostate cancer and who has had a prior negative transrectal ultrasonography-guided biopsy, MRI is felt to be the most appropriate study to perform. They found that MRI is a useful adjunct for tumor localization in biopsy negative patients, as in this patients case. A study concurs with the ACR assessment, MRUS fusion biopsy provides improved detection of PCa in men with prior negative biopsies and elevated PSA values. Most cancers found were clinically significant.  This patient fits the ACR criteria and the medical literature. All told, MRI is medically necessary for the evaluation of this patients medical condition. 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 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. ", "id": "77e40b38e86049fb953012a9845daacc", "question": "What is the background context in this case summary?", "title": "77e40b38e86049fb953012a9845daacc", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Monovisc injection to the right knee for treatment of the enrollees knee pain.", "This patient presents with chronic right knee pain with associated stiffness, swelling and weakness. Functional limitations were documented with stairs and prolonged sitting. Clinical examination findings were consistent with the diagnosis of medial compartment osteoarthritis. He has not obtained significant symptom relief with prior conservative treatment, including medications, activity modification, and physical therapy. The records noted that prior viscosupplementation injections had provided significant sustained relief. It was also noted that he was attempting to delay knee replacement surgery given his young age."], "answer_start": [43, 299]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection to the right knee for treatment of the enrollees knee pain. Findings: The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient presents with chronic right knee pain with associated stiffness, swelling and weakness. Functional limitations were documented with stairs and prolonged sitting. Clinical examination findings were consistent with the diagnosis of medial compartment osteoarthritis. He has not obtained significant symptom relief with prior conservative treatment, including medications, activity modification, and physical therapy. The records noted that prior viscosupplementation injections had provided significant sustained relief. It was also noted that he was attempting to delay knee replacement surgery given his young age. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Monovisc injection to the right knee 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. 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. ", "id": "ed4da7d0f1a34efc910da4553a52f5ed", "question": "What is the background context in this case summary?", "title": "ed4da7d0f1a34efc910da4553a52f5ed", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Danmar soft shell helmet for treatment of the enrollees seizure disorder.", "In the past, the patient has tolerated a Danmar helmet well with reported reduction of head traumas during seizures.", "The patient requires protection from potential risk of head trauma when her seizures occur."], "answer_start": [42, 708, 912]}, "context": "Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Danmar soft shell helmet for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that the submitted documentation as well as the medical literature provide support for the requested equipment in this patients case. There is medical literature that documents the association between seizures and head injuries. Head trauma is a common occurrence in patients with intractable epilepsy.  The ramifications of this event can be reduced through the use of a helmet.  In this case, compliance and use of a standard bike helmet would be limited given the patients baseline strength. In the past, the patient has tolerated a Danmar helmet well with reported reduction of head traumas during seizures. To this end, it is reasonable for this patient to continue to use this type of helmet. The patient requires protection from potential risk of head trauma when her seizures occur. For these reasons, Danmar soft shell helmet is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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. ", "id": "64381af3e59a45dfb3e2169ae9c78517", "question": "What is the background context in this case summary?", "title": "64381af3e59a45dfb3e2169ae9c78517", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has requested authorization and coverage for hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees knee pain.", "it is documented the patient has been treated with physical therapy, braces, Norco, and underwent corticosteroid injections.", "the patient is not a reasonable candidate for repeat corticosteroid injections so close to the time of planned revision right knee arthroplasty which might increase risk of periprosthetic joint infection. Previously, the patient has experienced success with viscosupplementation."], "answer_start": [43, 1026, 1161]}, "context": "Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees knee pain. Findings: The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, it is documented the patient has been treated with physical therapy, braces, Norco, and underwent corticosteroid injections. Moreover, the patient is not a reasonable candidate for repeat corticosteroid injections so close to the time of planned revision right knee arthroplasty which might increase risk of periprosthetic joint infection. Previously, the patient has experienced success with viscosupplementation. For these reasons, the requested hyaluronan (Orthovisc) injections in the left knee is supported as medically necessary for treatment of this patients medical condition. 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. ", "id": "619aa3a7b5754841bedb8f298de1c75f", "question": "What is the background context in this case summary?", "title": "619aa3a7b5754841bedb8f298de1c75f", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Vemlidy 25 mg tablets."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg tablets. Findings:  The physician reviewer found that : Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared to the alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including decreased risk of osteopenia and renal disease. For this reason, the request for Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B.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. ", "id": "cf07505d1a6b468b8d7991634ee7f045", "question": "What is the background context in this case summary?", "title": "cf07505d1a6b468b8d7991634ee7f045", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for compound medication (progesterone micronized 100% powder)", "In this case, the patient was of an advanced maternal age and attempted pregnancy via embryo transfer.", "In this patients case, the provider recommended micronized progesterone suppositories, and there are no prescription suppositories currently manufactured by a pharmaceutical company."], "answer_start": [43, 356, 843]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for compound medication (progesterone micronized 100% powder) provided Findings:  The physician reviewer found that the physician reviewer found that progesterone supplementation is routinely used in assisted reproduction to increase pregnancy success rates.  In this case, the patient was of an advanced maternal age and attempted pregnancy via embryo transfer. As noted by a study, there is little doubt that endometrial receptivity plays a major role in the success or failure of embryo implantation after in vitro fertilization (IVF). To optimize endometrial receptivity, it is common practice to administer a progesterone supplement during the luteal phase. Thus, treating this patient with micronized progesterone was medically appropriate. In this patients case, the provider recommended micronized progesterone suppositories, and there are no prescription suppositories currently manufactured by a pharmaceutical company.  The medical evidence supports the medication at issue in this clinical setting. All told, compound medication (progesterone micronized 100% powder) provided during the dates of dispute was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 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. ", "id": "b166895b36b442ae859c137557953ec2", "question": "What is the background context in this case summary?", "title": "b166895b36b442ae859c137557953ec2", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement for emergency medical services."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The documentation submitted for review does not demonstrate evidence of an emergency medical condition. The medical records provided for review, fail to show past medical history addressing a mechanism of injury leading to the reported acute presentation or evidence of chronicity. In addition, there is no documentation of imaging to rule out underlying injury/pathology that would lead to the reported emergency presentation. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oriental medicine and 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. ", "id": "415ce5d7a59d402ba60625cffe1e8178", "question": "What is the background context in this case summary?", "title": "415ce5d7a59d402ba60625cffe1e8178", "sufficiency_score": 1}
+{"answers": {"text": ["The parent of an enrollee has requested reimbursement for the gene panel testing."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the gene panel testing. Findings:  The physician reviewer found that the gene panel testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genotype testing for genetic polymorphisms to determine psychotropic drug metabolizer status holds promise for improving the treatment of individuals with autism spectrum disorder who could benefit from pharmacotherapy. However, at present time there are insufficient controlled, adequately powered published studies to support its general adaptation . Variables such as age, sex, precision of diagnosis and environmental influences have not been addressed in currently available published studies. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three of the reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in pediatrics and neurology with special qualification in child neurology 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.", "id": "2059219ed0ce4489b5f8d2f97aa36082", "question": "What is the background context in this case summary?", "title": "2059219ed0ce4489b5f8d2f97aa36082", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested reimbursement for Botox."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox. Findings:  The physician reviewer found that The Botox provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although trials evaluating the effect of intrapyloric Botox injection on gastroparesis have been reported, there is no definitive agreement whether Botox can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. Bai and colleagues performed a systemic review on intrapyloric Botox injection for gastroparesis. The authors concluded that there is no evidence to recommend Botox injection for the treatment of gastroparesis. Moreover, the American College of Gastroenterology clinical guideline on the management of gastroparesis states Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. All told, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the service at issue was 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 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.", "id": "991e1b4ff36d455b8a8eb21855c0a024", "question": "What is the background context in this case summary?", "title": "991e1b4ff36d455b8a8eb21855c0a024", "sufficiency_score": 2}
+{"answers": {"text": ["The enrollee has requested reimbursement for residential treatment services for treatment of the enrollees substance abuse.", "the patient was not in withdrawals as she had only used once and did not require detoxification. She was not a danger to herself or others and she was not gravely disabled.", "She was not psychotic or manic and she was medically and psychiatrically stable.", "She was cooperative and participated in her treatment plan. She had multiple prior treatments"], "answer_start": [43, 212, 541, 695]}, "context": "Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment services for treatment of the enrollees substance abuse. Findings:  The physician reviewer found that the patient was not in withdrawals as she had only used once and did not require detoxification. She was not a danger to herself or others and she was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential treatment center (RTC) level of care. She was not psychotic or manic and she was medically and psychiatrically stable. Her medication regimen could have been managed in an ambulatory setting. She was cooperative and participated in her treatment plan. She had multiple prior treatments and therefore had a base of knowledge from which to continue to build her relapse prevention plan. Her difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring in the absence of unstable medical or psychiatric conditions. She could have safely been treated in an ambulatory level of care, with the assistance of medically assisted treatment such as suboxone for opiate use disorder if deemed appropriate by her provider. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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. ", "id": "7e4c8e12c01843fe90db509fcb56b48d", "question": "What is the background context in this case summary?", "title": "7e4c8e12c01843fe90db509fcb56b48d", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of an enrollee has requested authorization and coverage for 16 hours per week of applied behavioral analysis (ABA) services.", "The records submitted for review document that the patient has autism spectrum disorder and has received ABA therapy for five years . The patients ABA service provider has recommended parent training due to the barriers to the implementation of direct intervention services."], "answer_start": [43, 328]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 16 hours per week of applied behavioral analysis (ABA) services. Findings:  The physician reviewer found that the request for ABA therapy is not medically necessary for treatment of the patients medical condition. The records submitted for review document that the patient has autism spectrum disorder and has received ABA therapy for five years . The patients ABA service provider has recommended parent training due to the barriers to the implementation of direct intervention services. The providers recommendation for caregiver training to occur prior to consideration of re-introduction of direct intervention services is medically reasonable and appropriate in this clinical setting. As such, the request for 16 hours per week of ABA services is not clinically indicated 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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. ", "id": "ab10cc7dc9f846bc903d2579e26b1be6", "question": "What is the background context in this case summary?", "title": "ab10cc7dc9f846bc903d2579e26b1be6", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition.", "the patients abuse of opiates, benzodiazepines and cannabinoids use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. The patient was unable to sustain employment and lost his apartment.  His motor vehicle license had been revoked due to substance use.  He was prescribed psychotropic medications including an atypical antipsychotic. This patient had reportedly tried buprenorphine prior to the episode of care, although the documentation did not specify if it was obtained illicitly or by prescription. Upon presentation, the patient was malnourished, circumstantial, anxious, agitated and depressed.  He endorsed symptoms consistent with a withdrawal syndrome.", "However, the patient had positive support from this patients family and a recent three and half year history of sobriety. The patient also has prior success with community programming."], "answer_start": [43, 273, 1388]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patients abuse of opiates, benzodiazepines and cannabinoids use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. The patient was unable to sustain employment and lost his apartment.  His motor vehicle license had been revoked due to substance use.  He was prescribed psychotropic medications including an atypical antipsychotic. This patient had reportedly tried buprenorphine prior to the episode of care, although the documentation did not specify if it was obtained illicitly or by prescription. Upon presentation, the patient was malnourished, circumstantial, anxious, agitated and depressed.  He endorsed symptoms consistent with a withdrawal syndrome.  Finally, despite outpatient services and a brief residential stay during the episode of illness, the patient was unable to maintain sobriety in his environment.  The patient was clinically unstable and had not consolidated the treatment gains necessary to succeed in the outpatient setting and promptly would have relapsed in a community based setting if he was not admitted that day. However, the patient had positive support from this patients family and a recent three and half year history of sobriety. The patient also has prior success with community programming. The documentation supports that 2 weeks of services were medically necessary.  The two weeks of treatment would have been reasonably expected to improve this patients condition and prevent a more serious episode of illness while fulfilling the initial projected length of stay and providing a total of four weeks of residential treatment, which would be a duration of care consistent with community standards. For these reasons, a portion of the residential treatment center services was medically necessary for treatment of this patients medical condition. Specifically, the residential treatment center services for 2 weeks were medically necessary, but not thereafter. Final Result: The reviewer determined that the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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. ", "id": "b1b1e8a753414154bb65d000f44b3b66", "question": "What is the background context in this case summary?", "title": "b1b1e8a753414154bb65d000f44b3b66", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care provided.", "According to the documentation submitted for review, the patient has function deficits due to a brain tumor (glioblastoma)."], "answer_start": [43, 324]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care provided. Findings:  The physician reviewer found that skilled nursing care provided was not and is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has function deficits due to a brain tumor (glioblastoma). There is a lack of peer-reviewed literature supporting rehabilitation in this clinical setting. Roberts and colleagues studied intensive rehabilitation for glioblastoma, finding that there was functional benefit but not survival benefit. In this case, the patient has received an adequate trial of skilled nursing care level of care without functional benefit. Thus, the medical documentation provided does not support the medical necessity for continued skilled nursing level of care.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. ", "id": "d251f4bb093947238cb65bf5aead334b", "question": "What is the background context in this case summary?", "title": "d251f4bb093947238cb65bf5aead334b", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Divigel 1 mg/gram (0.1%) gel packet for treatment of the enrollees menopausal symptoms."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Divigel 1 mg/gram (0.1%) gel packet for treatment of the enrollees menopausal symptoms.  Findings:  The physician reviewer found that according to a study, Once a decision has been made to treat a postmenopausal woman with estrogen, consideration should be given to the type of estrogen and the route by which it is to be given, as well as the need for progestin and the most appropriate progestin regimen. Estrogen is available in many forms: oral, transdermal, topical gels and lotions. The potency and therefore the doses of these estrogen preparations differ, but they differ little in efficacy. The documentation provided for review does not show that the patient has tried any of the Health Plans formulary alternatives. In addition, various patches may use different adhesives, so one might be tolerated when another was not. An oral option eliminate the possibility of skin reactions. 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. ", "id": "0edc5ce4f5254ce69ebc1d892538c179", "question": "What is the background context in this case summary?", "title": "0edc5ce4f5254ce69ebc1d892538c179", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus.Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. 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. ", "id": "ea6eb0c29d0946c882f7861a7a07bfcb", "question": "What is the background context in this case summary?", "title": "ea6eb0c29d0946c882f7861a7a07bfcb", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services for treatment of the enrollees opiate use disorder.", "this patients post-acute withdrawal symptoms were not described other than his cravings and moods.", "He continuously expressed that he lacked interest in pursuing sobriety and relapse prevention. He was discharged on Suboxone"], "answer_start": [43, 246, 672]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services for treatment of the enrollees opiate use disorder. Findings:  The physician reviewer found that this patients post-acute withdrawal symptoms were not described other than his cravings and moods. There was no evidence that he was a danger to self or others. He was cognitively intact, and his level of emotional and behavioral issues were not severe enough to warrant ongoing RTC services. He demonstrated inappropriate behavior in group therapy. However, he was not manic, psychotic, or agitated. He was medically stable. He continuously expressed that he lacked interest in pursuing sobriety and relapse prevention. He was discharged on Suboxone, of which the management did not require the RTC setting. Given the patients lack of motivation and distinct, well-defined, and verbalized intent to resume drinking and use cannabis, the RTC services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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. ", "id": "7fd37b30c07f45e6820a11f1df003da7", "question": "What is the background context in this case summary?", "title": "7fd37b30c07f45e6820a11f1df003da7", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services provided for treatment of the enrollees behavioral health condition.", "The patient has a history of three suicide attempts. She attempted to overdose on beta blockers and slit her wrists. All these attempts were made when the patient was intoxicated. When the patient is sober, she does not have suicidal ideation and loves life and wants to live. As the patient was sober and did not have any suicidal ideation or homicidal ideation.", "When the patient has relapsed from sobriety, she is unable to work and has to take time off to recover. The patient is currently employed. The patients recent gains in sobriety have been achieved while participating in treatment in structured settings.", "The patient has a significant co-morbidity of alcohol use disorder, anxiety, and depression. The patient also has a history of pancreatitis and cirrhosis of her liver. The patient has a history of utilizing alcohol despite negative consequences. The patient has a history of driving under the influence and was recently cited for public intoxication.", "The patient is financially stable and has family and friends that are supportive.", "The patient has supportive family and friends.", "Previous treatment had allowed the patient to obtain six months of sobriety.", "The patient is cooperative and compliant with treatment. The patient is noted to be highly motivated for sobriety."], "answer_start": [43, 454, 890, 1250, 1683, 1837, 1981, 2154]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services provided for treatment of the enrollees behavioral health condition. Based on the Level of Care Utilization System (LOCUS) criteria,  the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is three (3), moderate risk of harm. The patient has a history of three suicide attempts. She attempted to overdose on beta blockers and slit her wrists. All these attempts were made when the patient was intoxicated. When the patient is sober, she does not have suicidal ideation and loves life and wants to live. As the patient was sober and did not have any suicidal ideation or homicidal ideation. The patients functional status score is three (3), moderate impairment, When the patient has relapsed from sobriety, she is unable to work and has to take time off to recover. The patient is currently employed. The patients recent gains in sobriety have been achieved while participating in treatment in structured settings. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, anxiety, and depression. The patient also has a history of pancreatitis and cirrhosis of her liver. The patient has a history of utilizing alcohol despite negative consequences. The patient has a history of driving under the influence and was recently cited for public intoxication. The patients recovery environment score is two (2), mildly stressful environment. The patient is financially stable and has family and friends that are supportive. The patients level of support score is two (2), supportive environment. The patient has supportive family and friends. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous treatment had allowed the patient to obtain six months of sobriety. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. The patient is noted to be highly motivated for sobriety. Based on these criteria, the patient has a total score of 18, which would meet criteria for treatment in a less restrictive environment, such as an intensive outpatient program (IOP). Although the patient continues to need treatment for her alcohol use disorder, the patient improved enough to be treated in a less restrictive environment. Therefore, the PHP services provided was not and is not medically necessary for treatment of the patients medical condition. 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 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. ", "id": "66c01ee18ad649eabdadfbbd222683e9", "question": "What is the background context in this case summary?", "title": "66c01ee18ad649eabdadfbbd222683e9", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement for the genomic analysis for evaluation of the enrollees recurrent breast cancer."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genomic analysis for evaluation of the enrollees recurrent breast cancer. Findings:  2/3 of the physician reviewers found that there is a lack of support in the medical literature for the services at issue in this clinical setting. FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are a variety of nonrandomized studies exploring the value of molecular profiling but none of which have been convincing as to the efficacy of these analyses. While colleagues noted these ongoing studies, they also expressed serious limitations of such studies. This viewpoint was also expressed in an editorial by West in 2016. Moreover, a randomized trial by colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus the oncologists clinical judgment. Finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. In this patients case, the decision was to proceed with advanced hormonal therapy, which was not based on the FoundationOne assay. Therefore, the genomic analysis provided was not likely to have been superior over the standard options available for the evaluation of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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.", "id": "1a570895180c42a58f3626d1443eef2f", "question": "What is the background context in this case summary?", "title": "1a570895180c42a58f3626d1443eef2f", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse.", "the patient was admitted in active withdrawal with an elevated COWS score", "Although not suicidal, homicidal, or self-harming, she rated depression and anxiety as 10, and isolation as five to six", "The patients self-care was lacking in her disheveled presentation and reported high levels of stress."], "answer_start": [43, 285, 387, 540]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patient was admitted in active withdrawal with an elevated COWS score, which warranted admission. Although not suicidal, homicidal, or self-harming, she rated depression and anxiety as 10, and isolation as five to six, which also supported admission. The patients self-care was lacking in her disheveled presentation and reported high levels of stress. Thus, RTC was the best treatment option and was medically necessary. Treatment during these dates would afford the patient an opportunity to become more physically comfortable with less intense withdrawals, and increase the chances of compliance with medically assisted treatment with Subutex at a less restrictive level of care. However, RTC services after were not and are not medically necessary. For these reasons, RTC level of care services provided were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and addiction 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. ", "id": "32abc8a3c88e4fb7b1d40a533568a3f5", "question": "What is the background context in this case summary?", "title": "32abc8a3c88e4fb7b1d40a533568a3f5", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for individual weekly psychotherapy for treatment of the enrollees depression and trauma."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual weekly psychotherapy for treatment of the enrollees depression and trauma. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients afflicted with major depressive disorder. Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Individual psychotherapy is a standard treatment intervention of major depressive disorder, and a brief course of individual psychotherapy is warranted in this patients case. Such treatment could help build a therapeutic rapport by capitalizing on the principles of patient centricity, prepare the patient for a transition to the group setting and/or community programming, and facilitate additional evaluation for consideration of other treatments, such as cognitive behavioral therapy for pain, trauma-focused therapy or dialectical behavioral therapy. The American Psychiatric Association (APA) suggests that time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. In addition, the provider should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of provider and patient rated scales at regular intervals. If eight weeks of treatment does not yield at least moderate improvement with 20% or greater diminution in symptoms, the provider should thoroughly review and reappraise the treatment plan. As such, a course of eight individual therapy appointments delivered once a week over a span of eight weeks with systematic monitoring and re-assessment of the patients clinical needs upon conclusion of the treatment episode would be safe, appropriate and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Accordingly, a portion of the requested services are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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. ", "id": "63d7a24f30334b9cb7069b58c38d8677", "question": "What is the background context in this case summary?", "title": "63d7a24f30334b9cb7069b58c38d8677", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Zepatier 50/100 mg for treatment of the enrollees hepatitis C infection."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for treatment of the enrollees hepatitis C infection. Findings:  The physician reviewer found that According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg is medically necessary for the treatment of this patients hepatitis C infection.  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. ", "id": "71b248078a2d4efeb60b017c611dd9cc", "question": "What is the background context in this case summary?", "title": "71b248078a2d4efeb60b017c611dd9cc", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for his Oncotype Dx Prostate Cancer Assay.", "This patients prostate cancer was not newly diagnosed and the initial Oncotype was done in 2013."], "answer_start": [43, 749]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for his Oncotype Dx Prostate Cancer Assay.  Findings:  Three physician reviewers found that while the Oncotype Dx Prostate Cancer Assay has the propensity to determine the risk of recurrence and sometimes change therapeutic intervention based on risk, there is currently a lack of well designed, controlled clinical trials to demonstrate an improvement in health outcomes based on its use.  The National Comprehensive Cancer Network guidelines lists Oncotype Dx for patients post biopsy for patients with very low risk and low risk prostate cancer who did not receive therapy and are candidates for surveillance or active therapy with a life expectancy of 10 years. This patients prostate cancer was not newly diagnosed and the initial Oncotype was done in 2013. This patients progression of the Gleason score over a period of three years from 6 to 7 was enough to demonstrate progression. Thus, the Oncotype Dx Prostate Cancer Assay provided did not add any additional information not provided by the clinical situation and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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.", "id": "225b91e726e14d329a0ca723b9436b4b", "question": "What is the background context in this case summary?", "title": "225b91e726e14d329a0ca723b9436b4b", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for WalkAide for treatment of the enrollee, who has history of right foot drop, functional gait disorder, and pressure ulcer of the right foot."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for WalkAide for treatment of the enrollee, who has history of right foot drop, functional gait disorder, and pressure ulcer of the right foot. Findings: Three physician reviewers found that the requested equipment is documented extensively in the medical literature as beneficial for central nervous system neurological injuries but not for peripheral nervous system pathology. While the provider stated that WalkAide will provide dorsiflexion assistance in this patients case, the current studies are lacking.  There is a lack of peer reviewed literature to support a rationale or mechanism by which the requested treatment would be effective or operational for a peripheral nervous system lesion as described in this patients case.  In sum, WalkAide is not likely to be more beneficial than the standard treatment options for this patient.Final Result: The three 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: All three physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. The reviewer 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.", "id": "e91e6f950f0d475493c84f9cc807e452", "question": "What is the background context in this case summary?", "title": "e91e6f950f0d475493c84f9cc807e452", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested LINX procedure (CPT code 0392T, laparoscopic anti-reflux surgery)for treatment of his gastroesophageal reflux disease (GERD)."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX procedure (CPT code 0392T, laparoscopic anti-reflux surgery)for treatment of his gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that the LINX device received U.S. Food and Drug Administration (FDA) premarketing approval for four years, effective 3/22/12. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. As noted by in a study, sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. This patients records support a diagnosis of GERD based on pH recording off PPI therapy, and per charted comments he has not optimally benefited from acid suppression treatment. Although symptomatic for many years, significantly he has not developed endoscopic evidence of esophagitis. From a symptomatic perspective, the patient may be considered medically refractory to acid blocker drugs. However, implantation of LINX in this patients clinical setting places him at significant risk for dysphagia post-LINX implantation given his known esophageal dysmotility. Final Result: The reviewers determined that the requested procedure 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: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.", "id": "7e89635d1599446199d8a8490c3c58c6", "question": "What is the background context in this case summary?", "title": "7e89635d1599446199d8a8490c3c58c6", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C"], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. The guidelines recommend several medications, but Epclusa is the most appropriate therapy in this case based on NS5A resistance testing. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewers 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 number is a 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.", "id": "594433502af145aa97fb7b5520a348e9", "question": "What is the background context in this case summary?", "title": "594433502af145aa97fb7b5520a348e9", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder.", "the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness.", "the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals."], "answer_start": [43, 456, 676]}, "context": "Nature of Statutory Criteria/Case Summary: The parent of a child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness. In addition, the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals. Final Result: The reviewers 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.", "id": "6890862c39c646f7854e12d664397c76", "question": "What is the background context in this case summary?", "title": "6890862c39c646f7854e12d664397c76", "sufficiency_score": 4}
+{"answers": {"text": ["Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.", "This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy."], "answer_start": [43, 293]}, "context": "Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.  Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy.  However, the records do not document that he has had a recent trial of conservative therapy.  The American Pain Society recommends a trial of conservative therapy before starting interventional therapy.  Conservative therapy includes physical therapy, chiropractic therapy or a home exercise program.  All told, the requested lumbar/sacral transforaminal epidural injection is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "b21e24a6fdca47438fa3ad84b6c31fae", "question": "What is the background context in this case summary?", "title": "b21e24a6fdca47438fa3ad84b6c31fae", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C.", "In this patients case, NS5A resistance testing results were not provided. "], "answer_start": [43, 1011]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks).  In this patients case, NS5A resistance testing results were not provided.  For these reasons, although hepatitis C treatment is needed, Zepatier 50-100 mg, one per day for 12 weeks is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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.", "id": "7e3e84dfa41b46a4984d426fa1e1c495", "question": "What is the background context in this case summary?", "title": "7e3e84dfa41b46a4984d426fa1e1c495", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.", "In this patients case, the records document dense breast tissue."], "answer_start": [43, 597]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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: All three reviewers are board certified in diagnostic radiology 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.", "id": "cf6ec2c6506e4ec68354d3478bf34664", "question": "What is the background context in this case summary?", "title": "cf6ec2c6506e4ec68354d3478bf34664", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for a joint jaw oral device (occlusal orthotic device)"], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a joint jaw oral device (occlusal orthotic device).Findings:  The physician reviewer found that there is sufficient support for the device at issue in this clinical setting.  Splint therapy has been shown to be beneficial in patients with temporomandibular joint disorder and myofascial pain.  Oral devices have been shown to decrease symptoms in 70 to 90% of cases.  The majority of patients with temporomandibular joint disorder can be treated with a single stabilization splint. Final Result: The reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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.", "id": "366e0d1071884282bb6ed3770d6b6742", "question": "What is the background context in this case summary?", "title": "366e0d1071884282bb6ed3770d6b6742", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for digital breast tomosynthesis.", "the patient underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination as well as a focused hand-held bilateral breast sonogram.  The current images were compared to a prior mammogram dated 4/12/11, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being extremely dense.  Considering the palpable abnormalities and the negative results on her imaging studies, it was recommended that the lumps be managed on clinical grounds. The Health Plan denied coverage for the bilateral breast tomosynthesis portion of the examination as investigational for the evaluation of this patient."], "answer_start": [43, 166]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.  Findings:  Three physician reviewers found that the patient underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination as well as a focused hand-held bilateral breast sonogram.  The current images were compared to a prior mammogram dated 4/12/11, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being extremely dense.  Considering the palpable abnormalities and the negative results on her imaging studies, it was recommended that the lumps be managed on clinical grounds. The Health Plan denied coverage for the bilateral breast tomosynthesis portion of the examination as investigational for the evaluation of this patient.Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are multiple reasonable indications for tomosynthesis. She has breasts that have been described as being extremely dense. It is specifically those patients who have very dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Secondly, in the clinical setting of palpable masses, it is imperative for the radiologist to be as sure as possible that there is not a radiographic correlate.Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.", "id": "c26ca587c23a45c6adcfb6e0674a8e72", "question": "What is the background context in this case summary?", "title": "c26ca587c23a45c6adcfb6e0674a8e72", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria.", "Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female.", "The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests.", "the submitted documentation supports that this patient has addressed these issues"], "answer_start": [42, 286, 1144, 1290]}, "context": "Nature of Statutory Criteria/Case Summary:An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria. Bilateral orchiectomies and vaginoplasty/labiaplasty are part of the surgical transition process for male to female transition. Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female. Furthermore, the medical literature recommends that after a diagnosis of gender identity disorder, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. In this patients case, the recommended criteria have been established. For treatment of her gender dysphoria, her external anatomy should be more consistent with a female anatomy than of a male. Bilateral orchiectomy and vaginoplasty/labiaplasty are consistent with the appropriate female anatomy. The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests. However, the submitted documentation supports that this patient has addressed these issues and her most recent office visits and therapy sessions appear consistent with the Health Plans clinical criteria. As such, the medical documentation supports the requested services in this patients case.Findings:The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The reviewer is board certified in plastic 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.", "id": "a547e5e4dce042e2acf972ca01db0417", "question": "What is the background context in this case summary?", "title": "a547e5e4dce042e2acf972ca01db0417", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollees gynecomastia."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. The patients pain and discomfort is not adequately supported in the medical documentation as likely due to distention and tightness from hypertrophied breast. In addition, the patients grade of gynecomastia is not adequately defined and photographs were not provided for review. The records do not demonstrate a concern for possible malignancy based on examination detail and other results. Other possible causes had not been sufficiently evaluated, including relevant laboratory studies and endocrine work-up. Therefore, the removal of tissue from the breasts performed has not been established as medically necessary for treatment of the patients. Final Result: The reviewers determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in plastic 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.", "id": "42ca288728974b1098d646e8b510c326", "question": "What is the background context in this case summary?", "title": "42ca288728974b1098d646e8b510c326", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees Crohns disease, ulcer and diarrhea."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees Crohns disease, ulcer and diarrhea. Findings:  The physician reviewers found that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohns disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful. Capsule endoscopy has been proven to be more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis, and capsule endoscopy resulted in a change in management in a significant number of patients based on findings missed by other tests. Capsule endoscopy is a valuable tool in evaluation of patients with Crohns disease and is more sensitive than conventional ileocolonoscopy for the diagnosis of small bowel Crohns disease activity. For these reasons, the requested wireless capsule endoscopy is likely to provide useful diagnostic information in this case, and is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested diagnostic procedure is 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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.", "id": "d547309309554fca9ec0ee496efa3b46", "question": "What is the background context in this case summary?", "title": "d547309309554fca9ec0ee496efa3b46", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested laser hair removal for their arms, axilla, chest, face, neck, low back. The patient was born with genetics to grow the terminal hair in her arms, axilla, chest, face, neck and low back."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested laser hair removal for their arms, axilla, chest, face, neck, low back. The patient was born with genetics to grow the terminal hair in her arms, axilla, chest, face, neck and low back. It would be abnormal for a female to have terminal hair on the face, chest, neck and low back.  This hair growth in a woman is known as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female body parts that are normally found in males. As such, the removal of terminal hair to the face, chest, neck and low back is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. These treatments will create a more feminine appearance for this patient and provide more than a minimal improvement in appearance. Moreover, removal of terminal hair to the face, chest, neck and low back will also improve this patients emotional function. However, females would be expected to have terminal hair in the axilla and on their arms. Therefore, removal of terminal hair to the axilla or arms is not medically necessary for treatment of this patient. Nor would removal of hair on the axilla and arms be considered reconstructive surgery, as the presence of hair in these areas is not considered an abnormal structure.Final Result: The reviewer determined that a portion of the requested services is medically necessary, and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.", "id": "f294e9dd726c49e19f6caf64d7917cea", "question": "What is the background context in this case summary?", "title": "f294e9dd726c49e19f6caf64d7917cea", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. In addition, the guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks. This is based on the SYNERGY trial for Harvoni, which showed a 100% cure rate despite including some patients who had failed prior therapy (Kohli, et al). The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). For these reasons, treatment with Harvoni for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.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.", "id": "020969108b7749779e83b3dedc2e7ad3", "question": "What is the background context in this case summary?", "title": "020969108b7749779e83b3dedc2e7ad3", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Rituxan for treatment of the enrollees antiphospholipid syndrome."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees antiphospholipid syndrome.  Findings: Two reviewers found that Antiphospholipid syndrome is a serious disorder of abnormal arterial and venous thromboses. Antiphospholipid syndrome is an autoimmune disorder where antibodies are generated against self-antigens that drive the clotting cascade. Some patients have antiphospholipid syndrome and systemic lupus erythematosus whereas others have antiphospholipid syndrome alone. Anticoagulation is the mainstay of therapy, which includes enoxaparin, warfarin, and aspirin. Some studies have suggested that the addition of Plaquenil may be effective in preventing thromboses. All these therapies were tried in this case but the patient still developed clots. Rituxan is a monoclonal antibody directed at CD20, an antigen expressed on B cells. Thus, Rituxan can induce B cell cytopenia and reduction in antibody producing B cells. Rituxan is commonly used in autoimmune disorders based on this mechanism (Gurcan, et al; Rastetter, et al; Zaja, et al). Therefore, Rituxan has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested medication 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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.", "id": "3fd59f9c746149699fc3fcedded6ccc2", "question": "What is the background context in this case summary?", "title": "3fd59f9c746149699fc3fcedded6ccc2", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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. ", "id": "5af6bbfbb00044efa80ba0c05473db57", "question": "What is the background context in this case summary?", "title": "5af6bbfbb00044efa80ba0c05473db57", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder.", "In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior"], "answer_start": [43, 399]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 30 hours per week of ABA services have been established as medically necessary for treatment of the patients autism. In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior and ABA services can be utilized to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism. Therefore, ABA therapy at the frequency of the recommended 30 hours per week is medically necessary for treatment of the patients medical condition. 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 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. ", "id": "d8b99300e57549f69fcfa2b6428edc6d", "question": "What is the background context in this case summary?", "title": "d8b99300e57549f69fcfa2b6428edc6d", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.", "In this patients case, her breasts have been described as heterogeneously dense. "], "answer_start": [43, 577]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor, especially considering the area of right-sided asymmetry.  Thus, digital breast tomosynthesis was likely to have been more efficacious than other treatment alternatives.Final Result: Three reviewers determined that the service at issue was 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: All three physician reviewers are board certified in diagnostic radiology 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.", "id": "ae86282192b14a5199bba2d0d6882c10", "question": "What is the background context in this case summary?", "title": "ae86282192b14a5199bba2d0d6882c10", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested reimbursement for the digital breast tomosynthesis for the evaluation of the enrollees medical condition."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for the evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis often allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of the three 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 number one, two, and three are board certified in diagnostic radiology 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.", "id": "40a4f379c3484f77adb204797c52b473", "question": "What is the background context in this case summary?", "title": "40a4f379c3484f77adb204797c52b473", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested the ReWalk robotic exoskeleton system for treatment of her spinal cord injury (paraplegia).", "the patient has a history of spinal cord injury with lower thoracic paraplegia."], "answer_start": [45, 521]}, "context": "Nature of Statutory Criteria/Case Summary:   An enrollee has requested the ReWalk robotic exoskeleton system for treatment of her spinal cord injury (paraplegia). Findings:  Three physician reviewers found that per the submitted documentation, robotic exoskeleton systems are intended to enable individuals with spinal cord injury at levels T7 to L5 to perform ambulatory functions with supervision of a specially trained companion in accordance with the user assessment and training certification program. In this case, the patient has a history of spinal cord injury with lower thoracic paraplegia. At this level of injury, the patient should be able to perform all essential activities of daily living at a modified independent wheelchair level, consistent with her spinal cord injury. She would be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning. She could be expected to be able to stand and ambulate with the use of conventional lower extremity orthoses potentially at a community level which would be included as standard available therapy. Use of a standing frame and regular standing program could be included in an independent home exercise program. In terms of pressure ulcers, performing regular pressure relief while in her wheelchair is the standard of care and an integral part of spinal cord injury education and ongoing management. Lastly, there is a lack of quality studies comparing the requested device against conventional treatments. In sum, the requested ReWalk robotic exoskeleton system is not likely to be more beneficial over other treatment options. Final Result: Three reviewers determined that the requested device 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: All three reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "5d2ee7ff4801412c9dd4bd83b7d81c17", "question": "What is the background context in this case summary?", "title": "5d2ee7ff4801412c9dd4bd83b7d81c17", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested breast tomosynthesis for evaluation of her medical condition."], "answer_start": [45]}, "context": "Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that performance of three dimensional breast imaging in this patient was indicated since the medical literature has been demonstrated that the sensitivity and specificity of three dimensional breast imaging is superior to two dimensional imaging alone for the detection of occult, non-palpable breast cancer. Three dimensional tomosynthesis allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. All told, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "a8d143f2001043a2a74a0339a9e3de87", "question": "What is the background context in this case summary?", "title": "a8d143f2001043a2a74a0339a9e3de87", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested breast tomosynthesis for evaluation of her medical condition."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "2b28f819dbfc4fd782d654c45112311d", "question": "What is the background context in this case summary?", "title": "2b28f819dbfc4fd782d654c45112311d", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested applied behavior analysis (ABA) services for treatment of his autism."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested applied behavior analysis (ABA) services for treatment of his autism.  Findings: Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The requested ABA services are medically necessary for modification of this patients autism spectrum disorder.  The requested number of hours of ABA services are well within the guidelines of best medical practice.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, exists and can be utilized to improve overall neurologic health.  ABA therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism spectrum disorder.  In sum, the requested services ABA services are medically indicated for the treatment of this patient.  Final Result: Two reviewers 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:  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "4254aa2bc03144babff820bb55cda71e", "question": "What is the background context in this case summary?", "title": "4254aa2bc03144babff820bb55cda71e", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested 10 hours per week of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 2 hours per month of parent training for treatment of his medical condition", "In this case, the patient has been treated with ABA services with documented progress in social skills with peers and adults. However, he requires prompting to complete his tasks. The patient has deficits related to autism that require ABA services."], "answer_start": [44, 565]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested 10 hours per week of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 2 hours per month of parent training for treatment of his medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in the peer reviewed literature in this clinical setting. According to Foxx, The only interventions that have been shown to produce comprehensive, lasting results in autism have been based on the principles of ABA. In this case, the patient has been treated with ABA services with documented progress in social skills with peers and adults. However, he requires prompting to complete his tasks. The patient has deficits related to autism that require ABA services. As recommended by the patients ABA provider, 10 hours per week of ABA therapy, 10 hours per month of supervision and 2 hours per month of parent training is medically necessary for this patients autism. Final Result: The reviewers 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: All three reviewers are board certified in child neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "67bae212a0d5490e8b6415e63eff9857", "question": "What is the background context in this case summary?", "title": "67bae212a0d5490e8b6415e63eff9857", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested proton beam radiation therapy for treatment of her medical condition."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg Peak) so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability as it is simply another means to deliver radiation. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality. While proton therapy is not an accepted standard outside of sinonasal cancers abutting critical structures or in the setting of re-irradiation of targets abutting critical CNS structures, both of these situations apply in this patients case. In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull. Thus, the requested proton beam radiation therapy is likely to be more beneficial in treating this patients squamous cell carcinoma than any other available standard therapy.  Final Result: Two 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:  All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "fe3fb53b85224ae89ae94912f0015cea", "question": "What is the background context in this case summary?", "title": "fe3fb53b85224ae89ae94912f0015cea", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested Synvisc One injections in both knees for treatment of her bilateral knee pain.", "In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment."], "answer_start": [46, 1338]}, "context": "Nature of Statutory Criteria/Case Summary:    An enrollee has requested Synvisc One injections in both knees for treatment of her bilateral knee pain.  Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation (hyaluronan) injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment. Therefore, the requested Synvisc One injections for both knees would be considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy 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. ", "id": "3fb88e487ecd4f00af028a16e84bce3a", "question": "What is the background context in this case summary?", "title": "3fb88e487ecd4f00af028a16e84bce3a", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested breast tomosynthesis for evaluation of her medical condition."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "44d4dad1be1445ef912b42fd5107dfab", "question": "What is the background context in this case summary?", "title": "44d4dad1be1445ef912b42fd5107dfab", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.", "Initially the patient had many symptoms that resulted in her admission, however, subsequently, she appeared to stabilize."], "answer_start": [44, 428]}, "context": "Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services, on the dates at issue, were not medically necessary for treatment of the patients behavioral health conditions. Initially the patient had many symptoms that resulted in her admission, however, subsequently, she appeared to stabilize. Medications continue to be adjusted, however, none of the medication adjustments required treatment at the level of residential care. All told, the patient did not require 24 hour supervision for psychiatric treatment. There was no reasonable expectation that the patients symptoms or level of functioning would have significantly improved with residential care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "df287b6018764da6985993dd2d6f013c", "question": "What is the background context in this case summary?", "title": "df287b6018764da6985993dd2d6f013c", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition. Findings:  Three physician reviewers found that bilateral sacroiliac joint fusion surgery is not likely to be more beneficial for treatment of her medical condition than any available standard therapy. In this case, the patient has not had a complete SI exam. Local SI tenderness is not diagnostic of SI joint disease, nor is a single finding as a positive thrust test confirmatory of SI joint disease. There is a lack of confirmatory evidence that she has SI joint pain or that the SI joint is her pain generator. Moreover, there is a lack of large, prospective, randomized, scientific, studies that have shown the long term safety and effectiveness of SI fusion for chronic degenerative disease of the SI joint. Thus, the proposed surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "547c6fed98e443adba39ca304d71b517", "question": "What is the background context in this case summary?", "title": "547c6fed98e443adba39ca304d71b517", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition.", "This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness."], "answer_start": [44, 1709]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition. Findings: The physician reviewer found that an MRI is supported if additional imaging is necessary or internal derangement is suspected. The American College of Radiology imaging criteria for non-traumatic knee pain state that the initial imaging examination for non-traumatic knee pain is radiography. An MRI examination for non-traumatic knee pain is indicated when the pain is persistent and conventional radiographs are non-diagnostic or when additional information is necessary before instituting treatment. Therefore, in this patient, the MRI is medically necessary as adjunctive diagnostically and potentially to affect treatment.  Regarding the requested knee surgery, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for knee osteoarthritis generally recommend conservative treatment of osteoarthritis of the knee including weight loss for patients with body mass index greater than or equal to 25, self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engaging in physical activity consistent with national guidelines. The AAOS does not recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.  Peer-reviewed evidence based medical guidelines do not support arthroscopic surgical treatment of knee osteoarthritis and support knee joint replacement for select patients with severe osteoarthritis failing conservative treatment. This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness. However, the specific surgical procedure has not been identified in detail. Therefore, the requested right knee surgery is not considered medically necessary.  All told, the medical records demonstrate the medical necessity of an MRI for more definitive evaluation of this patients medical condition; but, the medical records do not support the medical necessity for knee surgery.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Specifically, an MRI of the right knee is medically necessary. Therefore, the Health Plans denial should be partially 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.", "id": "8598f88ec3cc474194eef5085365bdd8", "question": "What is the background context in this case summary?", "title": "8598f88ec3cc474194eef5085365bdd8", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Provigil (modafinil) for treatment of her condition."], "answer_start": [45]}, "context": "Nature of Statutory Criteria/Case Summary:   An enrollee has requested Provigil (modafinil) for treatment of her condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the medical necessity for the requested medication has not been established. There is a lack of a documentation describing the patients degree of fatigue, consequences of fatigue, contributing factors to the fatigue, previous therapeutic trials, and current status of the MS. Given the lack of information provided for review, modafinil is not medically necessary. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in 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. ", "id": "fd6d84433a2e475bbabc1b7bc5aac8c4", "question": "What is the background context in this case summary?", "title": "fd6d84433a2e475bbabc1b7bc5aac8c4", "sufficiency_score": 2}
+{"answers": {"text": ["An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials.  There is a lack of controlled data comparing the LINX procedure to a standard reflux operation, Nissen fundoplication.  All told, the LINX Anti-Reflux procedure is not likely to be more efficacious than other treatment options.  Final Result: Three reviewers determined that the requested services are 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "bd9ede388375484c855f9c4af302fc9c", "question": "What is the background context in this case summary?", "title": "bd9ede388375484c855f9c4af302fc9c", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition."], "answer_start": [43]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the services at issue were likely to have been of greater benefit than other modalities for evaluating this patient.   Final Result: Three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.", "id": "5a4fdd76625b49ee96d0300879e03262", "question": "What is the background context in this case summary?", "title": "5a4fdd76625b49ee96d0300879e03262", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV)."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the guidelines all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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. ", "id": "2fe4aa2ac81c48f8a83ccbc1a8cd77a7", "question": "What is the background context in this case summary?", "title": "2fe4aa2ac81c48f8a83ccbc1a8cd77a7", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus."], "answer_start": [45]}, "context": "Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physian reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per guidelines, treatment-naive genotype 3 patients should be treated with one of three regimens: Sovaldi/Daklinza for 12 weeks, Sovaldi/ribavirin with peginterferon for 12 weeks, or Sovaldi/ribavirin for 24 weeks.  Harvoni is not U.S. Food and Drug Administration (FDA) approved for treatment of genotype 3 and is not recommended by the guidelines, which note that the ELECTRON-II trial showed 64% cure rate with the requested regimen of Harvoni for 12 weeks. The activity of ledipasvir (part of Harvoni) against genotype 3 hepatitis C has been shown to be weak.  Although treatment is indicated in this case, and AASLD guidelines cite data showing increased survival with earlier treatment, alternatives for safe and effective therapy are available and recommended by AASLD. For these reasons, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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. ", "id": "76248b96778a45b0846b609754f38858", "question": "What is the background context in this case summary?", "title": "76248b96778a45b0846b609754f38858", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.", "This patient has had stable mammograms", "This patient reports severe discomfort in her left breast."], "answer_start": [44, 924, 1288]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the last several years, there has been significant growth in the use of breast MRI.  Breast MRI has an important role in both screening and diagnostic settings.  However, from a screening perspective, there is no indication that this patient meets the criteria for being at high-risk for developing breast cancer, as defined as having a 20-25% likelihood of developing the disease.  MRI studies of the breast are highly sensitive but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  This patient has had stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence supporting the use of MRI as a surveillance tool rather than conventional mammography.  This patient reports severe discomfort in her left breast.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In this patients case, there is no reason to doubt the accuracy of the mammogram.  In conclusion, there is there is insufficient data to support the requested services in this patients case.  All told, the requested MRI of the left breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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 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. ", "id": "8ac99cfd6d1943fe88e599e9f7f43b53", "question": "What is the background context in this case summary?", "title": "8ac99cfd6d1943fe88e599e9f7f43b53", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.", "The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function."], "answer_start": [45, 382]}, "context": "Nature of Statutory Criteria/Case Summary:   An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. There is lack of documentation submitted for review supporting a diagnosis of stress urinary incontinence. The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function. This could be suggestive of overflow urinary incontinence with urinary retention and placement of a sling will increase outflow resistance leading to urinary obstruction. Moreover, the European Association of Urology (EAU) guidelines on urinary incontinence state, In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. They are often used in combination which makes it difficult to determine which components are effective. Per EAU guidelines conservative therapies include simple clinical intervention, behavior and physical therapies, lifestyle intervention and pharmacologic management. In this case, other than Vesicare which was noted to be helpful, there is lack of evidence showing the patient has tried and failed conservative therapy such as physical therapy. Based on the clinical documentation submitted, the sling procedure surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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. ", "id": "f01b02f78e6f4e879f82b741470022c2", "question": "What is the background context in this case summary?", "title": "f01b02f78e6f4e879f82b741470022c2", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested breast tomosynthesis for evaluation of her medical condition."], "answer_start": [45]}, "context": "Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two rteviewers determined that the diagnostic procedure at issue was 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "4273a4f1c2584179a5cc1a11419e998c", "question": "What is the background context in this case summary?", "title": "4273a4f1c2584179a5cc1a11419e998c", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to standard two dimensional (2D) mammography. The addition of three dimensional (3D) breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, 3D breast tomosynthesis has been shown to improve patient outcomes in this clinical setting. Thus, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Two 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "2932384a5a004414b13453a5f36dd567", "question": "What is the background context in this case summary?", "title": "2932384a5a004414b13453a5f36dd567", "sufficiency_score": 3}
+{"answers": {"text": ["An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus."], "answer_start": [44]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus. Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks (Class I, Level A recommendation). Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Viekira Pak and weight-based ribavirin for 12 weeks is medically necessary in this patients case. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. ", "id": "b2255a91707e4c4585c375e171b6cee6", "question": "What is the background context in this case summary?", "title": "b2255a91707e4c4585c375e171b6cee6", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury.", "with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board."], "answer_start": [43, 231]}, "context": "Nature of Statutory Criteria/Case Summary: An enrollee requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury. Findings:  The physician reviewer found that with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board.  Therefore, the power seat elevation feature is needed in this patients case.  This recommendation is consistent with the current standard of care in the field of rehabilitation medicine.  Customized power mobility equipment to allow independence with transfers is an appropriate practice in rehabilitation.  Because power seat elevation significantly facilitates transfers and promotes independence in this patients case, the requested power seat elevator for her power wheelchair is medically indicated. 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 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.", "id": "7433c6c9aa854ce180324cc9278d58fa", "question": "What is the background context in this case summary?", "title": "7433c6c9aa854ce180324cc9278d58fa", "sufficiency_score": 4}
+{"answers": {"text": ["An enrollee has requested Harvoni for three months for treatment of his chronic hepatitis C virus genotype 1b.", "The Health Plan has approved Viekira Pak with ribavirin.", "However, this patients provider has recommended Harvoni to avoid use of ribavirin"], "answer_start": [44, 488, 682]}, "context": "Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for three months for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that since this patient is genotype 1b, as per the data from the clinical trials and American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Viekira Pak should be used alone and the addition of ribavirin is not recommended. The Health Plan has approved Viekira Pak with ribavirin. Viekira Pak and Harvoni are both considered first-line therapies with similar patient outcomes in terms of sustained virologic response. However, this patients provider has recommended Harvoni to avoid use of ribavirin. For these reasons, the requested Harvoni is medically necessary for treatment of this patients hepatitis C virus genotype 1b infection. Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are 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. ", "id": "943a6017deff459491ff8fdeda80cdc8", "question": "What is the background context in this case summary?", "title": "943a6017deff459491ff8fdeda80cdc8", "sufficiency_score": 4}
+{"answers": {"text": ["A female enrollee requested Harvoni for medical treatment of her hepatitis C."], "answer_start": [0]}, "context": "A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America noted the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Initiation of treatment may avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C.  Therefore, Harvoni is medically indicated for the treatment of this patient.", "id": "0248e061e60148ac917c83b7aed1b274", "question": "What is the background context in this case summary?", "title": "0248e061e60148ac917c83b7aed1b274", "sufficiency_score": 3}
+{"answers": {"text": ["A male enrollee requested Harvoni for medical treatment of his hepatitis C.", "the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years."], "answer_start": [0, 221]}, "context": "A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that based on the information provided, which includes two non-invasive assessments of liver fibrosis, the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years.  He is unlikely to gain meaningful benefit from eradication of hepatitis C, and his prognosis is excellent.  This patient should have significant fibrosis in order to warrant treatment with Harvoni.  In this clinical setting, longitudinal assessments via noninvasive measures of fibrosis are medically appropriate.  All told, Harvoni is not medically indicated for the treatment of this patient.", "id": "cd81a165a6644b2d9f9220f2e45539a4", "question": "What is the background context in this case summary?", "title": "cd81a165a6644b2d9f9220f2e45539a4", "sufficiency_score": 4}
+{"answers": {"text": ["A female enrollee requested residential treatment center services for treatment of her behavioral health condition. "], "answer_start": [0]}, "context": "A female enrollee requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request for residential treatment services is not medically necessary for treatment of the patients medical condition. In reviewing the records of this case, partial hospitalization services provided previously were safe, appropriate and adequately addressing the patients needs. Thus, there is no evidence that the patient has failed a less restrictive treatment setting. Further, since there were no clinical assessments provided, making the patients current status unknown, it is not possible to assert that a higher level of care is indicated.  Therefore, residential treatment center services are not medically necessary for treatment of the patients medical condition. ", "id": "ca6e9ca9fbb4481680c0eb11aea89b52", "question": "What is the background context in this case summary?", "title": "ca6e9ca9fbb4481680c0eb11aea89b52", "sufficiency_score": 2}
+{"answers": {"text": ["A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.", "this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options"], "answer_start": [0, 164]}, "context": "A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options (National Institutes of Health). Zaltrap has been used off-label in ovarian cancer. There are phase II data that demonstrate efficacy with limited toxicity especially in the resolution of malignancy ascites. Based on this medical evidence, it is medically appropriate to treat this patient with Zaltrap. Thus, the Zaltrap provided from the time period specified and forward was and is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. ", "id": "9c6f0e7a51fd40eabc4f4d218e2977c6", "question": "What is the background context in this case summary?", "title": "9c6f0e7a51fd40eabc4f4d218e2977c6", "sufficiency_score": 4}
+{"answers": {"text": ["A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea."], "answer_start": [0]}, "context": "A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea.   Findings:  The physician reviewer found that some patients do fail to lose or maintain weight loss following sleeve gastrectomy. Based on the documentation provided, it is not clear that this patient has been compliant with diet and activity requirements following surgery. Overall, the patient specific causes that might lead to a failure of a second operation with durable weight loss have not been addressed. Given the absence of a more thorough assessment and documentation of compliance with a diet and exercise regimen, the requested revision of the gastric sleeve is not supported as medically necessary for treatment of this patients medical condition. ", "id": "4f00b019dbe0418aa38b69b885e3828f", "question": "What is the background context in this case summary?", "title": "4f00b019dbe0418aa38b69b885e3828f", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.", "this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures."], "answer_start": [0, 239]}, "context": "The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on the available medical records, this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures. Given his age, it is too early to make a prediction of final adult height. It is difficult to distinguish whether the patients short stature and delayed bone age are due to constitutional delay or occult systemic disease. According to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient satisfies only two of these criteria, and no information is provided to document that all other systemic and nutritional causes of short stature have been ruled out. All told, there is inadequate evidence to support the medical necessity of Genotropin GH treatment for treatment of this patients short stature. ", "id": "a753421bbfdd43dea3c4234b65c532b8", "question": "What is the background context in this case summary?", "title": "a753421bbfdd43dea3c4234b65c532b8", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.", "In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.", "The patient has some mobility impairments, but the records indicate that he is a household ambulator.", "he has chronic health conditions, such as hyperlipidemia and hypertension"], "answer_start": [0, 390, 588, 705]}, "context": "A 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device.  In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.  He could also use a manual wheelchair, if needed.  The patient has some mobility impairments, but the records indicate that he is a household ambulator.  Additionally, he has chronic health conditions, such as hyperlipidemia and hypertension, and would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.", "id": "1184fdc7ef264d6ca15d11c88d70473d", "question": "What is the background context in this case summary?", "title": "1184fdc7ef264d6ca15d11c88d70473d", "sufficiency_score": 2}
+{"answers": {"text": ["A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction.", "This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief."], "answer_start": [0, 477]}, "context": "A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction. Findings:  Two physician reviewers found that the clinical information submitted for review provided substantial evidence that lower levels of care intended to treat the patients sacroiliac joint dysfunction have failed to resolve her symptoms.  Per the current medical evidence, when nonoperative treatment fails, sacroiliac joint fusion may be appropriate.  This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief.  In this patients case, proceeding with surgical intervention is warranted.  All told, the requested sacroiliac fusion is likely to be more effective than other treatment options.", "id": "b8d013bbcdcc4ac8a4b20eb4adb74261", "question": "What is the background context in this case summary?", "title": "b8d013bbcdcc4ac8a4b20eb4adb74261", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer."], "answer_start": [0]}, "context": "A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer.  Findings:  Two physician reviewers found that according to the NCCN guidelines, the Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. In this case, it was under these circumstances that the Foundation One assay was ordered, and as such, its use was consistent with current standards of care and was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. ", "id": "ef55b1b7e4874eeda269b05941a0a970", "question": "What is the background context in this case summary?", "title": "ef55b1b7e4874eeda269b05941a0a970", "sufficiency_score": 3}
+{"answers": {"text": ["A 25-year-old male enrollee requested rituximab (Rituxan) infusion for treatment of his Crohns disease and autonomic neuropathy.", "This patient is suspected to have autonomic neuropathy, and has a history of Crohns disease, which is an autoimmune condition. Treatment directed at Crohns has thus far not helped the patients autonomic symptoms."], "answer_start": [0, 379]}, "context": "A 25-year-old male enrollee requested rituximab (Rituxan) infusion for treatment of his Crohns disease and autonomic neuropathy.  Findings:  Two physician reviewers found that based on the current peer-reviewed medical literature, the requested Rituxan is not likely to provide this patient with an improved health outcome beyond that expected with standard available therapies. This patient is suspected to have autonomic neuropathy, and has a history of Crohns disease, which is an autoimmune condition. Treatment directed at Crohns has thus far not helped the patients autonomic symptoms. Rituxan has been shown of potential benefit with treatment of conditions such as chronic inflammatory demyelinating polyneuropathy (CIDP), multiple sclerosis, and myasthenia gravis. Data regarding treatment of Crohns disease with Rituxan is mixed, with some patients experiencing an exacerbation with treatment. Rituxan has also been associated with the development of progressive multifocal leukoencephalopathy. All told, the request for Rituxan is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. ", "id": "7abb3a73784042c6b9e4dcbbb77e83ca", "question": "What is the background context in this case summary?", "title": "7abb3a73784042c6b9e4dcbbb77e83ca", "sufficiency_score": 4}
+{"answers": {"text": ["A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma."], "answer_start": [0]}, "context": "A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma.  Findings:  Three physician reviewers found that neuroblastoma is a malignancy of childhood, with 90% of diagnoses occurring in children younger than five years of age. When diagnosed in adolescents and young adults it is often characterized by a prolonged course with use of chemotherapy. Because of the relative rarity of the disease, there are no large randomized trials that provide high-grade evidence on the most effective treatments. The available evidence indicates that radioactive MIBG is an efficacious agent, with response rates in various studies ranging from 0% to 75%. However, in this case, the patient has already responded to the treatment modality requested which provides a reasonable expectation that the treatment would work if administered again. All told, I131-MIBG targeted radiation therapy is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. ", "id": "223b995bea0147b9ba774cc8db14e889", "question": "What is the background context in this case summary?", "title": "223b995bea0147b9ba774cc8db14e889", "sufficiency_score": 3}
+{"answers": {"text": ["A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia."], "answer_start": [0]}, "context": "A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are many medical and surgical alternatives to hysterectomy for the management of abnormal bleeding and painful periods.  These include oral contraceptives used for non-contraceptive reasons, as well as Mirena intrauterine device.   Non-contraceptive progestins can also be used.  There is a non-hormonal treatment, tranexamic acid, which is an antifibrinolytic agent that significantly reduces heavy periods when taken orally at the time of menses.  In addition, nonsteroidal anti-inflammatory drugs can be prescribed for heavy flow and menstrual cramps.  If hormonal treatments fail to control the problem, endometrial ablation is an appropriate alternative, with less morbidity than a hysterectomy.  This patient has had an incomplete evaluation of her abnormal bleeding, with an insufficient work-up to evaluate for other etiologies for her abnormal bleeding.  Per the submitted documentation, there is no record of a complete blood count, thyroid screening, or cervical cancer screening.  Various hormonal and endometrial causes for abnormal bleeding exist, and these require blood work and endometrial sampling by biopsy or dilation and curettage to assess.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.", "id": "40b0fa0cc1b74ffc92887f670b99c240", "question": "What is the background context in this case summary?", "title": "40b0fa0cc1b74ffc92887f670b99c240", "sufficiency_score": 3}
+{"answers": {"text": ["A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition."], "answer_start": [0]}, "context": "A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the services at issue were not likely to have been more effective than other available modalities.  Per the submitted documentation, the available blood and imaging records gave no indication for advanced liver disease or tumor.  Contemporary measurement of liver fibrosis is made serologically and/or by elastography.  The systematic review and meta-analysis by Singh and colleagues noted that the degree of liver stiffness, using elastography, can predict outcomes in patients with chronic liver diseases.  Per the authors, liver stiffness measurement may be used in risk stratification.  Thus, the superior efficacy of SPECT scan has not been established.", "id": "8cc6225e6f744df2a6f3d0516ac24a92", "question": "What is the background context in this case summary?", "title": "8cc6225e6f744df2a6f3d0516ac24a92", "sufficiency_score": 2}
+{"answers": {"text": ["A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition."], "answer_start": [0]}, "context": "A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition.   Findings:  Two physician reviewers found that in the medical literature, Claassen and colleagues reported that PET and 3-dimensional stereotactic surface projection  provide a useful diagnostic method to support a clinical diagnosis of primary lateral sclerosis. Studies with PET demonstrate predominant primary motor strip involvement. This pattern is illustrative of a stripe of hypometabolism. Thus, the literature does support the use of the requested PET for the evaluation of primary lateral sclerosis, looking for a stripe of hypometabolism. All told, the requested PET scan would be helpful to exclude primary lateral sclerosis in this patients condition. ", "id": "187d7a62a8f74092bd385f45e3d2be0b", "question": "What is the background context in this case summary?", "title": "187d7a62a8f74092bd385f45e3d2be0b", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.", "A 57-year-old", "This patient has been diagnosed with prostate cancer."], "answer_start": [0, 0, 275]}, "context": "A 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment options.  This patient has been diagnosed with prostate cancer.  However, the records do not document a repeat biopsy to determine if there has been any progression of disease.  Per the medical evidence, there is a lack of support for the UroLift procedure for patients with known prostate cancer.  At this time, long-term studies are needed to support the safety and efficacy of this procedure.  Thus, the requested UroLift procedure is not likely to be more effective than other available modalities.", "id": "bdc20822fb6448a1af18212f5f79a319", "question": "What is the background context in this case summary?", "title": "bdc20822fb6448a1af18212f5f79a319", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old male enrollee requested services provided on an emergent basis.", "The patient presented with reported symptoms of itching and jaundice for more than 20 days."], "answer_start": [0, 265]}, "context": "A 60-year-old male enrollee requested services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention.  The patient presented with reported symptoms of itching and jaundice for more than 20 days. There is no documentation during this pre-hospitalization window, nor immediately following hospitalization, of hemodynamic instability, respiratory compromise, or shock which might necessitate emergent treatment. In addition, the records do not support that an emergency medical condition existed at the onset of symptoms or in the early days of hospitalization.  All told, the patients symptoms did not meet prudent layperson criteria for emergency care.", "id": "ce0b7816cf3f4af9ba98684196963c00", "question": "What is the background context in this case summary?", "title": "ce0b7816cf3f4af9ba98684196963c00", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C."], "answer_start": [0]}, "context": "A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested regimen in this clinical setting.  It is medically appropriate to treat the patient before complications of liver disease occur.  Current national guidelines support treatment in this patients case.  Thus, Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks is medically indicated for the treatment of this patient.", "id": "96ee902c552e450f921c87bae2d0d702", "question": "What is the background context in this case summary?", "title": "96ee902c552e450f921c87bae2d0d702", "sufficiency_score": 3}
+{"answers": {"text": ["A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.", "the patient presented to the labor and delivery department with an acute history of an abnormal NST."], "answer_start": [0, 135]}, "context": "A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.  Findings:  The physician reviewer found that the patient presented to the labor and delivery department with an acute history of an abnormal NST. The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is considered a good indicator of normal fetal autonomic function. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia. The NST results are categorized as reactive or nonreactive. As noted by the American College of Obstetricians and Gynecologists (ACOG), the most common definition of a reactive, or normal, NST is if there are two or more fetal heart rate accelerations within a 20 minute period. A nonreactive NST is one that lacks sufficient fetal heart rate accelerations over a 40 minute period. In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result may be performed by induction of labor, with continuous intrapartum monitoring of the fetal heart rate and uterine contractions. The finding of an abnormal fetal heart rate pattern, including tachycardia and arrhythmia in this patient, may indicate fetal distress. Fetal distress is an emergent condition requiring acute care of the mother and fetus. The records indicate this patent required inpatient admission to undergo obstetrical triage at this facility. However, the patient could have been evaluated at an adjacent obstetrical triage unit prior to consideration for immediate inpatient admission. If abnormal fetal surveillance was found at that time, then the patient could have been admitted for acute management. Consistent with these findings, the hospital stay was not medically necessary for treatment of this patients medical condition. ", "id": "f3151341db994cd08a3b19c1416de860", "question": "What is the background context in this case summary?", "title": "f3151341db994cd08a3b19c1416de860", "sufficiency_score": 3}
+{"answers": {"text": ["A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain."], "answer_start": [0]}, "context": "A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain.  Findings:  Three physician reviewers found that according to an article in the American Academy of Orthopaedic Surgeons (AAOS), the literature on the clinical use of PRP suggests that considerable variability exists in its effectiveness, even in the same clinical setting. Available data indicates that PRP may be valuable in enhancing soft tissue repair and in wound healing. However, the clinical role of PRP in bone repair remains controversial. Delos and colleagues reported that there are no definite indications for the use of PRP. In the absence of scientific data demonstrating the safety and effectiveness of PRP for treatment of painful ankle conditions, the PRP tissue grafting was not likely to provide this patient with an improved health outcome when compared to standard available alternatives. ", "id": "bac38abd1d6c4051a1c4cdf7a1616534", "question": "What is the background context in this case summary?", "title": "bac38abd1d6c4051a1c4cdf7a1616534", "sufficiency_score": 3}
+{"answers": {"text": ["A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation."], "answer_start": [0]}, "context": "A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation. Findings:  Two physician reviewers found that the testing at issue was likely to have been superior over other methods of evaluating this patient.  There is support for gene expression profiling using AlloMap testing for acute cellular rejection screening in appropriate low-risk patients who are between six months and five years post transplant.  The current medical evidence supports the testing at issue in this clinical setting.  In this patients case, AlloMap testing was consistent with well-established guidelines for postoperative management and follow-up.  Therefore, AlloMap testing was consistent with current standard of care and was likely to have been more beneficial for this patient than standard therapy.", "id": "14f7c36a0bc54bbc8f298c5a68b7f2c8", "question": "What is the background context in this case summary?", "title": "14f7c36a0bc54bbc8f298c5a68b7f2c8", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition.", "The patient has various respiratory conditions"], "answer_start": [0, 785]}, "context": "A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation or has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if an individual is unable to perform sufficient pressure relief independently.  However, the submitted records do not establish that the patient has any impairment that would require a semi-electric hospital bed, gel mattress overlay or bed rails.  The patient has various respiratory conditions, but no documented objective need to have the head of the bed frequently elevated.  She has no documented neurological or musculoskeletal conditions that would preclude self-repositioning in bed for her pain conditions.  There are no impairments, major risk factors for pressure ulcers, or other medical conditions that establish the need for a gel mattress overlay.  There are no impairments that need to be addressed with rails on a semi-electric bed.  All told, the requested semi-electric hospital bed, gel mattress overlay and rails are not medically necessary for the treatment of this patient.", "id": "a9adc48e40f641a58c270934442f5203", "question": "What is the background context in this case summary?", "title": "a9adc48e40f641a58c270934442f5203", "sufficiency_score": 2}
+{"answers": {"text": ["A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain."], "answer_start": [0]}, "context": "A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. To fuse the lumbar spine in the absence of dynamic instability, more than 2 mm on flexion/extension views or severe spinal stenosis for the lumbar spine, is not consistent with standards of good medical practice. In addition, randomized trials have not demonstrated the efficacy of surgical treatment in chronic low back pain and disc degeneration. Brox and colleagues demonstrated conservative care to be equal to lumbar fusion with a return to work rate at 22% in the surgical group compared with 33% in the non-surgical group. The authors concluded that the overall success rates were equivalent. Fairbank and colleagues performed a randomized controlled trial of spinal fusion versus rehabilitation for patients with chronic low back pain and reported no differences between the groups. Finally, in this patients case, there is no evidence of instability or severe spinal stenosis to warrant a lumbar fusion at the L5-S1 level. Based on the medical literature and the documentation submitted for review, the requested procedure is not medically necessary for treatment of the patients medical condition. ", "id": "3ab6a14eb89f4711a2f4ae9faada9a66", "question": "What is the background context in this case summary?", "title": "3ab6a14eb89f4711a2f4ae9faada9a66", "sufficiency_score": 3}
+{"answers": {"text": ["A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.", "During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission."], "answer_start": [0, 292]}, "context": "A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support continued inpatient hospitalization from the specified date forward.  During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission.  In sum, by the specified date, there was no evidence of an acute psychiatric syndrome necessitating continued inpatient hospitalization.  All told, continued inpatient hospitalization from the specified date forward was not and is not medically indicated for the treatment of this patient.", "id": "e6e933495aca4d49b680e850476ececc", "question": "What is the background context in this case summary?", "title": "e6e933495aca4d49b680e850476ececc", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 10-year-old male enrollee has requested indirect consultation for treatment of the enrollees autism and speech and language delays.", "the patient is non-verbal and intellectually disabled. At the age of eight his language comprehension and expressive skill was between 6 and 8 months age equivalency.", "since the advent of a picture communication system his comprehension of language has markedly improved."], "answer_start": [0, 323, 499]}, "context": "The parent of a 10-year-old male enrollee has requested indirect consultation for treatment of the enrollees autism and speech and language delays.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. Based on the documentation submitted, the patient is non-verbal and intellectually disabled. At the age of eight his language comprehension and expressive skill was between 6 and 8 months age equivalency. However, since the advent of a picture communication system his comprehension of language has markedly improved. Thus, a picture exchange system is the treatment of choice for this patient. According to the study by Kaiser and Roberts, speech impaired children whose parents are directly involved with the childs speech therapy simultaneously with the therapist have improved language outcomes compared with parents who are independently instructed. Thus, it is important that the patients parent receive instruction of the picture communication system.  Engaging the mother actively within the therapy and spending a few minutes of each hour in parental instruction is medically reasonable and sufficient. ", "id": "63a5bb4b358b473dabb4ce0cd9dd0e71", "question": "What is the background context in this case summary?", "title": "63a5bb4b358b473dabb4ce0cd9dd0e71", "sufficiency_score": 4}
+{"answers": {"text": ["A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis."], "answer_start": [0]}, "context": "A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  There have been double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis to evaluate the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors noted that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.", "id": "cb3da987fccf479aaf4753c7db189e32", "question": "What is the background context in this case summary?", "title": "cb3da987fccf479aaf4753c7db189e32", "sufficiency_score": 3}
+{"answers": {"text": ["A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.", "this patient presents with chronic pain. However, his pain generator has not been identified.", "the patient has not reportedly received substantial relief after piriformis injection."], "answer_start": [0, 178, 442]}, "context": "A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.  Findings:  The physician reviewer found that this patient presents with chronic pain. However, his pain generator has not been identified. He has normal neurologic and orthopedic examinations and there is a lack of documentation by examination to substantiate a diagnosis of piriformis syndrome. In addition, the patient has not reportedly received substantial relief after piriformis injection. In the medical literature, Filler noted that before surgery is considered, two successful blocks should have been received. Further, there are no large, prospective, scientific studies that have shown the efficacy of this surgery. Only small, retrospective studies are reported (Benson and Schutzer). There is no large body of literature that supports the diagnosis of piriformis syndrome. Campbell and Landau noted that, there is little definite evidence in the literature to support the diagnosis of piriformis syndrome. Miller and colleagues noted that, diagnosis is hampered by lack of agreed upon clinical criteria and lack of definitive investigation such as imaging or electrodiagnostic studies. Thus, any surgery on this patients sciatic nerve for piriformis syndrome is not supported as medically necessary. ", "id": "66987317b5344c119e6e0ded10de4460", "question": "What is the background context in this case summary?", "title": "66987317b5344c119e6e0ded10de4460", "sufficiency_score": 4}
+{"answers": {"text": ["A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.", "The patient has received more than three years of weekly psychotherapy treatment", "the patient remains symptomatic."], "answer_start": [0, 311, 533]}, "context": "A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the outpatient psychotherapy provided from the date indicated forward was not and is not medically necessary for this patients medical condition. The patient has received more than three years of weekly psychotherapy treatment; the patients notes reflect no measurable improvements, treatment goals or attainable discharge dates. Despite the therapy received to date, the patient remains symptomatic. According to Gelenberg and colleagues, For psychotherapy, treatment should be reassessed if there has not been a meaningful improvement after a few months. Patients should be reassessed every 3-4 months to ensure adequate improvement. Regardless of treatment modality, lack of improvement over time warrants reconsideration of interventions. Continued weekly insight-oriented sessions are not consistent with the standard of care in this setting. All told, the services at issue have not produced any measurable gains or improvement and continued use of this modality at this frequency is not medically necessary.", "id": "e666ab44f0ac4af3af507e6f525a7431", "question": "What is the background context in this case summary?", "title": "e666ab44f0ac4af3af507e6f525a7431", "sufficiency_score": 4}
+{"answers": {"text": ["A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.", "The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment.", "the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups."], "answer_start": [0, 953, 1170]}, "context": "A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that based on the records provided for review, residential treatment center services were medically necessary for treatment of this patients medical condition from the time frame specified. Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness. The American Psychiatric Association (APA) supports residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and lack sufficient social and vocational skills. Based on this guidance, residential placement was initially reasonable for this patient as his life was dominated by substance use. The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment. However, the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups. Consistent with the APA recommendations, the residential treatment services were medically necessary from the time frame specified, but are not supported as medically necessary during the subsequent time frame. ", "id": "813fa61fe88e48a2bef2c544f6de2009", "question": "What is the background context in this case summary?", "title": "813fa61fe88e48a2bef2c544f6de2009", "sufficiency_score": 4}
+{"answers": {"text": ["A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.", "The medical records noted that there were no lower urinary tract symptoms (LUTS)", "the patient indicates that he has BPH"], "answer_start": [0, 363, 630]}, "context": "A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, the clinical notes do not document the diagnosis of benign prostatic hypertrophy (BPH). The medical records noted that there were no lower urinary tract symptoms (LUTS), which is a symptom of BPH. Moreover, BPH has not been fully evaluated or addressed as there is no documentation of a digital rectal exam, which should be done to diagnose BPH. Although the patient indicates that he has BPH, the urologists diagnosis did not indicate BPH, and the current medical evidence does not support daily use of Cialis 5mgin this setting. All told, daily use of Cialis 5mg is not medically indicated for the treatment of this patient.", "id": "7701354f075342f0b199ec08e459bbcc", "question": "What is the background context in this case summary?", "title": "7701354f075342f0b199ec08e459bbcc", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.", "This 16-year-old patient has been receiving ABA therapy for at least 7 years."], "answer_start": [0, 1001]}, "context": "The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 16-year-old patient has been receiving ABA therapy for at least 7 years. While intensive ABA services are not likely to result in further significant improvement, continuation of ABA therapy at a reduced frequency is medically necessary to maintain the patients current level of function. As such, continued ABA therapy at a frequency of 5 hours per week of direct ABA therapy, 1 hour per week of supervision and 1 hour per month of parent consultation is medically necessary to maintain the patients present level of function.", "id": "73225811b2aa4b088e0231be2a3afc73", "question": "What is the background context in this case summary?", "title": "73225811b2aa4b088e0231be2a3afc73", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old male enrollee has requested continued posterior tibial neurostimulation (percutaneous tibial nerve stimulation) for treatment of his benign prostatic hyperplasia with urinary frequency.", "This patient has", "symptomatic benign prostatic hyperplasia"], "answer_start": [0, 365, 419]}, "context": "A 60-year-old male enrollee has requested continued posterior tibial neurostimulation (percutaneous tibial nerve stimulation) for treatment of his benign prostatic hyperplasia with urinary frequency. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  This patient has subjective and objective evidence of symptomatic benign prostatic hyperplasia.  Percutaneous tibial nerve stimulation is not indicated in this clinical setting.  Per the medical records, this patient has not received standard treatment for benign prostatic hyperplasia.  All told, continued percutaneous tibial nerve stimulation is not likely to be more efficacious than other modalities for the treatment of this patient.", "id": "c5f99159f310413bbca913cdc130b8da", "question": "What is the background context in this case summary?", "title": "c5f99159f310413bbca913cdc130b8da", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin.", "The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis."], "answer_start": [0, 567]}, "context": "A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Panniculectomy involves the removal of the lower abdominal skin without the muscle tightening or supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty.  Per the submitted photographs, this patients pannus skin fold has resulted in a disruption of skin integrity.  The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.", "id": "6bc7c9ab5e6044e0b8acf42bcb5b4d06", "question": "What is the background context in this case summary?", "title": "6bc7c9ab5e6044e0b8acf42bcb5b4d06", "sufficiency_score": 4}
+{"answers": {"text": ["A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis.", "this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping."], "answer_start": [0, 241]}, "context": "A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewer found that this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping.  In this clinical setting, given the biomechanical pathology, the current medical evidence supports custom molded orthotics.  The use of custom molded orthotics is an established treatment for overpronation and heel pain.  In this patients case, the requested custom molded orthotics and follow-up podiatry visit are medically indicated.  However, cast supplies and application of short leg splint are not medically necessary.  The progress notes do not support the need for a short leg splint or cast supplies.  All told, the submitted documentation demonstrates the medical necessity of a portion of the requested services.  ", "id": "d808e91eaf75479f9d6cb986e2e5b600", "question": "What is the background context in this case summary?", "title": "d808e91eaf75479f9d6cb986e2e5b600", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism."], "answer_start": [0]}, "context": "The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Multiple studies of Lovaas-based approaches and early intensive behavioral intervention variants resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Sallows and Graupner). Individual treatment is a defining feature and integral component of ABA. The Individual Program Plan for this patient is constructed to identify all behavioral needs including communication, functional living, self-help skills, social interaction, and recreation. These domains are noted as program components for intensive ABA therapy. All told, the ABA therapy incorporating Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity, is medically necessary for treatment of this patients medical condition. ", "id": "d8ff8efb6ab04e3fa6d14efc39fa7963", "question": "What is the background context in this case summary?", "title": "d8ff8efb6ab04e3fa6d14efc39fa7963", "sufficiency_score": 3}
+{"answers": {"text": ["A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.", "the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone"], "answer_start": [0, 151]}, "context": "A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.   Findings:  The physician reviewer found that the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone, which is a potassium-sparing diuretic that has anti-androgen properties.  This medication can help excessive hair growth.  In this patients case, it has not been established that the excessive hair constitutes an abnormal structure of the body.  The submitted documentation does not indicate the distribution of hair that the patient wishes to remove.  Additionally, there is no evidence of any associated functional deficit produced by the excessive hair growth.  All told, the requested laser hair removal is not reconstructive in nature and is not medically necessary in this patients case.", "id": "74b15694507b4f6b89150921db7f04f8", "question": "What is the background context in this case summary?", "title": "74b15694507b4f6b89150921db7f04f8", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.", "He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.", "Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider."], "answer_start": [0, 427, 1275]}, "context": "A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities in this patients case.  He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.  Per the current medical evidence, treatment approaches can include combinations of medical therapy, behavioral intervention, interventional therapies, and rehabilitative interventions.  The current medical research indicates that treatment with narcotic analgesics for a period of greater than two weeks does not result in more favorable pain control than the use of non-steroidal anti-inflammatories or acetaminophen. Many studies have documented the high degree of comorbidity between depression and chronic pain, and there is evidence that the incidence of depression among patients with chronic pain is higher than for other chronic illnesses.  Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider.  This constitutes a breach in his signed Controlled Substance Contract.  The current medical evidence does not support the requested increase in medications in this clinical setting.  All told, the requested increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) is not medically indicated for the treatment of this patient.", "id": "123c430bd94540658952874467e59dff", "question": "What is the background context in this case summary?", "title": "123c430bd94540658952874467e59dff", "sufficiency_score": 4}
+{"answers": {"text": ["A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.", "The clinical notes indicate that the patient is able to ambulate without documented deficits"], "answer_start": [0, 685]}, "context": "A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this clinical setting.  The medical records do not demonstrate the medical necessity of non-emergency transportation in this patients case.  There is no documentation indicating that she requires transportation other than by means of public or private conveyance.  She has no specific impairments which require transportation to and from medical visits.  The clinical notes indicate that the patient is able to ambulate without documented deficits, and she has no medical condition which requires structured transportation.  All told, the requested transportation is not medically indicated in this case.", "id": "4e266671c8a6413389d2092ee0e1aad6", "question": "What is the background context in this case summary?", "title": "4e266671c8a6413389d2092ee0e1aad6", "sufficiency_score": 3}
+{"answers": {"text": ["The representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.", "the patient has sustained a severe brain injury.", "This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction.", "he continues to have severe brain injury and ventilator dependence more than three months post-stroke."], "answer_start": [0, 321, 718, 927]}, "context": "The representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.   Findings:  The physician reviewer found that based on review of the available records, the patient has sustained a severe brain injury. His hospitalization with severe pneumonia in underscores the severity of his illness. The medical literature, including Eskildsen and colleagues review, discuss the indications for long-term acute care. Specifically, the authors noted that a patient needs to have an unstable condition with a need for multiple specialists providing frequent care. This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction. In addition, he continues to have severe brain injury and ventilator dependence more than three months post-stroke. He is unable to make gains consistent with intense rehabilitation. He will need a protracted course with rehabilitation with small gains expected over a long period of time. The anticipated benefit from acute rehabilitation follows from progressive recovery from brain injury. The degree of this patients brain injury prohibits him from progressing with intensive therapy at this time. All told, the requested services are not supported as medically necessary in treating this patients medical condition. ", "id": "437db08ec1514e0e91ce0bb6fcdf3f44", "question": "What is the background context in this case summary?", "title": "437db08ec1514e0e91ce0bb6fcdf3f44", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.", "Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy."], "answer_start": [0, 268]}, "context": "The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.  Findings:  The physician reviewer found that Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy. The patients intellectual disability is a frequent co-morbid diagnosis in autistic children. However, this condition does not preclude the patient from benefitting extensively from ABA therapy. ABA therapy is well-documented as the only consistently successful intervention for autistic children. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a documented 40-year track record of substantially improving motor, verbal, and socially interactive skills in autistic children. Myers and Johnson indicate that the effectiveness of ABA-based intervention in autism spectrum disorder has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Further, the authors report that, children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. This patient has been diagnosed as autistic, for which ABA therapy is the well-documented therapy of choice. There is consensus among clinical psychologists that ABA therapy should be intensively initiated as soon as a diagnosis of autism is established. With regard to the appropriate frequency of ABA therapy, at the requested 35 hours per week of ABA services, there would be inadequate time to develop group socialization or trials of mainstreaming the patient during school hours. A frequency of 20 hours of ABA therapy per week is more appropriate in this setting. All told, it is medically necessary that ABA therapy be continued for this patient. However, the recommendation is for 20 hours of ABA therapy per week.  ", "id": "91d3547f11c24a38a7aab043d8f12811", "question": "What is the background context in this case summary?", "title": "91d3547f11c24a38a7aab043d8f12811", "sufficiency_score": 4}
+{"answers": {"text": ["A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema."], "answer_start": [0]}, "context": "A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema.  Findings:  The physician reviewer found that based on review of the available records, the patient has a severe and rare debilitating condition that requires a multifaceted approach for effective treatment. The medical literature indicates that clinical benefits from an aquatics program include improvement in strength, mobility, and overall well-being. Consistent with this support, this patient would benefit from a therapeutic aquatic exercise program. Given the significant pain and limited mobility associated with her condition, aquatic therapy is medically necessary. ", "id": "975c327b2f104e7183b86645f736464f", "question": "What is the background context in this case summary?", "title": "975c327b2f104e7183b86645f736464f", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity."], "answer_start": [0]}, "context": "A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the medical records do not document completion of a multidisciplinary evaluation, including a dietary evaluation, behavioral evaluation, and medical evaluation.  In the absence of this documentation, the medical necessity of the requested procedure cannot be established.  Additionally, failed weight loss efforts should be documented prior to the requested surgery.  All told, the requested gastric Lap-band surgery is not medically indicated for the treatment of this patient at this time.    ", "id": "16644266ee464b9e9431035bbe788308", "question": "What is the background context in this case summary?", "title": "16644266ee464b9e9431035bbe788308", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain.", "the patient remains symptomatic"], "answer_start": [0, 851]}, "context": "A 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain. Findings:  The physician reviewer found that there is no clinically significant benefit with respect to analgesic, health or functional outcomes is expected with chiropractic therapy at this time based on the available clinical data.  There is no proven benefit of chiropractic treatment in the setting of chronic low back pain, chronic hip pain, or other musculoskeletal conditions.  In the review by Ernst and colleagues, the authors concluded that rigorous clinical trials have not demonstrated that chiropractic care is an effective intervention for pain control.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  Although the patient remains symptomatic, the requested chiropractic therapy is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise program.  All told, the requested chiropractic services are not medically indicated for the treatment of this patient. ", "id": "1117990d29494d19af7040ad248c9a5a", "question": "What is the background context in this case summary?", "title": "1117990d29494d19af7040ad248c9a5a", "sufficiency_score": 3}
+{"answers": {"text": ["A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity."], "answer_start": [0]}, "context": "A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that based on review of the records, medical necessity has not been established for the requested bariatric surgery procedure. As noted in the medical literature by Smith and colleagues, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. This patients records do not document any of these conditions.  Accordingly, the requested surgery is not medically necessary for treatment of the patients medical condition. ", "id": "8a3123d62781489d856f0701235978a2", "question": "What is the background context in this case summary?", "title": "8a3123d62781489d856f0701235978a2", "sufficiency_score": 3}
+{"answers": {"text": ["A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant."], "answer_start": [0]}, "context": "A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of breast implants would be considered medically necessary for the treatment of active infection, impending or actual implant extrusion, painful symptomatic grade IV capsular contracture, or leakage of silicone gel.  The existence of any of these conditions is not documented in the reviewed materials.  It is unlikely that a deflated saline implant in the absence of grade IV capsular contracture or infection would cause any functional deficit.  Based on the information provided, removal of breast implants is not medically necessary for the treatment of this patient. Given the absence of high-grade capsular contracture, capsulectomy is also not medically necessary.  ", "id": "bd1543853f9243008802c44180577632", "question": "What is the background context in this case summary?", "title": "bd1543853f9243008802c44180577632", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.", "the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.", "This patient has", "undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic."], "answer_start": [0, 318, 1228, 1253]}, "context": "A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.  In this patients case, the requested services are likely to be of greater benefit than other available treatment alternatives.  The American Psychiatric Association has noted that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond to medication therapy.  This patient has already undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic.  In this clinical setting, transcranial magnetic stimulation is likely to be more beneficial than other treatment modalities.  All told, the requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) is likely to be superior over other treatment options in this patients case.  ", "id": "56bd10172c9c49cb9f1df816d9dd8758", "question": "What is the background context in this case summary?", "title": "56bd10172c9c49cb9f1df816d9dd8758", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder."], "answer_start": [0]}, "context": "The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder.  Findings:  The physician reviewer found that feeding difficulties are common in early life with 25% of children reported to have some form of feeding disorder. Consequences of feeding disorders can be severe, including growth failure and susceptibility to chronic illness. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Caretto and colleagues evaluated the role of occupational therapists in parent education of infant feeding in the neonatal intensive care unit. The occupational therapists were most frequently identified as responsible for teaching about positioning, infant development, and infant states and cues and were highly involved in educating parents about feeding. Although this study involved neonates, this does prove that occupational therapists have a role in the treatment of feeding problems and are the main providers in the treatment of feeding disorders. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psychosocial and organic factors. Disordered feeding in a child is seldom limited to the child alone and is oftentimes a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the patients inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. For these reasons, the requested occupational therapy is medically necessary to prevent malnourishment, failure to thrive, and to reduce morbidity in the treatment of this patients medical condition. ", "id": "bcc7885c133140678699aa39f5ab6714", "question": "What is the background context in this case summary?", "title": "bcc7885c133140678699aa39f5ab6714", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees speech delay."], "answer_start": [0]}, "context": "The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved. ", "id": "469fbf548c4048af94048e324174115b", "question": "What is the background context in this case summary?", "title": "469fbf548c4048af94048e324174115b", "sufficiency_score": 3}
+{"answers": {"text": ["A 28-year-old male enrollee has requested coverage for past emergency services provided.", "the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention."], "answer_start": [0, 135]}, "context": "A 28-year-old male enrollee has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.  California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Chalazions are not acute medical emergencies. They are typically managed with warm compresses and antibiotic ointment with referral to an ophthalmologist when that fails.  In this case, the patient reports he experienced a significant worsening of pain and swelling and that his vision was blurry. The emergency physician record indicates that the patients pain in the emergency room was 2-3 out of 10 and his visual acuity was 20/20. The patient did not require narcotic analgesia. He received Motrin for pain. All told, the objective medical record documentation does not support the contention that the patient experienced a significant worsening of pain, swelling and vision problems at the time he sought emergency services. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health and thus would not have sought immediate medical attention for the patients complaints.  ", "id": "b9d35bf152444ba8a2b80d4997b4156b", "question": "What is the background context in this case summary?", "title": "b9d35bf152444ba8a2b80d4997b4156b", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder."], "answer_start": [0]}, "context": "The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder.  Findings:  The physician reviewer found that this patient has ASD but does not exhibit other symptoms to suggest a mitochondrial disorder. Signs of mitochondrial disease include elevations of lactic acid, which the patient does demonstrate.  However, blood lactate and pyruvate measurements are known to be prone to erroneous increases due to such issues as prolonged tourniquet application, (see Bonini, et al. and Haas). Other biochemical markers are often present including elevation of plasma alanine in the amino acids, elevations of urine organic acids and especially dicarboxylic acids due to omega oxidation of fat in the cytoplasm when mitochondria are not functioning normally.  Elevations of acylcarnitine derivatives are usually seen, as well.  Ammonia can also be elevated with mitochondrial disease (Haas). The patient exhibited none of these biochemical markers. Finally, patients with mitochondrial diseases usually have progressive deterioration in their neurological functioning (Haas) which is also not evident in the documentation provided regarding this patient. Therefore, without additional signs or symptoms as outlined above, a muscle biopsy for the purpose of a mitochondrial disease work-up is not medically necessary for the patient.", "id": "cab63649952d4118873a425ea1826e04", "question": "What is the background context in this case summary?", "title": "cab63649952d4118873a425ea1826e04", "sufficiency_score": 3}
+{"answers": {"text": ["A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease."], "answer_start": [0]}, "context": "A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease. Findings:  The physician reviewer found that the literature evidences that the etiology of Peyronies Disease is not clearly understood, however the effect of the disease is a plaque that affects the elasticity of the corporal body. This results in non-uniform distension of the corporeal bodies which leads to a curvature of the erection. The surgical treatment of the plaque is still considered to be the standard method of treatment when a patients disease is determined to be stable and mature (Gordon). As with other methods of treatment for Peyronies Disease, Interferon therapy requires further investigation to define its efficacy, proper dosing regimens and side-effect profiles (Larsen & Levine). In sum, the requested medication is not considered medically necessary in this setting, as this treatment modality is still being evaluated and is not considered to be an accepted option for treatment of the patients medical condition.", "id": "1257baaa2fad4b66875e294247fd5710", "question": "What is the background context in this case summary?", "title": "1257baaa2fad4b66875e294247fd5710", "sufficiency_score": 3}
+{"answers": {"text": ["A 61-year-old female enrollee has requested for emergency services indicating emergency care.", "complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility."], "answer_start": [0, 139]}, "context": "A 61-year-old female enrollee has requested for emergency services indicating emergency care. Findings:  The physician reviewer found that complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility.", "id": "0dde5b0480d54e4cbb8ed25c790963a9", "question": "What is the background context in this case summary?", "title": "0dde5b0480d54e4cbb8ed25c790963a9", "sufficiency_score": 4}
+{"answers": {"text": ["A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.", "The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living"], "answer_start": [0, 475]}, "context": "A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.  Findings:  The physician reviewer found that this patient has goals of competing in the 2012 Paralympics, and he has requested a prosthetic running limb. Prostheses for running are specially adapted for this task.  However, these adaptations are not necessary for an individual to accomplish basic mobility-related activities of daily living. The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living, including community mobility. The requested equipment adds to the patients options for exercise and recreation, but it is not medically necessary.  The submitted medical records do not demonstrate the medical necessity of the requested equipment.  All told, the requested prosthetic running limb is not medically indicated.", "id": "bae1a7708e044549b6f6f02a1aeccf09", "question": "What is the background context in this case summary?", "title": "bae1a7708e044549b6f6f02a1aeccf09", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism."], "answer_start": [0]}, "context": "The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient with autism will continue to benefit from intensive ABA therapy and has shown impressive gains in all domains since the start of treatment. The American Academy of Pediatrics (AAP) recommends a minimum of 25 hours per week of ABA therapy per week for children with autism. As this is the standard of care for patients with autism, 25 hours per week of ABA therapy is medically necessary for the management of this patients behavioral issues associated with autism. ", "id": "f26e6d55072045a5a445414f85bf1682", "question": "What is the background context in this case summary?", "title": "f26e6d55072045a5a445414f85bf1682", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay."], "answer_start": [0]}, "context": "The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  The current medical evidence indicates that early intervention can improve speech and language skills.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of his speech and language delay, the requested speech therapy is standard of care. There is sufficient medical evidence supporting the requested services in this clinical scenario.  All told, the requested speech therapy services are medically indicated for the treatment of this patient. ", "id": "07fcbc517cc04ec3a989f2edfa6c970c", "question": "What is the background context in this case summary?", "title": "07fcbc517cc04ec3a989f2edfa6c970c", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.", "the provider states that there is a lifetime risk of breast cancer of approximately 20%"], "answer_start": [0, 1066]}, "context": "A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.  Findings:  Two physician reviewers found that Lynch syndrome (hereditary non-polyposis colorectal cancer) is characterized by the development of colorectal cancer, endometrial cancer and various other cancers.  Protocols for surveillance in Lynch syndrome include colonoscopy, gynecological examinations, which may include regular ultrasounds and biopsies, and abdominal ultrasound screening.  The American College of Radiology has recognized the increased sensitivity of MRI for high-risk patients.  Clinical situations in which breast MRI may be warranted include patients with BRCA mutations, patients who are untested but who have a first-degree relative with BRCA mutations and patients with a lifetime risk of breast cancer of 20 to 25% or greater as defined by BRCAPRO or other models that are largely dependent on family history. This patient does meet established criteria for breast MRI.  Although the provider states that there is a lifetime risk of breast cancer of approximately 20%, this cannot be established based upon any given model.  All told, the requested MRI of the breast is not likely to be superior over other methods of evaluation.", "id": "6f9ab81ded5544edb095de2dd880e69f", "question": "What is the background context in this case summary?", "title": "6f9ab81ded5544edb095de2dd880e69f", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.", "the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal."], "answer_start": [0, 195]}, "context": "The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal.  She has no complaints or symptoms of pituitary insufficiency and no history of pituitary abnormality.  There is no evidence of growth hormone deficiency.  All told, in this patients case, the requested Genotropin growth hormone therapy is not medically indicated.", "id": "cb8dfeeb033842fe806e8035450c73ff", "question": "What is the background context in this case summary?", "title": "cb8dfeeb033842fe806e8035450c73ff", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.", "The power mobility device form signed by the patients primary care physician", "endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day."], "answer_start": [0, 763, 870]}, "context": "A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation does not substantiate the presence of impairments that would preclude the patient from accomplishing his mobility-related activities of daily living within the home with the aid of a manual wheelchair.  The records do not document any neurological or musculoskeletal impairment or pathology affecting the upper limbs.  He does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish his mobility-related activities of daily living.  The power mobility device form signed by the patients primary care physician on the said date specifically endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day.  With respect to falls, there is no evidence in the present case that would support that there would be a significant additional risk of falling when comparing a manual versus a power wheelchair.  All told, the requested motorized wheelchair (power-operated vehicle) is not medically necessary this patient.", "id": "bfb7656f64a04f16811b3c588f8316f3", "question": "What is the background context in this case summary?", "title": "bfb7656f64a04f16811b3c588f8316f3", "sufficiency_score": 4}
+{"answers": {"text": ["A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures.", "the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain."], "answer_start": [0, 193]}, "context": "A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures. Findings:  Three physician reviewers found that the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain. A literature search revealed no studies demonstrating or even assessing the efficacy of a heating/cooling system for the treatment of low back pain. As such, this therapy should be considered experimental at this time absent additional clinical trials demonstrating the equivalence or superiority of the device when compared to standard alternatives.", "id": "55179dc0c27d49569fae6a8b1eebc090", "question": "What is the background context in this case summary?", "title": "55179dc0c27d49569fae6a8b1eebc090", "sufficiency_score": 3}
+{"answers": {"text": ["A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain.", "with the exception of x-rays, imaging has not been done.", "This patient has a history of a foot neuroma."], "answer_start": [0, 160, 465]}, "context": "A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain. Findings:  The physician reviewer found that with the exception of x-rays, imaging has not been done.  Whole body MRI is not medically indicated for this patient since there is no history of malignancy. Whole body MRI, although not widely available, is generally reserved for the detection of skeletal metastases as well as other organ involvement.  This patient has a history of a foot neuroma.  Due to the fact that imaging of her feet has not been done despite symptoms which have persisted for over one year, bilateral MRI of the feet is medically indicated for the evaluation of this patient.  All told, in this patients case, evaluation with bilateral MRI of the feet is medically appropriate given her symptoms. ", "id": "4d19c41bad8441a48914f708183f1a56", "question": "What is the background context in this case summary?", "title": "4d19c41bad8441a48914f708183f1a56", "sufficiency_score": 4}
+{"answers": {"text": ["A 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.", "this patient", "exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting."], "answer_start": [0, 166, 187]}, "context": "A 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.  Findings:  The physician reviewer found that this patient clearly exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting.  The inpatient hospitalization was consistent with standards of medical practice in the community and his care could not be provided safely on an outpatient basis. Inpatient hospitalization was therefore medically necessary for this patient.", "id": "21a2b63b5ee14facaef556ca2b327e8e", "question": "What is the background context in this case summary?", "title": "21a2b63b5ee14facaef556ca2b327e8e", "sufficiency_score": 4}
+{"answers": {"text": ["A 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia.", "The patient has a serum ferritin from last year of 13 ng/mL", "her blood work from this year shows low iron saturation values which are low in the single digits"], "answer_start": [0, 382, 506]}, "context": "A 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia. Findings:  The physician reviewer found that this patients records are devoid of any current clinic notes which document anemia with an etiology of iron deficiency. Further, there is inadequate documentation of the patients failure to improve her iron stores with oral supplementation. The patient has a serum ferritin from last year of 13 ng/mL, which is low and suggestive of iron deficiency. More recently, her blood work from this year shows low iron saturation values which are low in the single digits and again suggestive of iron deficiency. However, the records do not clearly justify treatment at this time since there is insufficient documentation of an anemia work up or failure of oral supplements. In addition, the patients recent hemoglobin has not been provided for review. For these reasons, the requested therapy has not been demonstrated to be medically necessary for management of this patients condition. ", "id": "0d75d98f6a4d41cba550843f086d6022", "question": "What is the background context in this case summary?", "title": "0d75d98f6a4d41cba550843f086d6022", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism."], "answer_start": [0]}, "context": "The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing the medical literature, there are numerous studies addressing the functional benefits of ABA therapy. When ABA therapy was first initiated, some providers recommended that 40 hours per week was indicated but this was later reduced to 20 hours per week as a result of the burden of the intensity that the therapy puts on families and service providers. Since that time, additional studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (more than 20 hours per week) to further assess the outcome relative to additional hours of treatment. In addition, studies have been conducted to address the need for intensive behavior therapy versus standardized care. Overall, the scientific data is supportive of the utility of behavioral therapy and suggest that patients who receive this treatment show a statistical improvement in cognitive, language and adaptive behavior skills when compared to patients who were untreated. However, Spreckley and Boyds meta analysis of the literature found that appropriately powered clinical trials with broader outcomes are still needed to fully establish the role of ABA in managing young patients with ASD. The authors cited a study by Roberts, et al. which determined that for best results, a minimum of 20 hours per week of intervention over 2 years, taking into account of each patients strengths and weaknesses and family circumstances, is essential for young patients with ASD to make gainsWhile there is no literature specifically addressing the utility of 25 hours per week of ABA therapy, there is support for high intensity therapy of at least 20 hours per week. Therefore, based on the clinical documentation provided as well as review of the relevant scientific evidence, there is adequate support for 20 hours of ABA therapy per week for this patient. ", "id": "518aa87fdfd340f1a6edb7a0f0d54d74", "question": "What is the background context in this case summary?", "title": "518aa87fdfd340f1a6edb7a0f0d54d74", "sufficiency_score": 3}
+{"answers": {"text": ["A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.", "this patient reported significant pain relief from the right sacroiliac (SI) joint injection", "this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up"], "answer_start": [0, 288, 797]}, "context": "A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.  Findings:  Three physician reviewers found that this patient reported significant pain relief from the right sacroiliac (SI) joint injection, which is a clinical indication that she will benefit from the requested procedures. The available peer reviewed medical literature suggests that radiofrequency (RF) ablation of the SI joint is no longer investigational. Further, Ferrante and colleagues concluded that RF denervation has been shown to be efficacious for about six months of pain relief when used in patients with a successful SI joint injection. As this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up, she is an appropriate candidate for the proposed treatment. ", "id": "c13fa79170ca4e819208f6f614965e16", "question": "What is the background context in this case summary?", "title": "c13fa79170ca4e819208f6f614965e16", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis."], "answer_start": [0]}, "context": "A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis.  Findings:  The physician reviewer found that the literature supports the effectiveness of manual therapy and spinal manipulative therapy for the management of chronic neck pain (Hurwitz, et al.). In addition, Wolsko and colleagues concluded that chiropractic techniques are commonly applied for the treatment of neck pain, and have been rated very helpful by patients. Moreover, Bronfort and colleagues reported positive outcomes with spinal manipulative therapy and mobilization for the management of low back pain. ", "id": "ec1dda2c01724a0bbde3f14f7b651313", "question": "What is the background context in this case summary?", "title": "ec1dda2c01724a0bbde3f14f7b651313", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency.", "the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm", "The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight."], "answer_start": [0, 331, 435]}, "context": "The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patients projected adult height could approximate six feet according to the Greulich and Pyle Hand Atlas Table. However, the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm, which is subnormal. The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight. Relative obesity is also associated with blunted GH responses, especially in a patient who is insulin-resistant. Based on the evidence provided, this is a patient who has markedly delayed puberty who appears to be destined to reach a normal adult height (given the heights of his parents). The objective documentation does not does not provide confirmatory evidence of the stated low growth rate of 1.2 cm per year. In this case, there is no documented evidence over time of an abnormally low growth rate; a valid growth rate requires height measurements of six to twelve months in duration, and not over a lesser period of time. The submitted records in this patients case do not support the medical necessity of Nutropin AQ.", "id": "3f9179352a694d4f8802d1f7be4d3eaa", "question": "What is the background context in this case summary?", "title": "3f9179352a694d4f8802d1f7be4d3eaa", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus."], "answer_start": [0]}, "context": "The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus. Findings:  Two physician reviewers found that Subtalar arthroereisis has proven efficacy in the treatment of pediatric flatfoot with overpronation syndrome. One of the major benefits of the procedure is that it is minimally invasive and reversible. A study by Forg and colleagues reported on the use of the Smith subtalar arthroereisis implant (STA-peg) to correct severe collapsing pes valgoplanus in children. Twenty-one patients with a total of 40 STA-peg procedures were evaluated subjectively and objectively. The average age at the time of surgery was 9.7 years (4 to 16 years). The follow-up period averaged 36 months (12 to 90 months). The authors concluded that subjective, objective, and radiographic results were positive and the complication rate was low. ", "id": "0ddc68c5dba74b7a9c36d41b56abae25", "question": "What is the background context in this case summary?", "title": "0ddc68c5dba74b7a9c36d41b56abae25", "sufficiency_score": 3}
+{"answers": {"text": ["A 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches."], "answer_start": [0]}, "context": "A 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches. Findings:  Three physician reviewers found that the medical literature indicates that cervical discography is of equivocal help in terms of identifying a pain generator and predicting results from surgery. However, in this case, the patients history of chronic neck pain as well as associated fibromyalgia and multilevel degenerative findings on MRI are key factors. Regardless of the outcome of the multilevel discogram, this patient would be a poor candidate for cervical surgery.  Confirming a pain generator is particularly challenging given the comorbid diagnoses of fibromyalgia and chronic pain. For these reasons, the medical literature does not demonstrate that discography was indicated in this case, as it would not have been likely to alter the treatment plan", "id": "8a0e0a9a0aef4d7192a13369ff47202f", "question": "What is the background context in this case summary?", "title": "8a0e0a9a0aef4d7192a13369ff47202f", "sufficiency_score": 3}
+{"answers": {"text": ["A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer."], "answer_start": [0]}, "context": "A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer. Findings:  The physician reviewer found that the medical literature does not support the clinical benefit of the administration of radiation to grossly positive lymph node metastatic disease after treatment with chemotherapy and hormone ablation. Radiation, specifically IMRT, for the treatment of metastatic adenocarcinoma in retroperitoneal lymph nodes is of unproven efficacy and not medically necessary in this setting. The standard of care remains chemotherapy or hormone ablation. For this patient, with metastatic disease, the requested local treatment is not likely to provide positive results and remains unproven in the medical literature. ", "id": "6f96b57654d44c5a955c77af8a4f48b5", "question": "What is the background context in this case summary?", "title": "6f96b57654d44c5a955c77af8a4f48b5", "sufficiency_score": 3}
+{"answers": {"text": ["A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity."], "answer_start": [0]}, "context": "A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients records do not document a complication of the Roux-en-Y gastric bypass procedure. In addition, the patient admits to emotional eating since the Roux-en-Y procedure and a laparoscopic gastric band placed over the bypass will not necessarily prevent such cravings. Given the patients small pouch and lack of documented follow-up, aggressive dietary and behavioral counseling with exercise would be the next appropriate step in this setting. At this time, there is a paucity of studies regarding the long-term (greater than two years) outcome of patients who have undergone revision of previous gastric bypass. Thus, the proposed procedure remains of questionable efficacy and is indicated to remedy an anatomical failure of the previous surgery. In this case, anatomical failure is not demonstrated by the records provided.", "id": "2b451f08762547f4827fe2024ed54651", "question": "What is the background context in this case summary?", "title": "2b451f08762547f4827fe2024ed54651", "sufficiency_score": 3}
+{"answers": {"text": ["A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B.", "This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009."], "answer_start": [0, 181]}, "context": "A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B. Findings:  The physician reviewer found that This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009. Most primary care physicians are not familiar with the guidelines for the treatment of hepatitis B. The expertise and experience of gastroenterologists and hepatologists are needed for monitoring patients with hepatitis B. These specialists are familiar with antiviral therapy for hepatitis B, including the efficacy, resistance profile and stopping rules. These specialists also have the required expertise for monitoring for viral breakthrough and surveillance for hepatocellular carcinoma. Follow-up care with the patients gastroenterologist is medically appropriate and indicated.", "id": "8a00fc0ede3e41908859bbe17557d796", "question": "What is the background context in this case summary?", "title": "8a00fc0ede3e41908859bbe17557d796", "sufficiency_score": 4}
+{"answers": {"text": ["A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence.", "the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement."], "answer_start": [0, 609]}, "context": "A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical documentation does not demonstrate the medical necessity for continued acute inpatient/detoxification treatment. There is no report of a physical examination or vital signs documenting that the patient was unstable from a medical standpoint as of the last authorized date of service. In addition, although the records provide limited details regarding the detoxification protocol, it appears the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement. Thus, the submitted evidence does not establish that the patient was experiencing significant withdrawal symptoms during the period in question such that continued acute inpatient/detoxification services were required.", "id": "a9c3edc9e56f452582db0b830fd9b887", "question": "What is the background context in this case summary?", "title": "a9c3edc9e56f452582db0b830fd9b887", "sufficiency_score": 4}
+{"answers": {"text": ["A 58-year-old female has requested speech therapy for the treatment of her habit cough.", "this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation.", "her main complaint is the chronic cough", "Endoscopy showed significant plica ventricularis"], "answer_start": [0, 133, 255, 400]}, "context": "A 58-year-old female has requested speech therapy for the treatment of her habit cough. Findings:  The physician reviewer found that this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation. Although her main complaint is the chronic cough, her history and examination show evidence of vocal straining with use of the false cords for phonation. Endoscopy showed significant plica ventricularis, which is a laryngeal function disorder caused by phonation of the ventricular folds (false folds) rather than the true vocal folds. The patients condition traditionally is responsive to speech therapy.  Given the patients laryngeal dysfunction, speech therapy is medically indicated and appropriate.", "id": "1b067b04bb1e4d6286c71784becc120b", "question": "What is the background context in this case summary?", "title": "1b067b04bb1e4d6286c71784becc120b", "sufficiency_score": 4}
+{"answers": {"text": ["A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems.", "during her stay, several psychotropic medication adjustments were required.", "she was also highly anxious with nightmares and insomnia."], "answer_start": [0, 180, 371]}, "context": "A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that during her stay, several psychotropic medication adjustments were required. The overall medical documentation supports the level of care provided. The patient remained at risk for self harm, she was also highly anxious with nightmares and insomnia. The services provided are consistent with the recommendations of the American Psychiatric Association (APA), the level of care guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP) and the Association of Community Psychiatrists.", "id": "53fbf72d15c0449992072065bbe8d846", "question": "What is the background context in this case summary?", "title": "53fbf72d15c0449992072065bbe8d846", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation."], "answer_start": [0]}, "context": "A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation.  Findings:  Three physician reviewers found that guidelines from the American College of Cardiology (ACC) in 2006 regarding the recommended treatment of PAF. The decision to anticoagulate the patient with aspirin versus Coumadin is typically made by assessing her risk factors such as age, valvular disease or CAD. Real time telemetry has not been shown to change the assessment of the need for anticoagulation. Electrocardiogram monitoring has been recommended in the assessment episodes of asymptomatic PAF or to judge the adequacy of rate control. However, the guidelines do not, as of yet, recommend a real time component to the monitoring. Prolonged or frequent monitoring may be necessary to reveal episodes of asymptomatic atrial fibrillation (AF), which may be a cause of cryptogenic stroke. Ambulatory ECG (i.e., Holter) monitoring is also useful to judge the adequacy of rate control. This technology may provide valuable information to guide drug dosage for rate control or rhythm management.", "id": "2c61a43037c14fd8a9a2270d03757f9b", "question": "What is the background context in this case summary?", "title": "2c61a43037c14fd8a9a2270d03757f9b", "sufficiency_score": 3}
+{"answers": {"text": ["A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain."], "answer_start": [0]}, "context": "A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain. Findings:  The physician reviewer found that there is insufficient evidence in the literature to support the benefit of the prescribed program of computer-assisted exercise over standard physical therapy for chronic low back pain. In contrast, standard physical therapy including strengthening and stretching exercise, modalities, and transition to a home exercise program is more consistent with standard clinical practice, and as the literature suggests, may result in greater improvement in symptoms. The evidence does not demonstrate that computer-assisted exercise results in any added benefit over standard physical therapy for the treatment of low back pain.", "id": "e0d42b3adabb45e58a96474270efd73c", "question": "What is the background context in this case summary?", "title": "e0d42b3adabb45e58a96474270efd73c", "sufficiency_score": 2}
+{"answers": {"text": ["The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder.", "A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills."], "answer_start": [0, 266]}, "context": "The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patients language development appears normal. A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills. The submitted clinical documentation does not demonstrate that the patient had deficits in speech and language which necessitated speech therapy.", "id": "714dc5707b9d4e969f9c555398926606", "question": "What is the background context in this case summary?", "title": "714dc5707b9d4e969f9c555398926606", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy."], "answer_start": [0]}, "context": "The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy. Findings:  The physician reviewer found that this non-ambulatory patient will likely remain non-ambulatory and will require supportive wheelchairs throughout his lifetime. The  literature also shows that transportation load is non-variable and a constant, nearly daily need for children with cerebral palsy. The literature also notes that transportation safety depends on adequate restraints and support which would require an ultra-light wheelchair to have the supportive system recommended by the patients physical therapist.", "id": "4a8bd6d56c874253b496e04c3816db44", "question": "What is the background context in this case summary?", "title": "4a8bd6d56c874253b496e04c3816db44", "sufficiency_score": 3}
+{"answers": {"text": ["A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression."], "answer_start": [0]}, "context": "A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression.  Findings:  Two physician reviewers found that the proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. They analyzed 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System) by a single satisfactory diagnosis. A rigid selection protocol was used including: 1) satisfactory diagnosis of the pathologic process resulting in pain; 2) corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, (i.e., vascular peripheral nerve, spine); 3) lack of satisfactory response to non-interventional pain management modalities by an interdisciplinary pain clinic; and 4) independent psychological evaluation, including a structured interview was performed by a psychologist specializing in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one patient with cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trials (3 cervical and 21 thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continued to use the stimulator. The same number would choose to receive an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography were documented in the patients with RSD. They concluded that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.", "id": "08c6e79b26ff42d1af73b65f62553684", "question": "What is the background context in this case summary?", "title": "08c6e79b26ff42d1af73b65f62553684", "sufficiency_score": 3}
+{"answers": {"text": ["A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis.", "The plastic surgeons consultation note describes problems with intertrigo", "The patient has been treated by a chiropractor"], "answer_start": [0, 1462, 2040]}, "context": "A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While the patient has evidence of breast ptosis, this is a natural consequence of weight loss and aging. There is no evidence that the ptosis is secondary to macromastia. As such, the patient does not have an abnormal structure of the body. In the absence of evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, this patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Based on her photographs, this patient does not have heavy breasts. Rather, she has involutional ptosis from her weight loss. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well-established, the medical literature provides no evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The plastic surgeons consultation note describes problems with intertrigo, but the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or, despite initial response, have recurred and caused significant functional impairment. Likewise, the records do not include any office notes that document long-standing musculoskeletal symptoms that have failed to respond to conservative treatments. The patient has been treated by a chiropractor, but office notes are not submitted that document the indications and response to treatment. Irrespective of whether the patient has musculoskeletal symptoms, there is no scientific evidence that the proposed treatment will be effective for her complaints. Bilateral mastopexy is not medically necessary for this patient.", "id": "3f51ae3b8020419e9b866d7b98bb87d7", "question": "What is the background context in this case summary?", "title": "3f51ae3b8020419e9b866d7b98bb87d7", "sufficiency_score": 4}
+{"answers": {"text": ["A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer."], "answer_start": [0]}, "context": "A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer. Findings:  The physician reviewer found that chemoembolization is considered a relatively standard treatment for unresectable hepatocellular carcinoma and is endorsed by National Comprehensive Cancer Network Guidelines. Chemoembolization is not curative in this setting, but is used to improve disease control. Typically, if both lobes are involved, the lobes will be treated sequentially. Based upon the evidence provided, the patient was an appropriate candidate for the therapy and its use in this setting was clinically indicated.", "id": "839bdc805e174598ade9cde85d29a251", "question": "What is the background context in this case summary?", "title": "839bdc805e174598ade9cde85d29a251", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware.", "the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation."], "answer_start": [0, 193]}, "context": "A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware. Findings:  The physician reviewer found that the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation. It was imperative that pain relief was adequate after the patients nerve block wore out and prior to discharge. The acute hospital stay services provided on the dates in question were medically indicated and appropriate for this patients postoperative care.", "id": "5aead131dd4d49fba477526089a2237d", "question": "What is the background context in this case summary?", "title": "5aead131dd4d49fba477526089a2237d", "sufficiency_score": 4}
+{"answers": {"text": ["A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma."], "answer_start": [0]}, "context": "A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that there have been a few trials published documenting some degree of efficacy of the combination of oxaliplatin with gemcitabine in hepatocellular carcinoma. There is one phase II study combining these two drugs with Avastin by Zhu and colleagues. This trial demonstrated only that this combination was tolerable in terms of toxicity, but it was inconclusive as to whether the Avastin actually added significant benefit to the combination of oxaliplatin with gemcitabine. While oxaliplatinum with gemcitabine is of clinical benefit in this setting, Avastin remains unproven for this patients condition. ", "id": "c9d6c8a024c1451ba565017250f5ec5d", "question": "What is the background context in this case summary?", "title": "c9d6c8a024c1451ba565017250f5ec5d", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder.", "The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling."], "answer_start": [0, 210]}, "context": "The parent of a 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling.  Partial hospitalization allows for close monitoring of medication while adjustments occur, and it also allows for intense interventions for impulsivity and aggression and abnormal involuntary movements by a multi-disciplinary team.", "id": "3dc803d100854effb9b950b53c93c126", "question": "What is the background context in this case summary?", "title": "3dc803d100854effb9b950b53c93c126", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition."], "answer_start": [0]}, "context": "A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition. Findings:  The physician reviewer found that this need can be met by taking frequent breaks while driving, or he can recline in a private vehicle being transported by someone else. There is no documentation that the patient has any unusual anatomy or skin breakdown such that he cannot be positioned in a private vehicle. ", "id": "5937a36792ec48188033b3d631d6f49d", "question": "What is the background context in this case summary?", "title": "5937a36792ec48188033b3d631d6f49d", "sufficiency_score": 2}
+{"answers": {"text": ["A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition."], "answer_start": [0]}, "context": "A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition. Findings:  The physician reviewer found that the CPM device is used routinely postoperatively following knee replacement surgery. It has been used extensively for more than twenty years. The equipment is used for one to two weeks postoperatively, and it is sometimes used for knee procedures other than total knee replacement. The CPM device was medically indicated and appropriate for treatment of this patient. ", "id": "2ffb852d34e54f23883bdbc4ec310eaf", "question": "What is the background context in this case summary?", "title": "2ffb852d34e54f23883bdbc4ec310eaf", "sufficiency_score": 2}
+{"answers": {"text": ["A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition.", "His testicular pain had been present for two months.", "the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain."], "answer_start": [0, 598, 660]}, "context": "A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that a patient must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although this patient did report pain, the pain was not acute in onset. His testicular pain had been present for two months. Further, the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain. While his ongoing testicular pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, his symptoms do not meet criteria for an emergency.", "id": "6750d3ea79e741f6a972cee6e00a8944", "question": "What is the background context in this case summary?", "title": "6750d3ea79e741f6a972cee6e00a8944", "sufficiency_score": 4}
+{"answers": {"text": ["A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition."], "answer_start": [0]}, "context": "A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition. Findings:  The physician reviewer found that there is a lack of documentation justifying the MRI scan. There is no orthopedic exam is available to review in order to justify the MRI scan.  The MRI report describes some vague findings with respect to the menisci.  Grade II signal commonly is associated with myxoid degeneration of the meniscus, and there is no unequivocal description of pathology within the knee which even retrospectively could be construed as findings requiring operative intervention or even more conservative management such as lack of weight bearing. ", "id": "9558fb8ec5c149f284c41c08188662d7", "question": "What is the background context in this case summary?", "title": "9558fb8ec5c149f284c41c08188662d7", "sufficiency_score": 2}
+{"answers": {"text": ["The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition."], "answer_start": [0]}, "context": "The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition. Findings:  The physician reviewer found that there was no indication that the patient was profoundly depressed, oppositional, suicidal or homicidal. He was not acting out in an overly aggressive or disturbed manner. ", "id": "96db3cfb22094eeebe9a2a3181b361c2", "question": "What is the background context in this case summary?", "title": "96db3cfb22094eeebe9a2a3181b361c2", "sufficiency_score": 2}
+{"answers": {"text": ["A 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions.", "This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension."], "answer_start": [0, 271]}, "context": "A 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions. Findings:  The physician reviewer found that this patient meets nationally accepted criteria for authorization of bariatric surgery. This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension. The 2004 Bariatric Surgery Consensus Conference statement supports prompt bariatric surgery in this circumstance.  There is documentation that full reversal of diabetes is severely diminished when surgery is delayed.  Further, surgery will improve the patients life expectancy.  Additionally, and quite significantly, non-operative approaches have nearly 100% failure rate in class III obese patients, such as this patient. ", "id": "e3c0ded1b3b0403ca7b828d1ff72172c", "question": "What is the background context in this case summary?", "title": "e3c0ded1b3b0403ca7b828d1ff72172c", "sufficiency_score": 4}
+{"answers": {"text": ["The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches."], "answer_start": [0]}, "context": "The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that Botox is a well-accepted and standard of care medication amongst headache specialists for patients failing multiple medications in multiple classes of prophylactic drugs.", "id": "8cc4761c21cb41af9afeedb3216137bc", "question": "What is the background context in this case summary?", "title": "8cc4761c21cb41af9afeedb3216137bc", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain."], "answer_start": [0]}, "context": "A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain. Findings:  Three physician reviewers found that artificial disc replacement is a unique technique for the surgical treatment of discogenic back pain. However, there is a paucity of controlled studies and clinical trials showing the safety and efficacy of this procedure, particularly as compared to interbody fusion surgery.", "id": "28e7cf30f3a94040abe403746e3d997b", "question": "What is the background context in this case summary?", "title": "28e7cf30f3a94040abe403746e3d997b", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms."], "answer_start": [0]}, "context": "A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms. Findings:  Two physician reviewers found that the use of subcutaneous hormone replacement therapy (HRT) has been reported for many years. Subcutaneous HRT is particularly useful when patients require testosterone supplementation. Subcutaneous testosterone supplementation has been shown to be effective in improving bone density and treating reduced libido and other psychosexual problems. There is no other option currently available (such as transdermal patches) that is as reliable as this method. Transdermal creams and gels cannot be delivered in consistent, accurate doses. Estradiol replacement can be offered simultaneously with subcutaneous testosterone supplementation, providing good benefit and convenience.", "id": "c5c9be3ecccc4094b0ed486d960e05f9", "question": "What is the background context in this case summary?", "title": "c5c9be3ecccc4094b0ed486d960e05f9", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain."], "answer_start": [0]}, "context": "A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain. Findings:  The physician reviewer found that the request for continued manual treatment is consistent with a maintenance program and not a restorative program at this point. As such, additional physical therapy sessions are not clinically indicated. ", "id": "a71eeb0c33ba4e15a654ef0013053b7a", "question": "What is the background context in this case summary?", "title": "a71eeb0c33ba4e15a654ef0013053b7a", "sufficiency_score": 3}
+{"answers": {"text": ["A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma."], "answer_start": [0]}, "context": "A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma. Findings:  Two physician reviewers found that avastin appears active in glioblastoma when combined with chemotherapy and continues to be used in randomized trials to evaluate its efficacy in this population. A phase II trial of Avastin and CPT-11 showed a 63% radiographic response rate with 72% progression-free survival at six months. In this study, all 32 patients had progressed despite radiation therapy and Temodar. In another retrospective study, chemotherapy (carbo/etoposide/or CPT-11) was used with radiation therapy with a report of responses in 7 of 14 patients treated this way.", "id": "2c00d027fc1848e9830b36b088518614", "question": "What is the background context in this case summary?", "title": "2c00d027fc1848e9830b36b088518614", "sufficiency_score": 3}
+{"answers": {"text": ["A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.", "When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta"], "answer_start": [0, 238]}, "context": "A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.  Findings:  The physician reviewer found that the best measure of good diabetic control is currently a hemoglobin A1C of less than 6.5%. When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta; suggesting his glycemic control is dependent on other factors such as diet and exercise. Research has not yet determined the incremental benefit of improving postprandial blood glucose levels when the hemoglobin A1C is already at over below goal. ", "id": "5b964d3bf6634f728a0d972f9903995f", "question": "What is the background context in this case summary?", "title": "5b964d3bf6634f728a0d972f9903995f", "sufficiency_score": 4}
+{"answers": {"text": ["A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan."], "answer_start": [0]}, "context": "A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan.Findings:  Two physician reviewers found that the use of PET scans in the evaluation of large-cell lymphoma is endorsed by National Comprehensive Cancer Network (NCCN) guidelines and by the International Working Group (IWG). PET scans are recommended as baseline evaluations. If they are positive at baseline, they should be performed in follow-up. According to the IWG, PET is essential for post treatment follow-up of diffuse large B-cell lymphoma. PET scans are considered standard of care in this setting. ", "id": "59004576acf34d09a2687c5cfba8f820", "question": "What is the background context in this case summary?", "title": "59004576acf34d09a2687c5cfba8f820", "sufficiency_score": 3}
+{"answers": {"text": ["A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus.", "This patients blood glucose is under excellent control. She was", "begun on Byetta to help her lose additional weight"], "answer_start": [0, 395, 470]}, "context": "A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin, sulfonylureas, or thiazolidinediones, alone or in combination, but have not achieved adequate control. This patients blood glucose is under excellent control. She was apparently begun on Byetta to help her lose additional weight which is not the intended purpose of the medication. ", "id": "08a99ce1e66e4187879316cf2958c26c", "question": "What is the background context in this case summary?", "title": "08a99ce1e66e4187879316cf2958c26c", "sufficiency_score": 4}
+{"answers": {"text": ["A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain.", "the patient has been diagnosed with cervical dystonia"], "answer_start": [0, 163]}, "context": "A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain. Findings:  The physician reviewer found that the patient has been diagnosed with cervical dystonia and is being treated appropriately. Lyrica is not indicated for the pain associated with cervical dystonia. This residual pain is likely to respond to any of a number of interventions including more aggressive Botox therapy, muscle relaxants, Gabapentin or Amitriptyline. The use of Lyrica for this patient would not be considered the standard of care. ", "id": "69f0ea6f3b1544359c6891eecf89e7d7", "question": "What is the background context in this case summary?", "title": "69f0ea6f3b1544359c6891eecf89e7d7", "sufficiency_score": 3}
+{"answers": {"text": ["A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain.", "standard measures have not adequately addressed the patients  severe, on-going pain."], "answer_start": [0, 225]}, "context": "A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain. Findings:  The physician reviewer found that it is clear from the clinical record that standard measures have not adequately addressed the patients  severe, on-going pain. It is also clear that surgical correction of the lumbar radiculopathy or the carpal tunnel syndrome is not feasible because of other complicating medical problems. This is not a situation where high-potency narcotics are being utilized as an off-label substitute for more definitive measures to resolve the pain. Rather, this is a case in which the best available means of pain management has been employed and found to be effective. ", "id": "da53eb86304c4bd6afb20e1b0074e93a", "question": "What is the background context in this case summary?", "title": "da53eb86304c4bd6afb20e1b0074e93a", "sufficiency_score": 4}
+{"answers": {"text": ["A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer."], "answer_start": [0]}, "context": "A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX assay has been found to be reliable in predicting the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. It has only been validated in node-negative, estrogen receptor positive cancers. It is very difficult to make recommendations about adding adjuvant chemotherapy for this particular group of women. Not only does the Oncotype assay reliably predict the risk of recurrence without chemoterapy, it has also been found to predict the value of chemotherapy. Oncotype DX is widely accepted and has virtually become standard of care for many oncologists. This diagnostic procedure has clearly established clinical value ", "id": "195f93b7792d48ea808154c776fa0e10", "question": "What is the background context in this case summary?", "title": "195f93b7792d48ea808154c776fa0e10", "sufficiency_score": 3}
+{"answers": {"text": ["A 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation."], "answer_start": [0]}, "context": "A 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation. Findings:  The physician reviewer found that postoperative cold therapy is utilized by some orthopedists for managing pain and inflammation. However, use of cold therapy units has not been shown in long-term peer-reviewed literature to offer superiority over the traditional use of ice. The units studied have not been proven to significantly lower the intra-articular temperature of the knee. There is no study literature indicating that use of this device itself would decrease a patients hospital stay or shorten the rehabilitation period.  Appropriate monitoring of the application of ice packs eliminates the concern for skin or tissue break down.", "id": "288e22f55f42422fa642c2ad5c376910", "question": "What is the background context in this case summary?", "title": "288e22f55f42422fa642c2ad5c376910", "sufficiency_score": 3}
+{"answers": {"text": ["A 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma.", "the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant", "no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma."], "answer_start": [0, 216, 493]}, "context": "A 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma. Findings:  Two physician reviewers found that the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant, which can be performed with curative intent for myeloma. Thus, no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma. Given this patients age and prognosis, the proposed clinical trial is likely to be his best opportunity for disease control/eradication under these clinical circumstances. The proposed post-transplant randomization does not compromise the standard of care, and appears to be testing the role of a drug known to be active in this clinical setting. ", "id": "4e39b41a88094ea8b3f46229812b437f", "question": "What is the background context in this case summary?", "title": "4e39b41a88094ea8b3f46229812b437f", "sufficiency_score": 4}
+{"answers": {"text": ["The parents of a seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab)."], "answer_start": [0]}, "context": "The parents of a seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab).  Reviewers Findings:  The reviewing physician found that RSV infection has been associated with tachyarrhythmias including SVT that may be hemodynamically significant in infants such as this one.  The reviewing physician found that the Health Plan denial should be overturned.  ", "id": "2647ff8ac0fd46e687965265f3199d03", "question": "What is the background context in this case summary?", "title": "2647ff8ac0fd46e687965265f3199d03", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy."], "answer_start": [0]}, "context": "The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that a review of the recent peer-reviewed literature indicates that MEG and magnetic source imaging can play an important role in epilepsy mapping. While the procedures are not widely used, their use in select patients with intractable seizure activity has allowed physicians to determine if a patient is appropriate for epilepsy surgery and to provide detailed mapping for pre-surgical planning. In the past, the gold standard for epilepsy mapping was the use of intracranial electrodes. There is risk associated with any surgical procedure and  particularly with brain surgery. MEG is a safer, non-invasive means of obtaining the same information as would be obtained from intracranial EEG (ICEEG). ", "id": "c101a198fe564524893f3f12964946ba", "question": "What is the background context in this case summary?", "title": "c101a198fe564524893f3f12964946ba", "sufficiency_score": 3}
+{"answers": {"text": ["A forty-three year-old female with severe urticaria is requesting authorization of Xolair."], "answer_start": [0]}, "context": "A forty-three year-old female with severe urticaria is requesting authorization of Xolair.Reviewers Findings:  The reviewing physician found that the FDA approved indication for Xolair is moderate to severe persistent asthma in patients who have: a positive skin test or in vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and pre-treatment total IgE levels of 30 or greater. The submitted records document the patient does meet the criteria. The reviewing physician found that the Health Plan denial should be upheld.  ", "id": "eeb8cb98f1da4f06a384f7ec6c42c5c5", "question": "What is the background context in this case summary?", "title": "eeb8cb98f1da4f06a384f7ec6c42c5c5", "sufficiency_score": 3}
+{"answers": {"text": ["The parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy."], "answer_start": [0]}, "context": "The parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy.  Reviewers Findings:  The reviewing physician found that the relevant literature concerning MR spectroscopy shows there is insufficient proof of its value in this clinical setting at this time.  The reviewing physician found that the Health Plan denial should be upheld.   ", "id": "8d0fd266cfde4ad59ad8a5f3fbde48f1", "question": "What is the background context in this case summary?", "title": "8d0fd266cfde4ad59ad8a5f3fbde48f1", "sufficiency_score": 3}
+{"answers": {"text": ["A twenty-five year-old female with a history of bulimia nervosa is requesting reimbursement for residential treatment services."], "answer_start": [0]}, "context": "A twenty-five year-old female with a history of bulimia nervosa is requesting reimbursement for residential treatment services.Reviewers Findings:The reviewing physician found that the patient appears to have been greatly compromised by her eating disorder.  The reviewing physician found that the Health Plan denial should be overturned.   ", "id": "c43577d6020640b58163d0f3b9e14fd8", "question": "What is the background context in this case summary?", "title": "c43577d6020640b58163d0f3b9e14fd8", "sufficiency_score": 3}
+{"answers": {"text": ["A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor."], "answer_start": [0]}, "context": "A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor.  Findings:  Three physician reviewers found that Desmoid tumor (aggressive fibromatosis) can be a recurrent, though not metastatic, form of neoplasia. Standard chemotherapy has rarely been of much value. Gleevec, which is approved for use in chronic myelogenous leukemia and gastrointestinal stromal tumors, has indeed been reported to have some efficacy in desmoid tumors. There are multiple papers documenting this as cited above. Because of the rarity of desmoid tumor, Gleevec will probably never be approved for treatment of this condition. However, there is enough data to believe it is more likely to be effective than any of the more conventional forms of chemotherapy than might be offered.", "id": "4d65b954891c4f18b4bc0c8a4bf12118", "question": "What is the background context in this case summary?", "title": "4d65b954891c4f18b4bc0c8a4bf12118", "sufficiency_score": 3}
+{"answers": {"text": ["A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram."], "answer_start": [0]}, "context": "A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram.Reviewers FindingsAfter reviewing the requests, two of the three physicians found the electrogastrogram was not likely to be more beneficial for evaluation. Two of the three physicians found that antroduodenal motility/manometry studies were likely to be more beneficial for evaluation.  The reviewing physicians found the Health Plan denial should be partially overturned.  ", "id": "6dcad277b54444218e831f1f7bca022c", "question": "What is the background context in this case summary?", "title": "6dcad277b54444218e831f1f7bca022c", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device."], "answer_start": [0]}, "context": "The patient is a 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device.The use of a bone growth stimulator in this case was medically reasonable and acceptable. If the bone growth stimulator was effective, the patients pain would have diminished and her condition would have improved without the need for invasive treatment (i.e., surgery). Unfortunately, in this case union was not achieved and surgery was required. However, since the bone growth stimulator provided the potential of preventing the patient from having surgery, its use was clinically appropriate. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.", "id": "9803c3018294431d9c8a52ff5e2ef825", "question": "What is the background context in this case summary?", "title": "9803c3018294431d9c8a52ff5e2ef825", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary."], "answer_start": [0]}, "context": "The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful post-operatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the cold therapy unit following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "025a54d01ca5456d82f48be9ec1eff0c", "question": "What is the background context in this case summary?", "title": "025a54d01ca5456d82f48be9ec1eff0c", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 53-year-old woman who reports a six-year history of gastrointestinal problems. She states that she became ill in December 2000 after eating watercress and drinking water from a stream. She reports multiple problems including irritable bowel syndrome, constipation, gas and abdominal bloating. The patient also experiences extreme fatigue, concentration problems, and short-term memory loss. She wishes to undergo further workup with an Intestinal Permeability and Comprehensive Digestive Stool Analysis. The Health Plan indicates the proposed testing is not medically necessary for evaluation of the patients condition.", "she has undergone a thorough workup with evaluations by multiple specialists."], "answer_start": [0, 731]}, "context": "The patient is a 53-year-old woman who reports a six-year history of gastrointestinal problems. She states that she became ill in December 2000 after eating watercress and drinking water from a stream. She reports multiple problems including irritable bowel syndrome, constipation, gas and abdominal bloating. The patient also experiences extreme fatigue, concentration problems, and short-term memory loss. She wishes to undergo further workup with an Intestinal Permeability and Comprehensive Digestive Stool Analysis. The Health Plan indicates the proposed testing is not medically necessary for evaluation of the patients condition.The Health Plans denial is correct. The patient has vague and generalized symptoms. It appears she has undergone a thorough workup with evaluations by multiple specialists. The use of the proposed intestinal permeability test in this patient is not within the community standard of care. The requested testing is not likely to add clinically useful information for the care and management of this patient. Therefore, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.", "id": "e14299293bf745beb1f03b79fb5c675c", "question": "What is the background context in this case summary?", "title": "e14299293bf745beb1f03b79fb5c675c", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet.", "The patient reports GERD as a comorbid condition."], "answer_start": [0, 1602]}, "context": "The patient is a 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet. Review of the clinical evidence indicates the patients two previous weight loss surgical procedures were unsuccessful. The patients first procedure, the Lap-band, has a significant published rate of solid intolerance, nausea and vomiting associated with the procedure. After the gastric band was removed the patient underwent gastric bypass, also without success. The scientific data shows duodenal switch has the best long-term success of all weight loss surgical procedures. There is one peer-reviewed, published article that reports the outcome of patients with multiple weight loss surgical procedures. This article not only demonstrates the superior long-term outcome of the duodenal switch as a revisional operation, but also shows that patients with multiple previous restrictive operations (Lap-band, gastric bypass, etc.) will fail any other revision unless they have an operation that limits absorption as well.  The patient reports GERD as a comorbid condition. If her gastrojejunostomy anastomosis is reduced from 2.5 cm to 1.5 cm as proposed by her surgeon, it is likely the patients reflux disease will significantly worsen. Thus, although the patient meets criteria for a revisional weight loss procedure, the proposed procedure is not likely to result in adequate weight loss and will probably worsen her reflux disease. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.", "id": "64eacbd87bb84a919eecf5d86a4c207c", "question": "What is the background context in this case summary?", "title": "64eacbd87bb84a919eecf5d86a4c207c", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery."], "answer_start": [0]}, "context": "The patient is a 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery. There is no evidence that the patient has undergone a psychological evaluation to determine whether she is considered an appropriate candidate for weight loss surgery.With a BMI of 43 and comorbid conditions such as diabetes the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for weight loss surgery. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the requested procedure should not be authorized.", "id": "28401d0d26e442a881f009184957cd36", "question": "What is the background context in this case summary?", "title": "28401d0d26e442a881f009184957cd36", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary."], "answer_start": [0]}, "context": "The patient is a 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary.The patient does meet the clinical criteria for evaluation of a possible sleep disorder by polysomnography. However, an overnight stay in a hospital is not necessary if the option of an adequate home sleep study is available for diagnosis.  The home sleep study should include the monitoring of at least four parameters, not simply pulse oximetry or airflow.  If the patient needs support to ensure that the study is performed correctly, an attendant should be provided to assist with the setup of the equipment and possible monitoring.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.", "id": "1e8aadebebaa4ec78ae4916dffc5fed5", "question": "What is the background context in this case summary?", "title": "1e8aadebebaa4ec78ae4916dffc5fed5", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004.", "the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition."], "answer_start": [0, 609]}, "context": "The patient is a 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004. Based upon the information provided, it appears the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence demonstrates the patient meets medical necessity criteria for growth hormone therapy. In accordance with the AACE Medical Guidelines for growth hormone therapy, the therapy is medically necessary for patients such as this patient who was a small for gestational age infant who has not caught up, and is falling further from normal percentiles, and/or has idiopathic short stature and is not projected to achieve an adult height in the normal range and is under the care of a pediatric endocrinologist. The problem is however that the patients remaining growing time is very short and it is not known to what extent such therapy will be beneficial. Therefore, growth intervals should be obtained on a regular basis (every three months) to document that the patient is continuing to grow. In addition, a knee x-ray would be helpful to show the state of the epiphyses in the knee. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.", "id": "3717f47cc7a14ad8aaf8e985b91453cb", "question": "What is the background context in this case summary?", "title": "3717f47cc7a14ad8aaf8e985b91453cb", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain."], "answer_start": [0]}, "context": "The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain.The Health Plans denial should be upheld. The amount of OxyContin the patient is requesting is well beyond the standard of care in pain management medicine, even in extreme cases. The requested prescription is excessive and not medically appropriate. The patient should pursue alternative forms of pain management in addition to narcotic management in order to allow for a decrease in his current level of OxyContin. Accordingly, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.", "id": "300cb3da9f0549cb983bff8148bc5809", "question": "What is the background context in this case summary?", "title": "300cb3da9f0549cb983bff8148bc5809", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care.", "The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.", "In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.", "after the second chiropractic reassessment, she was on a supportive treating schedule."], "answer_start": [0, 286, 782, 1071]}, "context": "The patient is a 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care. The submitted records do not include detailed outcome assessments made by her provider.  The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.   A diagnosis of cervicogenic headache is one that is often treated successfully with chiropractic care.  Head pain can be a quality of life issue for the patient and it can be difficult for a clinician to achieve and maintain the desired results. Often, co-management is a better approach.  In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.  This patients condition however, is chronic and after the second chiropractic reassessment, she was on a supportive treating schedule. There is no documentation of objective outcome measures being consistently monitored to determine the patients progress. In the absence of such documentation, medical necessity for continued chiropractic care has not been established.The Health Plans alternative recommendation for orthopedic consultation, pain management evaluation and assessment of work and lifestyle for contributing factors is reasonable and those services should be made available to the patient.  Should that approach fail, the patients request for additional chiropractic care should be reconsidered.Based upon the information set forth above, I have determined the requested chiropractic care is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.", "id": "816e3396ef254e36a94c3a14398ade3e", "question": "What is the background context in this case summary?", "title": "816e3396ef254e36a94c3a14398ade3e", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response."], "answer_start": [0]}, "context": "The patient is a 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response. Although Tarcevas current indication is for second line treatment, it is another EGFR-targeted treatment that is routinely being used for subsets of patients with a high likelihood of benefit.  This patients response to Iressa indicates the expected benefit of Tarceva is far greater than that of a platinum-based chemotherapy.  The Health Plans guidelines would require a failed trial of platinum-based chemotherapy before the patient could continue with Tarceva, the treatment most likely to produce a positive result. Uninterrupted treatment with Tarceva is a more prudent course of treatment for this patient.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.", "id": "feb93e09a7d74d53bd80e576870cb314", "question": "What is the background context in this case summary?", "title": "feb93e09a7d74d53bd80e576870cb314", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition."], "answer_start": [0]}, "context": "The patient is a 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition.Because of the patients poor response to prescribed medications and her more favorable response to acupuncture treatment, continued acupuncture is more appropriate for treatment of the patients medical condition than pharmacotherapy. Since the patients symptoms appear to worsen during her menstrual period, one or two acupuncture treatments at that time are indicated for relief of migraines associated with her period. In addition, the patient should continue her exercise program and improved eating habits. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.", "id": "75dae3a9d95f4728950f85163f5a7c0e", "question": "What is the background context in this case summary?", "title": "75dae3a9d95f4728950f85163f5a7c0e", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition."], "answer_start": [0]}, "context": "The patient is a 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned. ", "id": "67e5c408bd7545339e0e02d66ddd5a47", "question": "What is the background context in this case summary?", "title": "67e5c408bd7545339e0e02d66ddd5a47", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition."], "answer_start": [0]}, "context": "The patient is a 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition.There are several indications for MRI of the breast, which include pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants.Since this patient had a relatively recent mammogram, ultrasound, ultrasound-guided biopsy, and excisional biopsy of the left breast, a new malignancy in the breast would be very unlikely. A repeat left breast mammogram and ultrasound and follow-up clinical exam would have been appropriate before considering MRI and possibly another biopsy. Given the specifics of this case, an MRI was not medically warranted for this patient.Based upon the information set forth above, I have determined that the MRI at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.", "id": "13e2a994378d41d2a3324f5bb1966930", "question": "What is the background context in this case summary?", "title": "13e2a994378d41d2a3324f5bb1966930", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary."], "answer_start": [0]}, "context": "The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary.The submitted photocopies of photographs are of poor quality. Therefore, it is not possible to confirm that the patients breast size results in medical complications. Furthermore, the submitted consultation notes are insufficient to support medical necessity for breast reduction surgery. As such, it has not been established the requested procedure is medically warranted at this time. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.", "id": "e9044ac870804d1cbb26012c69d220ae", "question": "What is the background context in this case summary?", "title": "e9044ac870804d1cbb26012c69d220ae", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary."], "answer_start": [0]}, "context": "The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary.Although the patient had symptoms consistent with active suicidality upon admission, these symptoms were most likely precipitated or exacerbated by active alcohol intoxication. There is scant evidence in the medical record to suggest ongoing suicidality. It would have been medically reasonable and appropriate to transfer the patient to partial hospitalization or outpatient chemical dependency program, at which point the patient was stable. There is no evidence of acute alcohol withdrawal symptoms at the time of admission. Detoxification was optimal and certainly could have been completed. Therefore, I have determined that inpatient psychiatric treatment services were medically necessary. The Health Plans denial should be partially overturned. ", "id": "e77b3f1842354d568e1aee88f6ab7e48", "question": "What is the background context in this case summary?", "title": "e77b3f1842354d568e1aee88f6ab7e48", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition."], "answer_start": [0]}, "context": "The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition.According to the California Department of Consumer Affairs, Acupuncture Board, the National Institutes of Health, and the World Health Organization, acupuncture is an acceptable and appropriate treatment for this patients condition. Acupuncture is commonly utilized to treat allergies/asthma, migraine headache, rhinitis, and sinusitis. There are controlled trials demonstrating acupuncture is an effective treatment for allergic rhinitis. Standard treatment for this patient would be acupuncture twice weekly for three to four weeks followed by evaluation to determine if further treatment is indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.", "id": "ed06db9efb424cd7b53e2460ea85dce0", "question": "What is the background context in this case summary?", "title": "ed06db9efb424cd7b53e2460ea85dce0", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction."], "answer_start": [0]}, "context": "The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction. The cause of erectile dysfunction is irrelevant to the treatment. Regardless of the cause of erectile dysfunction, medications such as Viagra and Levitra are considered first-line therapy. This patient has experienced benefit from Levitra after having failed Viagra. Based upon these results, treatment of the patients erectile dysfunction with Levitra is medically necessary. Therefore, the Health Plans denial should be overturned.", "id": "ea29ed5fe39c4d6c99b6ed8dbd37c1bb", "question": "What is the background context in this case summary?", "title": "ea29ed5fe39c4d6c99b6ed8dbd37c1bb", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.", "The drawing in the ophthalmologists record shows a moderate pinguecula"], "answer_start": [0, 417]}, "context": "The patient is a 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.The clinical evidence does not demonstrate the medical necessity of the requested medication. The submitted photographs do not provide clear or objective evidence of the patients condition. The drawing in the ophthalmologists record shows a moderate pinguecula with only a tiny extension onto the cornea. These are common, benign and virtually never require surgery. If they enlarge and extend onto the cornea, they are classified as pterygium. A decision to proceed with surgery would then be based on the extent to which the pterygium extended into the visual axis. There is no evidence of this in this case. Furthermore, inflamed pinguecula usually respond to topical therapy. There is no evidence this patient has attempted a trial of topical therapy. Moreover, a biopsy would be indicated prior to consideration of surgery after failure of topical therapy. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.", "id": "cb17fb48edef496eb943e801f283b645", "question": "What is the background context in this case summary?", "title": "cb17fb48edef496eb943e801f283b645", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder", "The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.", "the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating."], "answer_start": [0, 144, 1586]}, "context": "The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder, though not bulimia per se. The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.Analysis and Findings:While the patient entered partial hospitalization to better contain her overeating and anxiety, she had a rather protracted course of such treatment for a multitude of problems that are often treated with no more intensive therapy than outpatient care. In any event, the submitted records indicate the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating. There is nothing in the submitted records to indicate the patient warranted partial hospitalization beyond 5/12/04. There is no evidence that as of 5/12/04 the patient was experiencing any particularly acute problems. Outpatient treatment services as recommended by the Health Plan are medically reasonable and appropriate for the ongoing care of this patient. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.", "id": "f7009d866a114214b9f4a07a68221c9a", "question": "What is the background context in this case summary?", "title": "f7009d866a114214b9f4a07a68221c9a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor", "The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition."], "answer_start": [0, 608]}, "context": "The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor but the submitted documentation does not indicate if the exam was performed. The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition.Upon review of the patients records it appears she has made little progress with chiropractic care. Additionally, the submitted records do not demonstrate that other causes for the patients arm complaints have been ruled out or that referrals have been made. Chiropractic care has been given an adequate opportunity to cure or relieve the patients pain. Continued chiropractic care is not likely to be clinically beneficial to this patients current complaints. The patient should receive a referral to her primary care physician for further workup or a referral to rule out other causation or to suggest possible curative care approaches. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.", "id": "fb19938ae8f1488a9115bb6deeb00c59", "question": "What is the background context in this case summary?", "title": "fb19938ae8f1488a9115bb6deeb00c59", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary.", "the patient has had a positive response to Adderall XR", "the patient had significant positive response to immediate release Adderall."], "answer_start": [0, 709, 892]}, "context": "The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary. Though the submitted records indicate the patient has had a positive response to Adderall XR it has not been established that Adderall XR is medically necessary for treatment of the patients ADHD. The records demonstrate the patient had significant positive response to immediate release Adderall. There is no documentation of significant rebound on the immediate release version of Adderall. Furthermore, Adderall XR has not been approved for use in children under the age of six. Moreover, the submitted documentation does not demonstrate the patient has experienced complications that would warrant use of the long-acting version of Adderall. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.", "id": "bb9a249c670a4442ad61120d1e9c1bf1", "question": "What is the background context in this case summary?", "title": "bb9a249c670a4442ad61120d1e9c1bf1", "sufficiency_score": 4}
+{"answers": {"text": ["A 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence."], "answer_start": [0]}, "context": "A 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.", "id": "46c7622eb6d74206b40687bf2a493945", "question": "What is the background context in this case summary?", "title": "46c7622eb6d74206b40687bf2a493945", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old female enrollee requested authorization and coverage of a repeat Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis."], "answer_start": [0]}, "context": "A 57-year-old female enrollee requested authorization and coverage of a repeat Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested Dexa scan is not medically necessary. ", "id": "8e4d47fb6f664c6f91e197fe4f77286f", "question": "What is the background context in this case summary?", "title": "8e4d47fb6f664c6f91e197fe4f77286f", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old female enrollee requested authorization and coverage of an MRI of the left breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of a lump in the enrollees breast."], "answer_start": [0]}, "context": "A 57-year-old female enrollee requested authorization and coverage of an MRI of the left breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of a lump in the enrollees breast.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary. ", "id": "154ce91ff3a84213a3828e1da23da925", "question": "What is the background context in this case summary?", "title": "154ce91ff3a84213a3828e1da23da925", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity."], "answer_start": [0]}, "context": "A 38-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.", "id": "e32f9ac093ee4e7a810b5fc9263c36ae", "question": "What is the background context in this case summary?", "title": "e32f9ac093ee4e7a810b5fc9263c36ae", "sufficiency_score": 3}
+{"answers": {"text": ["A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied this request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid obesity."], "answer_start": [0]}, "context": "A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied this request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary. ", "id": "0172d61f5c3e4b1facc58d001277833c", "question": "What is the background context in this case summary?", "title": "0172d61f5c3e4b1facc58d001277833c", "sufficiency_score": 4}
+{"answers": {"text": ["A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hyperhidrosis."], "answer_start": [0]}, "context": "A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hyperhidrosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.", "id": "fb5667c89c4b41cbbc5b7a9dd669b9c9", "question": "What is the background context in this case summary?", "title": "fb5667c89c4b41cbbc5b7a9dd669b9c9", "sufficiency_score": 3}
+{"answers": {"text": ["A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary."], "answer_start": [0]}, "context": "A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is cosmetic in nature and not medically necessary.", "id": "d0f028f742084126a7c7d3755c45a20f", "question": "What is the background context in this case summary?", "title": "d0f028f742084126a7c7d3755c45a20f", "sufficiency_score": 3}
+{"answers": {"text": ["A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma."], "answer_start": [0]}, "context": "A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.", "id": "73fa4cb0de624e688440d3a5299c1398", "question": "What is the background context in this case summary?", "title": "73fa4cb0de624e688440d3a5299c1398", "sufficiency_score": 3}
+{"answers": {"text": ["A 35-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity."], "answer_start": [0]}, "context": "A 35-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.", "id": "c0388bb6e0c24178a8ff8abb846ee49b", "question": "What is the background context in this case summary?", "title": "c0388bb6e0c24178a8ff8abb846ee49b", "sufficiency_score": 4}
+{"answers": {"text": ["A 31-year-old female has requested reimbursement for lab tests that measure the levels of \nmedication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request \nindicating that the testing at issue was considered investigational for evaluation of the insureds \nulcerative colitis."], "answer_start": [20]}, "context": "Summary Reviewer 3 \nA 31-year-old female has requested reimbursement for lab tests that measure the levels of \nmedication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request \nindicating that the testing at issue was considered investigational for evaluation of the insureds \nulcerative colitis. The physician reviewer found that on review of the current peer-reviewed \nmedical literature, the drug assay testing for ADA performed on 8/1/22 was likely to be more \nbeneficial for the evaluation of this patient than any available standard therapy. The drug testing \nperformed was reactive drug monitoring since the test was recommended in response to the \npatients symptoms of ulcerative colitis. The most recent national guideline from the AGA \nspecifically  endorses  reactive  drug  monitoring  in  this  clinical  setting  when  the  patient  has \nsymptoms while on anti-TNF agents such as ADA (Feuerstein, et al.). The AGA guidelines cite \ndata that has shown that reactive drug monitoring is more beneficial than standard therapy \nincluding  change of  drug therapy without the drug  assay  and  is  supported with  consensus \nagreement among experts (Feuerstein, et al.; Papamichael, et al.). Thus, the lab tests that measure \nthe levels of adalimumab performed on 8/1/22 was likely more beneficial for evaluation of the \npatient than any available standard therapy. \n \n \n ", "id": "760fe71d200e441598b0e3a787d2dae0", "question": "What is the background context in this case summary?", "title": "760fe71d200e441598b0e3a787d2dae0", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that the ExoSym kinetic orthosis is a customizable energy-storing device that is designed to support and protect an array of lower extremity limb injuries. However, at this time, there is a lack of evidence to support that the published results can be duplicated on a reliable basis. Until quality data becomes available, this orthosis does not have adequate support for use outside of a clinical trial. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "09c4135983074cf6a5e565660a187eef", "question": "What is the background context in this case summary?", "title": "09c4135983074cf6a5e565660a187eef", "sufficiency_score": 3}
+{"answers": {"text": ["A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain.", "In this case", "the patient presented with", "pain", "Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder."], "answer_start": [20, 550, 570, 608, 861]}, "context": "Summary Reviewer \n\n\nA 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) state that if manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. In this case, while the patient presented with subjective pain, the provider has not documented clinical assessments and evaluations to support continued treatments. Most importantly, the records do not include discussions on objective functional improvement as an indication for the extended duration of care. Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. Overall, the medical necessity for continued chiropractic care cannot be determined without documentation of objective functional improvement. Therefore, reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "c2679e90bf9e41b4ac3ddde60b41fb30", "question": "What is the background context in this case summary?", "title": "c2679e90bf9e41b4ac3ddde60b41fb30", "sufficiency_score": 4}
+{"answers": {"text": ["A 27-year-old female enrollee has requested authorization and coverage for E1399 durable \nmedical equipment RT300 FES arm therapy system. The Health Insurer has denied this request \nand reported that the requested device is investigational for the treatment of the enrollees \nmedical condition."], "answer_start": [22]}, "context": "Summary Reviewer 2 \n \nA 27-year-old female enrollee has requested authorization and coverage for E1399 durable \nmedical equipment RT300 FES arm therapy system. The Health Insurer has denied this request \nand reported that the requested device is investigational for the treatment of the enrollees \nmedical condition. The physician reviewer found that the E1399 RT300 FES arm therapy system \nis not likely to be more beneficial than other available standard therapy. It is uncertain whether \nFES  can  restore  upper-extremity  function  or  improve  the  quality  of  life.  The  evidence  is \ninsufficient to determine the effects of the technology on health outcomes. The evidence for the \neffectiveness of the RT300 FES cycling in people with stroke is limited. There is insufficient \nevidence in the literature that supports that the use of the RT300 FES will be effective for this \npatients hemiplegia from stroke in long-term improvement of muscle strength, vascular blood \nflow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor \nmovement  or  reduction  muscle  atrophy  in  the  upper  and  lower  extremities.  Eraifej  and \ncolleagues performed a meta-analysis of 20 studies on the benefits of FES on activities of daily \nliving. Only three studies showed a significant benefit of FES on activities of daily living when \ninitiated within two months post-stroke. In three studies where FES was initiated more than one \nyear after stroke, no significant activities of daily living improvements were seen. Limitations of \nthe evaluable studies included, very low quality evidence in all analyses due to heterogeneity,  low participant numbers and lack of blinding. The authors concluded that FES is a promising \ntherapy that could play a part in future stroke rehabilitation. They noted that there is a need for \nhigh quality large-scale randomized controlled trials of upper limb FES after stroke to draw firm \nconclusions regarding its efficacy or its optimum therapeutic window. The evidence that FES \ncycling can have a long-term effect on bone mineral density is not found in the literature. An \nadditional study done on the prevention and treatment of osteoporosis by Soleyman-Jahi and \ncolleagues revealed very low-quality evidence that low-intensity cycling (three days per week) \nwith FES provided a benefit for reducing bone mineral density loss in individuals with chronic \nspinal  cord  injury  or  neurologic  injury.  All  told,  the  current  medical  evidence  has  not \ndemonstrated the superior efficacy of the requested device. Therefore, the requested for E1399 \ndurable medical equipment RT300 FES arm therapy system is not likely to be more beneficial \nthan any available standard therapy. \n \n", "id": "4ef94c51068c44f0ad2ca1ee42c627d3", "question": "What is the background context in this case summary?", "title": "4ef94c51068c44f0ad2ca1ee42c627d3", "sufficiency_score": 2}
+{"answers": {"text": ["A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the American College of Radiology urged tomosynthesis be removed from the investigational category in 2014 due to the advantage it brings radiologists interpreting mammograms especially in patients with dense breasts such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. In this case, the use of tomosynthesis likely aided the radiologist to detect the area of interest in the left breast in this patient with dense breast tissue. Thus, the addition of tomosynthesis was likely of greater benefit to the patient than had her exam been done with 2D imaging alone. For this reason, the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "5fac41aa719b434dac1067eab5d4cc8a", "question": "What is the background context in this case summary?", "title": "5fac41aa719b434dac1067eab5d4cc8a", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 58-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b.  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. \n\n\n\n", "id": "3a5e3ce31c64493c9ee58d0139259556", "question": "What is the background context in this case summary?", "title": "3a5e3ce31c64493c9ee58d0139259556", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.", "this patients family history is suggestive of a breast/ovarian cancer syndrome."], "answer_start": [20, 351]}, "context": "Summary Reviewer 3\n\nA 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 was likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "f0c07ccff90d4fd791e2308e4455d70e", "question": "What is the background context in this case summary?", "title": "f0c07ccff90d4fd791e2308e4455d70e", "sufficiency_score": 3}
+{"answers": {"text": ["A 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical literature supports the use of CT scan in diagnosis and treatment planning in the setting of chronic recurrent rhinosinusitis.  However, it is not within standard of care to repeat a scan in this clinical setting.  There is no medical indication for this patient to have undergone a second CT one month after a prior scan showed lack of disease.  All told, the CT scan of the sinuses performed on 1/12/16 was not medically indicated in this particular situation.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "02084267ed0c4b7ea16953b15e5bcb17", "question": "What is the background context in this case summary?", "title": "02084267ed0c4b7ea16953b15e5bcb17", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that \nthe patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The \npatient has requested authorization and coverage for PBRT. The Health Insurer has denied this \nrequest and reported that the requested service is not medically necessary for the treatment of this \npatient."], "answer_start": [10]}, "context": "Summary  \nThe patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that \nthe patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The \npatient has requested authorization and coverage for PBRT. The Health Insurer has denied this \nrequest and reported that the requested service is not medically necessary for the treatment of this \npatient. This denial is the subject of this appeal and determination. The physician reviewer found \nthat the submitted documentation does not support the medical necessity of the requested service \nProton beam has unique properties compared to standard photon or x-ray beam in its ability to \ndeposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered \nradiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard \nphoton beams. Proton therapy is currently utilized and strongly indicated in settings where severe \ntoxicities would result if normal tissue constraints cannot be met by photon beam. However, in the \nsetting of localized prostate cancer, there has not been a demonstrable clinically significant \nimprovement in either quality of life or reduction of high-grade toxicities. Studies in current \nmedical literature have not demonstrated a significant difference in overall survival nor normal \ntissue toxicities over photon beam in the treatment of prostate cancer. These data question the \nutility of proton beam radiation particularly for patients with localized disease. There are ongoing \nprospective trials investigating the potential benefits in disease outcomes and toxicities, however, \nno definite benefit has been demonstrated for proton beam at this time. While proton therapy may \nbe medically indicated in some cases of unusual anatomy or in cases of re-irradiation of adjacent \ntissues, this is not the case for this particular patient. In this clinical setting, given this patients \nmedical history and the nature of his prostate cancer diagnosis, the requested service is not \nmedically indicated. Therefore, PBRT is not medically necessary for the treatment of this patient. \n ", "id": "300bd8a1433e42d9b14483ee5df8a416", "question": "What is the background context in this case summary?", "title": "300bd8a1433e42d9b14483ee5df8a416", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain.", "Per the records, this patient has received", "a single set of diagnostic lumbar medial branch blocks."], "answer_start": [20, 389, 437]}, "context": "Summary Reviewer 1\n\nA 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found the current medical evidence does not support the requested services in this clinical setting.  Per the records, this patient has received only a single set of diagnostic lumbar medial branch blocks. Manchikanti and colleagues noted the evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. Additionally, the literature supports the use of a second set of diagnostic medial branch blocks. In this patients case, the pain relief did not exceed 75%, and a second set of diagnostic medial branch blocks was not performed. Therefore, the requested spine nerve treatment is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "ce4c84e476f44904802cb51f36fba40a", "question": "What is the background context in this case summary?", "title": "ce4c84e476f44904802cb51f36fba40a", "sufficiency_score": 3}
+{"answers": {"text": ["A 43-year-old male enrollee has requested reimbursement for a continuous positive airway pressure (CPAP) device provided on 2/9/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees medical condition.", "The patient noted he was not using CPAP because of seasonal allergies."], "answer_start": [20, 572]}, "context": "Summary Reviewer \n\n\nA 43-year-old male enrollee has requested reimbursement for a continuous positive airway pressure (CPAP) device provided on 2/9/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the clinical indication for CPAP device includes the requirement of documentation that the patient is compliant and is utilizing the CPAP device for at least four hours a night for at least 70% of the nights for a 30 day period. The patient noted he was not using CPAP because of seasonal allergies. There is a lack of documentation demonstrating that the patient utilized the device at issue for a 30 day period. Given the lack of documentation demonstrating compliance, CPAP was not medically necessary for treatment of the patients medical condition. Given the above reasons, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "345d702565ab4df190354b03105a38f1", "question": "What is the background context in this case summary?", "title": "345d702565ab4df190354b03105a38f1", "sufficiency_score": 3}
+{"answers": {"text": ["A 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure. The physician reviewer found that infection of a penile implant can cause complications from scarring after the penile implant is removed. Although a few studies with a small numbers of patients have shown that penile implants can be done in an outpatient setting, most providers prefer to continue preoperative antibiotics for at least 24 hours. The American Urological Associations (AUA) guideline for management of erectile dysfunction states, These antibiotics are administered before the incision is made and usually are continued for 24 to 48 hours postoperatively. The AUA best practice statement for antimicrobial prophylaxis in urologic surgery states, Although there are no [randomized controlled trials] RCTs regarding antimicrobial prophylaxis for insertion of penile prostheses, meta-analyses of mesh hernia repair 100 and orthopedic surgery 101 confirm that antimicrobial prophylaxis is beneficial when foreign material is implanted. A prolonged course of antimicrobials has been used by many practitioners following penile prosthesis insertion, but evidence from the orthopedic literature suggests that prophylaxis for 24 hours or less is adequate. In this case, there is a lack of documentation to support the medical necessity for inpatient care. Most patients who undergo penile prosthesis implantation can be discharged within 24 hours of presentation. The patient can be provided with perioperative antibiotics while on observation status without the need for inpatient stay. As such, the request for inpatient admission is not medically necessary for treatment of the patients medical condition. Therefore, the requested service is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "13b02b756f1d4750b85030d298b3f7af", "question": "What is the background context in this case summary?", "title": "13b02b756f1d4750b85030d298b3f7af", "sufficiency_score": 1}
+{"answers": {"text": ["A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition.", "In this case, the patient was at a significant risk from sudden cardiac death. He benefited from risk reduction with the wearable cardioverter defibrillator provided on 11/5/14.", "This patient was at risk for sudden cardiac death while awaiting improvement in left ventricular systolic function prior to consideration of a permanent ICD."], "answer_start": [21, 480, 912]}, "context": "Summary Reviewer 1\n\n\nA 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient was at a significant risk from sudden cardiac death. He benefited from risk reduction with the wearable cardioverter defibrillator provided on 11/5/14. An increase in the risk of sudden cardiac death, and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. This patient was at risk for sudden cardiac death while awaiting improvement in left ventricular systolic function prior to consideration of a permanent ICD. Given the above, the wearable cardioverter defibrillator provided on 11/5/14 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n\n", "id": "0f516003d65d4ae7ba5ae7441d31d027", "question": "What is the background context in this case summary?", "title": "0f516003d65d4ae7ba5ae7441d31d027", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment provided from 6/16/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition", "the documentation notes he has access to a private school, tutors, and therapists.", "he has shown poor resiliency and poor response to treatment.", "he has shown an obstructive engagement, as he was ambivalent, avoidant or distrustful in his relationship with clinicians and other care providers.", "his parents showed", "acceptance and engagement in his treatment."], "answer_start": [22, 1471, 1604, 1719, 1876, 1906]}, "context": "Summary Reviewer \n\n\n\n\nThe parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment provided from 6/16/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition The physician reviewer found that the residential treatment provided from 6/16/16 forward was not and is not medically necessary for treatment of the patients medical condition. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient qualifies for Level Four, intensive integrated services without 24-hour psychiatric monitoring. Specifically, this level of care would include placements such as group homes or foster care. This level qualifies him for treatment by a child psychiatrist and nurse as well as individual and family therapy. Support services should also be provided. Specifically, in Dimension I, risk of harm, he scores as some risk of harm. Dimension II, functional status, he qualifies as serious functional impairment. Dimension III, co-morbidity developmental, medical, substance use and psychiatric, he qualifies as major co-morbidity. In Dimension IV, recovery environment, he scores as minimally stressful environment as his material needs are met without significant cause for concern. He also has a highly supportive environment, as the documentation notes he has access to a private school, tutors, and therapists. In Dimension V, resiliency and treatment history, he has shown poor resiliency and poor response to treatment. In Dimension VI, treatment acceptance and engagement, he has shown an obstructive engagement, as he was ambivalent, avoidant or distrustful in his relationship with clinicians and other care providers. However, his parents showed an optimal acceptance and engagement in his treatment. Given the above, the RTC level of care as of 6/16/16 was not and is not medically necessary for treatment of the patients medical condition.Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n", "id": "8e9601f91fef43c98cf6ddb75126178f", "question": "What is the background context in this case summary?", "title": "8e9601f91fef43c98cf6ddb75126178f", "sufficiency_score": 4}
+{"answers": {"text": ["A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening \nusing chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. The \nHealth Insurer has denied this request and reported that the services at issue were investigational \nfor the evaluation of the enrollees medical condition.", "The patient has had a colon polyp (of the serrated type) in the \npast, and", "the diagnosis of \nulcerative colitis."], "answer_start": [22, 1208, 1351]}, "context": "Summary Reviewer 1 \n \nA 35-year-old female enrollee has requested reimbursement for colorectal cancer screening \nusing chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. The \nHealth Insurer has denied this request and reported that the services at issue were investigational \nfor the evaluation of the enrollees medical condition. The physician reviewer found that as noted \nby  Marion  and  colleagues,  chromoendoscopy  is  supported  as  superior  to  alternatives  for \nlocalization  of  dysplasia  in  randomized  trials.  Per  American  Society  for  Gastrointestinal \nEndoscopy (ASGE) guidelines for inflammatory bowel disease, chromoendoscopy allows better \ncharacterization  of  visible  lesions  as  endoscopically  resectable  or  unresectable,  and \nchromoendoscopy with targeted biopsies is the preferred surveillance technique to maximize \ndysplasia  detection.  Per  American  Gastroenterological  Association  guidelines,  Dye  spray \nchromoendoscopy...should be considered in all persons with colonic inflammatory bowel disease \nundergoing surveillance colonoscopy, particularly if a standard definition endoscope is used or if \nthere is a history of dysplasia. The patient has had a colon polyp (of the serrated type) in the \npast, and aside from that, warrants surveillance biopsies for dysplasia given the diagnosis of \nulcerative colitis. Per the guidelines cited above, surveillance colonoscopies should be performed \nusing  chromoendoscopy  when  possible.  Therefore,  colorectal  cancer  screening  using \nchromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22 was likely \nto have been more beneficial than any available standard therapy.  \n \n", "id": "c9017516458f4555827e531785ceeffe", "question": "What is the background context in this case summary?", "title": "c9017516458f4555827e531785ceeffe", "sufficiency_score": 4}
+{"answers": {"text": ["A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, the superior effectiveness of DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen has not been established in this patients case. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "17ae0a52c98945269adc974ff69183e4", "question": "What is the background context in this case summary?", "title": "17ae0a52c98945269adc974ff69183e4", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 61-year-old male with persistent, symptomatic atrial fibrillation with multiple \nhospital visits for chemical cardioversion. The patient has requested authorization and coverage \nfor hybrid convergent ablation treatment of atrial fibrillation (CPT 33266)."], "answer_start": [21]}, "context": "Summary Reviewer  \n \nThe patient is a 61-year-old male with persistent, symptomatic atrial fibrillation with multiple \nhospital visits for chemical cardioversion. The patient has requested authorization and coverage \nfor hybrid convergent ablation treatment of atrial fibrillation (CPT 33266). The physician reviewer \nfound  that  the  hybrid  convergent  procedure  has  superior  effectiveness  compared  with \nendocardial-only ablation in patients with advanced atrial fibrillation. This was demonstrated in \nthe CONVERGE trial, a multicenter, randomized clinical trial which also showed a significantly \nhigher number of patients in the hybrid convergent arm remaining free from cardioversion at 18 \nmonths follow-up. This was also associated with an acceptable safety profile. The cumulative \nexperience with the convergent procedure is now greater than 10,000 patients to date and has \nan established position in managing atrial fibrillation. Therefore, hybrid convergent ablation \ntreatment of atrial fibrillation (CPT 33266) is medically necessary for treatment of the patients \nmedical condition. \n ", "id": "50da69fc5b5648a59704615a8b278aba", "question": "What is the background context in this case summary?", "title": "50da69fc5b5648a59704615a8b278aba", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition.", "This patient has failed a", "biologic therapy according to the medical records."], "answer_start": [20, 1035, 1068]}, "context": "Summary Reviewer 3\n\nThe parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the use of Rituxan in this case is not likely to be more beneficial than the available standard therapy. According to the 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis, biologic medications available to treat children with juvenile idiopathic arthritis include Actemra, Enbrel, Humira, and Orencia after failure of standard DMARD therapy. According to the Rituxan prescribing information, it is indicated for the treatment of rheumatoid arthritis in combination with methotrexate in adult patients with moderately-to-severely active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies. This patient has failed a single biologic therapy according to the medical records. There are other options that are considered a standard of care in this case, including Orencia intravenous or subcutaneous, Actemra intravenous or subcutaneous, or Enbrel. These medications are indicated for juvenile idiopathic arthritis.  There is no data available to suggest that this patient would respond more to Rituxan as opposed to the biologic medications that are approved for juvenile idiopathic arthritis. Thus, Rituxan is not likely to be more beneficial than other available standard therapy.\n\n\n", "id": "f3bd1077e6424c139314c682f13aab3a", "question": "What is the background context in this case summary?", "title": "f3bd1077e6424c139314c682f13aab3a", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a nine-year-old female. The patient has requested reimbursement for neuropsychological testing performed from 1/18/20 through 8/13/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient.", "Neuropsychological testing indicated that the patient had a complex combination of ADHD combined subtype, non-verbal learning disorders in math and reading, dysgraphia/dyspraxia, and dysthymia with symptoms of anxiety and depression. The patientas symptoms were interfering with her social, academic and family functioning. She was noted to be at risk of social isolation, peer rejection and bullying."], "answer_start": [19, 436]}, "context": "Summary Reviewer \n\nThe patient is a nine-year-old female. The patient has requested reimbursement for neuropsychological testing performed from 1/18/20 through 8/13/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Neuropsychological testing indicated that the patient had a complex combination of ADHD combined subtype, non-verbal learning disorders in math and reading, dysgraphia/dyspraxia, and dysthymia with symptoms of anxiety and depression. The patientas symptoms were interfering with her social, academic and family functioning. She was noted to be at risk of social isolation, peer rejection and bullying. The neuropsychological testing and school evaluations that were performed were the only means by which the patientas complex combination of conditions could be clarified, and appropriate intervention instituted. Therefore, neuropsychological testing performed from 1/18/20 through 8/13/20 was medically necessary for the evaluation of this patient.", "id": "b2454623fafb413ca73bd35dde7e990d", "question": "What is the background context in this case summary?", "title": "b2454623fafb413ca73bd35dde7e990d", "sufficiency_score": 4}
+{"answers": {"text": ["A 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that according to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 7/25/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "10fa180cb6d344f692c1654b964a4a8e", "question": "What is the background context in this case summary?", "title": "10fa180cb6d344f692c1654b964a4a8e", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 39-year-old female with a history of large breasts, low back pain, rheumatoid \narthritis, spinal stenosis, degenerative disease, and herniated disc. The patient underwent breast \nreduction surgery on 9/12/22. The Health Insurer has denied the service at issue as not medically \nnecessary for the treatment of the patients medical condition.", "In this case, the patient has a \nhistory of back and neck pain. The patient also presented with rheumatoid arthritis, spinal stenosis, \ndegenerative disc disease, and herniated disc.", "The patient complained of intertrigo"], "answer_start": [10, 1230, 1622]}, "context": "Summary  \nThe patient is a 39-year-old female with a history of large breasts, low back pain, rheumatoid \narthritis, spinal stenosis, degenerative disease, and herniated disc. The patient underwent breast \nreduction surgery on 9/12/22. The Health Insurer has denied the service at issue as not medically \nnecessary for the treatment of the patients medical condition. This denial is the subject of this \nappeal and determination. The physician reviewer found that the American Society of Plastic \nSurgeons (ASPS) guidelines state that reduction mammaplasty should be performed based on \ndocumentation of the severity of the symptoms of macromastia and its impact on health-related \nquality of life. The guidelines indicate that reduction mammaplasty may be performed if at least \ntwo of the following quality-of-life signs are present: chronic breast pain due to breast weight, \nintertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, \nthoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial \nplexus compression syndrome secondary to the weight of the breasts being transferred to the \nshoulder strap area, headache, and congenital breast deformity. In this case, the patient has a \nhistory of back and neck pain. The patient also presented with rheumatoid arthritis, spinal stenosis, \ndegenerative disc disease, and herniated disc. There is a lack of documentation of chronic breast \npain  due  to  weight  of  the  breasts,  thoracic  kyphosis,  shoulder  grooving,  upper  extremity \nparesthesia, headache, or congenital breast deformity. The patient complained of intertrigo, but \nthere is a lack of documentation that the patients condition was unresponsive to adequate medical \nmanagement. Overall, there are fewer than two documented quality-of-life signs as defined by the \nASPS. Therefore, the breast reduction surgery performed on 9/12/22 was not medically necessary \nfor the treatment of this patient. \n ", "id": "52e324a4c21942128dce40fc945ece4a", "question": "What is the background context in this case summary?", "title": "52e324a4c21942128dce40fc945ece4a", "sufficiency_score": 4}
+{"answers": {"text": ["A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that there is a lack of support for the requested device in this patients case. The records do not document a nonsteroidal anti-inflammatory drug trial. There is no surgical consultation that addresses the extruded disc in her neck. While there is literature supporting the use of cervical spinal cord stimulator for cervical radiculopathy, there are several available alternatives before embarking on spinal cord stimulation. Therefore, the implanted electrical stimulator is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n\n", "id": "b033411698c641b09cb1b5e7d68641cd", "question": "What is the background context in this case summary?", "title": "b033411698c641b09cb1b5e7d68641cd", "sufficiency_score": 2}
+{"answers": {"text": ["The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.", "This patient has been diagnosed with gastroesophageal reflux disease. On 1/07/19, while the patient was on lansoprazole, the provider suggested a trial of hypoallergenic formula. The provider also recommended gastroenterology evaluation. On 2/15/19, the records noted that that the patient was intolerant of the hypoallergenic formula."], "answer_start": [20, 397]}, "context": "Summary Reviewer 2\n\nThe parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. This patient has been diagnosed with gastroesophageal reflux disease. On 1/07/19, while the patient was on lansoprazole, the provider suggested a trial of hypoallergenic formula. The provider also recommended gastroenterology evaluation. On 2/15/19, the records noted that that the patient was intolerant of the hypoallergenic formula. However, the records do not provide additional details regarding the symptoms of intolerance. Proton pump inhibitor therapy is recommended in infants only when there are findings of erosive esophagitis or in the presence of certain anatomic abnormalities (such as repaired tracheoesophageal fistula/esophageal atresia). Given that esophagitis was not documented in this case, lansoprazole is not likely to be more effective than other treatment options.\n\n\n", "id": "8b71bb441b644600ab05ad8e2c8ac6e8", "question": "What is the background context in this case summary?", "title": "8b71bb441b644600ab05ad8e2c8ac6e8", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nThe parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Lansoprazole may be indicated in select cases, such as patients with esophagitis and postoperative esophageal dysmotility. The article by Hassall and colleagues noted the presumed safety and efficacy of proton pump inhibitor therapy in this age-group, but this was in the setting of defined esophagitis. It is difficult to label an infant as having an acid-related disease based on clinical assessment alone. The trend has shifted away from routine use of prolonged acid suppression in otherwise healthy infants. There may be a role for empiric use in the setting of feeding aversions or poor weight gain, but neither of those situations were demonstrated here. Thus, lansoprazole is not likely to be superior over other treatment options.\n\n\n", "id": "800642f46d0545e7ac6932df7497b463", "question": "What is the background context in this case summary?", "title": "800642f46d0545e7ac6932df7497b463", "sufficiency_score": 2}
+{"answers": {"text": ["A 48-year-old female enrollee has requested authorization and coverage for Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.", "In this case, the patient has", "been treated with prednisone", "In this case, the patient has been diagnosed with dermatomyositis. Her treatment has included prednisone"], "answer_start": [19, 880, 915, 438]}, "context": "Summary Reviewer \n\nA 48-year-old female enrollee has requested authorization and coverage for Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that dermatomyositis is an idiopathic inflammatory myopathy. In this case, the patient has been diagnosed with dermatomyositis. Her treatment has included prednisone alone. Initial therapy for individuals diagnosed with this disorder includes high-dose glucocorticoid therapy with a taper to the lowest effective dose. Generally, a glucocorticoid-sparing agent is used in combination with glucocorticoid therapy. Treatment includes prednisone in combination with methotrexate, azathioprine or CellCept. In this case, the patient has only been treated with prednisone, and the requested medication is not considered a first-line medication. There is no documentation that she has failed treatment with a glucocorticoid-sparing agent, such as methotrexate, azathioprine or CellCept, which are considered first-line medications. The requested medication, Gamunex-C is not medically indicated. Therefore, Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml) is not medically necessary for the treatment of this patient.", "id": "2281a1c86326404e8caaa92998feb4ba", "question": "What is the background context in this case summary?", "title": "2281a1c86326404e8caaa92998feb4ba", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 52-year-old female with a history of refractory back pain, depression, anxiety, \nand chronic pain disorder status post pain pump placed in 2019. The provider has recommended \nplacement of a percutaneous implantation of spinal cord stimulator.", "at issue is whether the requested percutaneous implantation of neurostimulator \nelectrode array, epidural, is medically necessary for treatment of this patient.", "In this case, the patient has chronic low \nback pain that has been non-responsive to medication management, physical therapy, epidural \nsteroid injections, cognitive therapy and intrathecal pain pump."], "answer_start": [10, 305, 1705]}, "context": "Summary  \nThe patient is a 52-year-old female with a history of refractory back pain, depression, anxiety, \nand chronic pain disorder status post pain pump placed in 2019. The provider has recommended \nplacement of a percutaneous implantation of spinal cord stimulator. The physician reviewer \nfound that at issue is whether the requested percutaneous implantation of neurostimulator \nelectrode array, epidural, is medically necessary for treatment of this patient. A prospective, \nmulticenter, randomized controlled trial was conducted evaluating the long-term quality of life \nimprovement for patients with chronic intractable back and leg pain using spinal cord stimulation \n(Amirdelfan, et al.). The authors reported that of the 171 patients who received a permanent \nspinal cord stimulation device implant, a higher proportion of spinal cord stimulation patients \nhad marked improvement of their disability on the Oswestry Disability Index (ODI) to a moderate \nor minimal impact on their daily function versus the control group. The authors concluded that, \nIn  addition  to  superior  pain  relief,  10  kHz  spinal  cord  stimulation  provides  long-term \nimprovements in quality of life and functionality for subjects with chronic low-back and leg pain. \nSimilarly, a systematic review and meta-analysis performed by Head and colleagues evaluated a \nvariety of spinal cord stimulation systems and device parameters for use in patients with chronic \nlow back and leg pain. The authors concluded that data from level 1 randomized controlled trials \nhave elevated the status of spinal cord stimulation to a safe and effective alternative for the \ntreatment of neuropathic low back pain and leg pain. In this case, the patient has chronic low \nback pain that has been non-responsive to medication management, physical therapy, epidural \nsteroid injections, cognitive therapy and intrathecal pain pump. Based on the level one evidence \nto support the usage of spinal cord stimulation therapy for patients with chronic low back and \nleg pain that is refractory to other forms of conservative care, the requested spinal cord \nstimulation is appropriate for treatment of this patients chronic low back pain. Therefore, the \nrequested percutaneous implantation of neurostimulator electrode array, epidural, is medically \nnecessary for treatment of this patient.  \n ", "id": "f054fa6256e847848adf78f2d7f7f242", "question": "What is the background context in this case summary?", "title": "f054fa6256e847848adf78f2d7f7f242", "sufficiency_score": 4}
+{"answers": {"text": ["A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "The records noted intolerance to the use of continuous positive airway pressure therapy. A sleep study documented symptoms of obstructive sleep apnea with an apnea-hypopnea index at the moderate to severe level of obstructive sleep apnea syndrome, with oxygen desaturation to 82%."], "answer_start": [20, 440]}, "context": "Summary Reviewer 3\n\nA 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. The records noted intolerance to the use of continuous positive airway pressure therapy. A sleep study documented symptoms of obstructive sleep apnea with an apnea-hypopnea index at the moderate to severe level of obstructive sleep apnea syndrome, with oxygen desaturation to 82%. Hypoglossal nerve stimulation therapy has been demonstrated to be an effective modality for the treatment of obstructive sleep apnea in patients with tongue-based obstruction. The medical evidence supports the requested services for the treatment of this patient. Thus, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be of greater benefit than other treatment options.\n\n\n", "id": "4fa4f3f8fe9f483cad25a835aaed5a8c", "question": "What is the background context in this case summary?", "title": "4fa4f3f8fe9f483cad25a835aaed5a8c", "sufficiency_score": 4}
+{"answers": {"text": ["A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Osteoporosis is a condition of thinning of the bones that leads to an increased risk of fracture.  It  is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults), as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density assessment via DEXA is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.\n\n", "id": "bbac6361abde40549f645dd5083e399f", "question": "What is the background context in this case summary?", "title": "bbac6361abde40549f645dd5083e399f", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 15-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 5/9/15 through 8/7/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and parent-child relational problem.  "], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nThe parent of a 15-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 5/9/15 through 8/7/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and parent-child relational problem.  \n\n The physician reviewer found that the documentation provided for review does not support the medical necessity of residential mental health treatment services provided from 5/9/15 through 8/7/15. There is no evidence that treatment in a less restrictive setting would have been ineffective to manage the patient, since this had not been given an adequate trial. Similarly, there is a lack of objective evidence that continuation with a lesser intensity of care could not have provided improvement or prevention of deterioration. The patients level of symptomatology did not justify residential services. No suicidal ideations or homicidal ideations had been documented, but in one incident, which was assessed as an attempt to manipulate the staff. The patient was able to contract for safety and no additional intervention occurred. Further, continued residential services, especially at the highly intensive levels that were used, may have led to service dependency, which would be an adverse outcome. Therefore, this patient would have been more appropriately managed at a less restrictive, less intrusive intensity of services, such as outpatient care. For these reasons, the residential mental health treatment services provided from 5/9/15 through 8/7/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "209219472fba442b8221b6ca7d6ba64a", "question": "What is the background context in this case summary?", "title": "209219472fba442b8221b6ca7d6ba64a", "sufficiency_score": 3}
+{"answers": {"text": ["A 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain.", "this patient presented on 6/15/18 with recurrent right knee pain and limitations in functional mobility and activities of daily living. Clinical examination findings were consistent with reported radiographic evidence of right knee degenerative joint disease. Reasonable conservative treatment, including medications, activity modification, weight loss, and physical therapy have failed to provide adequate symptom relief. She was status post previous injections on 12/19/16 and 9/22/17 which had provided sustained pain relief and functional improvement for longer than six months."], "answer_start": [19, 304]}, "context": "Summary Reviewer \n\nA 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that this patient presented on 6/15/18 with recurrent right knee pain and limitations in functional mobility and activities of daily living. Clinical examination findings were consistent with reported radiographic evidence of right knee degenerative joint disease. Reasonable conservative treatment, including medications, activity modification, weight loss, and physical therapy have failed to provide adequate symptom relief. She was status post previous injections on 12/19/16 and 9/22/17 which had provided sustained pain relief and functional improvement for longer than six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, knee injections provided on 6/15/18 were medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "dfe4163af48c4391a5aaa6709a3cb99e", "question": "What is the background context in this case summary?", "title": "dfe4163af48c4391a5aaa6709a3cb99e", "sufficiency_score": 4}
+{"answers": {"text": ["A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Chromosomal microarray testing is an appropriate first-line test for patients with non-syndromic developmental delay/intellectual disability, as well as patients with autism spectrum disorders.  There are clear management implications that chromosomal microarray testing has provided for patients.  In sum, FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "31613bc76fe74705a56be2eee45166ea", "question": "What is the background context in this case summary?", "title": "31613bc76fe74705a56be2eee45166ea", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a 25-year-old female with a history of chronic sinus problems. The provider reports the patient presented with symptoms of recurring sinus infections requiring antimicrobial treatment four times in the preceding four months. The patients symptoms included facial pressure, headache, generalized fatigue and nasal congestion. The physical examination documented clear mucus and nasal septal deviation suggestive of acute rhinitis, most likely to be of bacterial origin and the provider recommended use of a topical fluticasone nasal spray and nasal irrigations along with computed tomography (CT) imaging of the paranasal sinuses. On 2/13/18, a follow-up note documented that the patient had been evaluated for nasal airway obstruction due to deviated nasal septum and rhinorrhea. CT imaging on 12/27/16 demonstrated that the frontal, ethmoid, maxillary and sphenoid sinuses were clear and that the sphenoid and frontal sinuses were found to be hypoplastic. The ostiomeatal units were found to be patent. This was in comparison to the previous CT scan dated 8/18/16. The patient has requested reimbursement for the CT maxillofacial without contrast material provided on 12/27/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary.", "the provider stated in the physical examination that the patient did have symptoms of recurrent acute sinusitis over four months or longer and had been placed on multiple different medical therapies including antibiotics and other medications, but still had repeated rhinosinusitis. The patient was found on physical examination to have persistent rhinorrhea in addition to nasal septal deviation"], "answer_start": [18, 1372]}, "context": "Summary Reviewer\n\nThe patient is a 25-year-old female with a history of chronic sinus problems. The provider reports the patient presented with symptoms of recurring sinus infections requiring antimicrobial treatment four times in the preceding four months. The patients symptoms included facial pressure, headache, generalized fatigue and nasal congestion. The physical examination documented clear mucus and nasal septal deviation suggestive of acute rhinitis, most likely to be of bacterial origin and the provider recommended use of a topical fluticasone nasal spray and nasal irrigations along with computed tomography (CT) imaging of the paranasal sinuses. On 2/13/18, a follow-up note documented that the patient had been evaluated for nasal airway obstruction due to deviated nasal septum and rhinorrhea. CT imaging on 12/27/16 demonstrated that the frontal, ethmoid, maxillary and sphenoid sinuses were clear and that the sphenoid and frontal sinuses were found to be hypoplastic. The ostiomeatal units were found to be patent. This was in comparison to the previous CT scan dated 8/18/16. The patient has requested reimbursement for the CT maxillofacial without contrast material provided on 12/27/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary. Upon the review of the documentation, the provider stated in the physical examination that the patient did have symptoms of recurrent acute sinusitis over four months or longer and had been placed on multiple different medical therapies including antibiotics and other medications, but still had repeated rhinosinusitis. The patient was found on physical examination to have persistent rhinorrhea in addition to nasal septal deviation, which is one of the physical findings on examination to meet criteria for CT scan imaging. Practice guidelines acknowledge that CT imaging, as opposed to the plain radiography or magnetic resonance imaging (MRI), is the diagnostic modality of choice for confirming chronic rhinosinusitis or as an alternative to nasal endoscopy. Thus, the CT maxillofacial without contrast material provided on 12/27/16 was medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.\n\n", "id": "84d2ea5f045c48e7992e184e047e158c", "question": "What is the background context in this case summary?", "title": "84d2ea5f045c48e7992e184e047e158c", "sufficiency_score": 4}
+{"answers": {"text": ["A 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that some evidence exists to suggest that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. However, the reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, the Anser IFX testing provided on 10/26/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "b1a0e16e1b5d48c9a3e3c4326c7dd03f", "question": "What is the background context in this case summary?", "title": "b1a0e16e1b5d48c9a3e3c4326c7dd03f", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "He has failed continuous positive airway pressure therapy"], "answer_start": [20, 1191]}, "context": "Summary Reviewer 3\n\nA 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulator has been demonstrated to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. This procedure has been approved by the U.S. Food and Drug Administration. With a body mass index of 26.6, apnea-hypopnea index of 19.3 and nonconcentric airway collapse, this patient meets the criteria. He has failed continuous positive airway pressure therapy, which is the gold standard treatment for obstructive sleep apnea. Thus, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be of greater benefit than other treatment options.\n\n\n", "id": "d7f0a4e9927b4237a7ce0ea0d152f41e", "question": "What is the background context in this case summary?", "title": "d7f0a4e9927b4237a7ce0ea0d152f41e", "sufficiency_score": 4}
+{"answers": {"text": ["A 46-year-old male enrollee has requested authorization and coverage for an oral appliance. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees mild obstructive sleep apnea.", "The patient has been diagnosed with mild obstructive sleep apnea. Per the records, treatment with CPAP was initially recommended. The clinical notes indicate that the patient is unable to tolerate CPAP therapy."], "answer_start": [19, 397]}, "context": "Summary Reviewer \n\nA 46-year-old male enrollee has requested authorization and coverage for an oral appliance. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees mild obstructive sleep apnea. The physician reviewer found that the submitted documentation supports the medical necessity of the requested device. The patient has been diagnosed with mild obstructive sleep apnea. Per the records, treatment with CPAP was initially recommended. The clinical notes indicate that the patient is unable to tolerate CPAP therapy. For patients who are unable to tolerate CPAP therapy, treatment with an oral appliance has been shown to improve symptoms of obstructive sleep apnea. The medical evidence supports the requested device in this clinical setting. Thus, the requested oral appliance is medically necessary for the treatment of this patient. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "231c3270597948588f7459ed28c7b46d", "question": "What is the background context in this case summary?", "title": "231c3270597948588f7459ed28c7b46d", "sufficiency_score": 4}
+{"answers": {"text": ["A 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.", "this patient had an early stage melanoma."], "answer_start": [20, 325]}, "context": "Summary Reviewer 2\n\nA 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures.  There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing performed on 12/11/19 was not likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "876d2854e95d437fbbdab012dbe324aa", "question": "What is the background context in this case summary?", "title": "876d2854e95d437fbbdab012dbe324aa", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 61-year-old male who was admitted for hospitalization on 8/5/21. The patient \nhas requested reimbursement for inpatient hospital level of care from 8/5/21 through 8/7/21. \nThe Health Insurer has denied this request and reported that the services at issue were not \nmedically necessary for the treatment of this patient.", "In this case, \nthe patient presented with non-ST-elevation myocardial infarction (NSTEMI), a form of heart \nattack, and pulmonary edema in the setting of rapid atrial fibrillation requiring rate control by \ncontinuous intravenous diltiazem infusion. At the time of presentation on 8/5/21, the patient \nwas at risk due to persisting rapid atrial fibrillation, worsening/evolving heart failure, respiratory \nfailure,  and  sudden  cardiac  death."], "answer_start": [21, 478]}, "context": "Summary Reviewer  \n \nThe patient is a 61-year-old male who was admitted for hospitalization on 8/5/21. The patient \nhas requested reimbursement for inpatient hospital level of care from 8/5/21 through 8/7/21. \nThe Health Insurer has denied this request and reported that the services at issue were not \nmedically necessary for the treatment of this patient. The physician reviewer found that the \nsubmitted documentation supports the medical necessity of the services at issue. In this case, \nthe patient presented with non-ST-elevation myocardial infarction (NSTEMI), a form of heart \nattack, and pulmonary edema in the setting of rapid atrial fibrillation requiring rate control by \ncontinuous intravenous diltiazem infusion. At the time of presentation on 8/5/21, the patient \nwas at risk due to persisting rapid atrial fibrillation, worsening/evolving heart failure, respiratory \nfailure,  and  sudden  cardiac  death.  Given  this  adverse  risk  profile,  the  patient  warranted \nadmission to inpatient status to facilitate intravenous diuresis or volume removal, close cardiac \nmonitoring with telemetry and repeat biomarkers, and continued intravenous infusion for rate \ncontrol to treat the underlying cause of his condition. Moreover, at the time of the inpatient \norder, it was reasonable to anticipate the patient would cross two midnights while receiving \nmedically necessary care, often considered the benchmark for inpatient admission, which was \nthe case for this hospital stay. In addition, the patient required ICU level care due to (1) his \npulmonary edema and tenuous respiratory status, and (2) his need for continuous intravenous \ninfusion of diltiazem, which cannot be safely delivered on the regular medicine floor in most \nhospital systems. Therefore, inpatient hospital level of care from 8/5/21 through 8/7/21 was \nmedically necessary for the treatment of this patient. ", "id": "8017346dd1334775af38d510b2a45a54", "question": "What is the background context in this case summary?", "title": "8017346dd1334775af38d510b2a45a54", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD)."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nThe parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. Based on the documentation submitted for review, the patient presents with symptoms consistent with autism. Maladaptive behaviors including aggression and tantrums are difficult to treat with other interventions. The research shows that although medications including Risperdal can reduce some of the aggression in children with ASD it does not treat the core symptoms and does not provide long term benefits. Matson and Jang performed a literature review on treating aggression in persons with ASD and found that the most effective interventions were behavioral interventions including ABA therapy. Based on the support in the peer-reviewed literature and the documented regression in behaviors with a reduction of hours, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n\n\n\n", "id": "22452f9085f8423590f41683a0727b70", "question": "What is the background context in this case summary?", "title": "22452f9085f8423590f41683a0727b70", "sufficiency_score": 3}
+{"answers": {"text": ["A 33-year-old female enrollee has requested reimbursement for exome sequence analysis (81415) provided on 8/15/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 33-year-old female enrollee has requested reimbursement for exome sequence analysis (81415) provided on 8/15/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the Society for Maternal-Fetal Medicine indicates that routine use of prenatal sequencing as a diagnostic test is not currently supported due to insufficient validation data and knowledge about its benefits and pitfalls. Although the technology is promising in genetic evaluation of an anomalous fetus, many challenges remain for the routine clinical use of exome sequencing. Interpreting results from exome sequencing is a very lengthy process, and is challenging due to reliance on phenotypic data that may be incomplete. Additionally, there are many counseling and ethical issues related to prenatal exome sequencing, including determining when to report secondary or incidental findings, the ongoing need for reanalysis of results, and the challenges of interpreting results in meaningful ways for patients. Therefore, given the complexities involved in interpretation of results, timeliness of results, and patient/family counseling, the decision to proceed with this type of testing should be made in consultation with a provider specializing in genetic testing, such as a certified genetic counselor or medical geneticist and is currently not the standard of care or medically necessary as in this case. Thus, CPT 81415 (exome sequence analysis) performed on 8/15/19 was not medically necessary for the evaluation of this patient.", "id": "c5d6d3da44d340acb300bc34025af54a", "question": "What is the background context in this case summary?", "title": "c5d6d3da44d340acb300bc34025af54a", "sufficiency_score": 2}
+{"answers": {"text": ["A 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer."], "answer_start": [19]}, "context": "Summary Reviewer 3\nA 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer. The physician reviewer found that currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy. A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton beam therapy when compared to photon therapy for head and neck cancer. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Thus, the superior efficacy of the requested proton beam therapy (77499) has not been established in this patients case. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n", "id": "810372b4af07467489e42abd2abf8c7d", "question": "What is the background context in this case summary?", "title": "810372b4af07467489e42abd2abf8c7d", "sufficiency_score": 3}
+{"answers": {"text": ["A 50-year-old male enrollee has requested authorization and coverage for Korlym 300 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 50-year-old male enrollee has requested authorization and coverage for Korlym 300 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Meningiomas are more commonly positive for progesterone receptors than for estrogen receptors. Several studies have been conducted on long-term oral therapy of unresectable meningiomas with the antiprogesterone mifepristone (RU486). In the study by Grunberg and colleagues, fourteen patients received mifepristone in daily doses of 200 mg for periods ranging from two to greater than 31 months (greater than or equal to six months in 12 patients). Five patients demonstrated signs of objective response (reduced tumor measurement on computerized tomography scan or magnetic resonance imaging, or improved visual field examination). Three patients experienced subjective improvement (improved extraocular muscle function or relief from headache). The side effects of long-term mifepristone therapy were noted to have been mild. The authors noted that long-term therapy with mifepristone may have efficacy in cases of unresectable benign meningioma. There is sufficient support for the requested medication in this clinical setting. Therefore, Korlym 300 mg tablets are medically necessary for the treatment of this patient.", "id": "13877ee8ae9644c9a3e9012ea32d3a7b", "question": "What is the background context in this case summary?", "title": "13877ee8ae9644c9a3e9012ea32d3a7b", "sufficiency_score": 2}
+{"answers": {"text": ["A 57-year-old female enrollee has requested reimbursement for the hysterectomy performed on 1/16/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees post-menopausal bleeding.", "the records provided for review document that this patient presented with a history of post-menopausal bleeding that interfered with her activities of daily living and did not responded to medical management.", "This patient was treated with conservative management, which was hormonal therapy"], "answer_start": [20, 320, 1168]}, "context": "Summary Reviewer \n\n\nA 57-year-old female enrollee has requested reimbursement for the hysterectomy performed on 1/16/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees post-menopausal bleeding. The physician reviewer found that the records provided for review document that this patient presented with a history of post-menopausal bleeding that interfered with her activities of daily living and did not responded to medical management. Per the American College of Obstetricians and Gynecologists (ACOG), late peri-menopausal patients may be treated with cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device (IUD), or cyclic hormone therapy. The ACOG further noted that women who have completed childbearing, in whom medical therapy has failed, or who have contraindications to medical therapy are candidates for hysterectomy without cervical preservation. Appropriate treatment includes an endometrial ablation or hysterectomy. Endometrial ablation is not definitive therapy and is generally considered for premenopausal women. This patient was treated with conservative management, which was hormonal therapy appropriate for her age. Given the ACOG recommendations for patients who have failed conservative therapy in this clinical setting, the hysterectomy performed on 1/16/17 was medically necessary for treatment of this patients post-menopausal bleeding. Based on the foregoing discussion, the surgery at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "557ba2335988428e8e761a117b6e3f4c", "question": "What is the background context in this case summary?", "title": "557ba2335988428e8e761a117b6e3f4c", "sufficiency_score": 4}
+{"answers": {"text": ["A 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "This patient has painful varicose veins bilaterally. She is status post radiofrequency ablation of left great saphenous vein and ultrasound-guided foam sclerotherapy.", "For the left leg, the veins are residual after a prior thermal ablation. She continues to be symptomatic.", "With regards to the right leg, the varicose veins are de novo. There is no saphenofemoral junction or saphenopopliteal junction reflux."], "answer_start": [20, 381, 610, 818]}, "context": "Summary Reviewer 3\n\nA 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is support for a portion of the services at issue. This patient has painful varicose veins bilaterally. She is status post radiofrequency ablation of left great saphenous vein and ultrasound-guided foam sclerotherapy. There is support for the requested services for the left leg. For the left leg, the veins are residual after a prior thermal ablation. She continues to be symptomatic. Thus, the requested services for the left leg are likely to be superior over other treatment options. With regards to the right leg, the varicose veins are de novo. There is no saphenofemoral junction or saphenopopliteal junction reflux. Per the medical evidence, endovenous thermal ablation is preferred to surgery and foam sclerotherapy in the treatment of small saphenous vein incompetence. In sum, the requested foam sclerosant/endovenous ablation of the left leg is likely to be of greater benefit than other treatment options.\n\n\n", "id": "90f0daa8b72945bb88e2395e77bdca98", "question": "What is the background context in this case summary?", "title": "90f0daa8b72945bb88e2395e77bdca98", "sufficiency_score": 4}
+{"answers": {"text": ["Prior evaluation has documented the degree of obstructive sleep apnea to be severe. The patient had trialed CPAP therapy for airway management and was intolerant to the use of this device.", "The patient is a 64-year-old female with severe obstructive sleep apnea. The medical records document a history of unsuccessful attempts to utilize", "continuous positive airway pressure (CPAP) therapy. On 9/12/17, the records noted a body mass index of 20.2. On 9/26/17, septoplasty and bilateral inferior turbinate reduction was performed. On 10/12/17, a home sleep study confirmed that the patient had a total of 162 obstructive apnea episodes, without central apnea. The documentation noted an apnea-hypopnea index of 43.0 episodes per hour of sleep. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient."], "answer_start": [1008, 20, 199]}, "context": "Summary Reviewer 2\n\nThe patient is a 64-year-old female with severe obstructive sleep apnea. The medical records document a history of unsuccessful attempts to utilize the gold standard treatment of continuous positive airway pressure (CPAP) therapy. On 9/12/17, the records noted a body mass index of 20.2. On 9/26/17, septoplasty and bilateral inferior turbinate reduction was performed. On 10/12/17, a home sleep study confirmed that the patient had a total of 162 obstructive apnea episodes, without central apnea. The documentation noted an apnea-hypopnea index of 43.0 episodes per hour of sleep. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  There is sufficient support for the requested device in this clinical setting. This patient meets clinical criteria for consideration of surgical management of her obstructive sleep apnea symptoms. Prior evaluation has documented the degree of obstructive sleep apnea to be severe. The patient had trialed CPAP therapy for airway management and was intolerant to the use of this device. Clinical studies indicate that patients only benefit from this device when they have a body mass index less than 32, and the patient meets this criteria. Per the medical evidence, patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of this disorder. All told, the requested implanted nerve stimulator is likely to be superior over other available treatment options. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "374d21e1b9644a74be0c2a90128859d8", "question": "What is the background context in this case summary?", "title": "374d21e1b9644a74be0c2a90128859d8", "sufficiency_score": 4}
+{"answers": {"text": ["A 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 5/26/20 was not likely to have been more beneficial than any available standard therapy.\n\n\n", "id": "9f86b659c1694e01a37aa9e5417a1279", "question": "What is the background context in this case summary?", "title": "9f86b659c1694e01a37aa9e5417a1279", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis.", "this patient has a history of cardiac sarcoidosis and symptomatic 2:1 atrioventricular block in need of pacemaker placement."], "answer_start": [20, 327]}, "context": "Summary Reviewer 2\n\nA 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that this patient has a history of cardiac sarcoidosis and symptomatic 2:1 atrioventricular block in need of pacemaker placement. In this circumstance of cardiac sarcoidosis and ejection fraction greater than 35% with an indication for pacemaker placement, it is reasonable to implant a defibrillator if meaningful survival of greater than one year is expected. Some patients with cardiac sarcoidosis with normal ejection fraction and no heart failure symptoms have high arrhythmic event rates, especially when late gadolinium enhancement is identified on cardiac MRI or abnormal findings are seen on cardiac PET imaging, such as this patient. The medical evidence supports the requested device in this case. Therefore, the requested cardioverter defibrillator is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "0d101eb0806747cbbb642cb364b6f73a", "question": "What is the background context in this case summary?", "title": "0d101eb0806747cbbb642cb364b6f73a", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that penile traction therapy is a therapeutic option for men with Peyronies disease. Penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. There is paucity of clinical justification regarding the efficacy of injection therapy with verapamil. Furthermore, addition of verapamil to oral therapy or other nonsurgical therapies does not appear to provide significant improvement. In sum, verapamil is not likely to be superior over other treatment options.\n\n\n", "id": "3981b4753eb44879ba14fccb837c60ef", "question": "What is the background context in this case summary?", "title": "3981b4753eb44879ba14fccb837c60ef", "sufficiency_score": 2}
+{"answers": {"text": ["A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by \nFoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service \nat issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether \nCDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for \nevaluation of the enrollee's condition than any available standard therapy."], "answer_start": [22]}, "context": "Summary Reviewer 1 \n \nA 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by \nFoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service \nat issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether \nCDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for \nevaluation of the enrollee's condition than any available standard therapy. The physician reviewer \nfound that the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of \nnon-small cell lung cancer (NSCLC) note that there is growing recognition of the molecular \nmechanisms of resistance to therapy. Retesting a sample from a tumor that is actively progressing \nwhile exposed to targeted therapy can shed light on appropriate next therapeutic steps. Broad \ngenomic profiling may be the most informative approach to examining potential mechanisms of \nresistance, which may require more than one instance of such profiling over the course of an \nindividual patients therapy. While liquid biopsy should not be used in lieu of tissue-based testing, \nRolfo  and  colleagues  note  that  isolation  and  analysis  of  circulating  cell-free  tumor \ndeoxyribonucleic acid (DNA) in plasma is a powerful tool with considerable potential to improve \nclinical outcomes across multiple cancer types, including NSCLC. Cell-free tumor DNA testing \ngenerally has very high specificity. While it may also have significantly compromised sensitivity, \nwith up to a 30% false-negative rate, current medical literature supports complementary testing to \nreduce turnaround time and increase the yield of targetable alteration detection. This is especially \ntrue with procedures that typically have a low yield of tissue such as endobronchial ultrasound \n(EBUS). Therefore, the service at issue was likely to have been more beneficial for treatment of \nthe patients medical condition than standard therapy with tissue-based testing alone. Therefore, \nCDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for \nevaluation of the patients condition than any available standard therapy. \n \n \n", "id": "b293b694e36e4829bc41d2598411c92f", "question": "What is the background context in this case summary?", "title": "b293b694e36e4829bc41d2598411c92f", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by \nFoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service \nat issue was investigational for the evaluation of the enrollees lung cancer.", "In this case, notes dated 7/27/22 reported that the patient underwent a repeat \nbiopsy on 4/12/22 by EBUS to confirm recurrent disease. Molecular testing and FoundationOne \nCDx liquid testing were requested from this sample at the same time."], "answer_start": [20, 1408]}, "context": "Summary Reviewer 3 \nA 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by \nFoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service \nat issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether \nCDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for \nevaluation of the enrollee's condition than any available standard therapy. The physician reviewer \nfound that Metastatic adenocarcinoma of the lung is an incurable disease, but many advances have \nbeen made with targeted therapies to help extend survival. Multiple guidelines including by the \nNCCN,  College  of  American  Pathologists  (CAP),  American  Society  of  Clinical  Oncology \n(ASCO), and European Society for Medical Oncology (ESMO), recommend testing for mutations \nsuch as epidermal growth factor receptor (EGFR), KRAS, anaplastic lymphoma kinase (ALK), \nand c-ros oncogene (ROS1) on tumor samples to help direct therapy options. If patients are not fit \nfor biopsy, or if the tissue sample is insufficient for testing, then cell-free testing may help identify \nmutations.  Cell-free tests, such as the FoundationOne CDx liquid test at issue, are very specific \nbut not as sensitive as tissue testing for mutations and are not a substitute when appropriate tissue \ncan be obtained. In this case, notes dated 7/27/22 reported that the patient underwent a repeat \nbiopsy on 4/12/22 by EBUS to confirm recurrent disease. Molecular testing and FoundationOne \nCDx liquid testing were requested from this sample at the same time. In this clinical setting, given \nthat the tissue sample is considered more sensitive/specific than liquid biopsy and is the standard \nfor diagnostic management, the service at issue was not likely to have been more beneficial than \nthe standard management. Therefore, CDx laboratory testing by FoundationOne on 4/29/22 was \nnot likely to have been more beneficial for evaluation of the patients condition than any available \nstandard therapy. \n \n ", "id": "842f04a53c2d4c65ac208295ee4fbf41", "question": "What is the background context in this case summary?", "title": "842f04a53c2d4c65ac208295ee4fbf41", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS).", "the patient has juvenile dermatomyositis"], "answer_start": [21, 563]}, "context": "Summary Reviewer 3\n\n\nThe parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient has juvenile dermatomyositis which is moderate to severe and a biologic such as Remicade (infliximab) would likely be beneficial for this patient. Moreover, infliximab has been shown to be safe and effective in children with juvenile dermatomyositis. Riley and colleagues assessed the response of five refractory juvenile dermatomyositis patients to infliximab. The authors reported Improvements in all five patients as shown by positive changes in physician visual analogue scale (VAS), Childhood Myositis Assessment Score (CMAS), Childhood Health Assessment Questionnaire (CHAQ), joint range of movement and, in some, regression of calcinosis and skin signs. There were no major side effects observed with addition of infliximab to the therapeutic regime. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.", "id": "2fb46423c93140e995e41f40172358b1", "question": "What is the background context in this case summary?", "title": "2fb46423c93140e995e41f40172358b1", "sufficiency_score": 3}
+{"answers": {"text": ["A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, breast tomosynthesis performed on 1/26/16 was likely to have been of greater benefit than other methods of evaluation.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "04408335d1b44094952ebd7fb96291be", "question": "What is the background context in this case summary?", "title": "04408335d1b44094952ebd7fb96291be", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 62-year-old male with a progressive group of symptoms consistent with a neurodegenerative disorder.  He has developed dysarthria, ataxia and possibly cognitive abnormalities of executive functioning. Per the records, magnetic resonance imaging (MRI) of the brain showed atrophy of the cerebellum, cerebellar peduncles, and pons and medulla consistent with multisystem atrophy or possibly spinocerebellar degeneration. The provider recommended dopamine transporter single photon emission computed tomography (DaT SPECT). The patient has requested reimbursement for DaT SPECT scan of the brain performed on 9/23/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nThe patient is a 62-year-old male with a progressive group of symptoms consistent with a neurodegenerative disorder.  He has developed dysarthria, ataxia and possibly cognitive abnormalities of executive functioning. Per the records, magnetic resonance imaging (MRI) of the brain showed atrophy of the cerebellum, cerebellar peduncles, and pons and medulla consistent with multisystem atrophy or possibly spinocerebellar degeneration. The provider recommended dopamine transporter single photon emission computed tomography (DaT SPECT). The patient has requested reimbursement for DaT SPECT scan of the brain performed on 9/23/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the services at issue in this clinical setting.  The differential diagnosis of spinocerebellar degeneration versus multiple system atrophy is established by clinical grounds. There is a lack of data demonstrating adequate sensitivity or specificity of DaT SPECT scanning in this clinical setting.  Therefore, DaT SPECT scan of the brain performed on 9/23/16 was not likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "2d06c888639f484d8ebb2f0ac18b1845", "question": "What is the background context in this case summary?", "title": "2d06c888639f484d8ebb2f0ac18b1845", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition.", "the patient has a history of osteoporosis and multiple non-traumatic fractures.", "This patient has been treated with Fosamax, with no benefit on the patients bone mineral density.  The medical notes indicate that the patients markers of bone turnover were elevated"], "answer_start": [21, 315, 570]}, "context": "Summary Reviewer 3\n\n\nA 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient has a history of osteoporosis and multiple non-traumatic fractures.  The patient is at a high risk for a major osteoporotic fracture, and pharmacological therapy is recommended.  The medical evidence supports Prolia in this clinical setting.  This patient has been treated with Fosamax, with no benefit on the patients bone mineral density.  The medical notes indicate that the patients markers of bone turnover were elevated, indicating poor absorption or increased bone turnover from rheumatoid arthritis while on Fosamax therapy.  Thus, the Prolia injection provided on 8/27/15 was likely to have been more effective than other treatment options.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "92742b57539c4eb4a03aea1d83642443", "question": "What is the background context in this case summary?", "title": "92742b57539c4eb4a03aea1d83642443", "sufficiency_score": 4}
+{"answers": {"text": ["A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis performed on 7/13/15 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "0328d753f7064e41b53811632d1e3a21", "question": "What is the background context in this case summary?", "title": "0328d753f7064e41b53811632d1e3a21", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.", "in this case, the patients presenting symptom was breast pain.", "her breast density was described as containing scattered areas of fibroglandular elements."], "answer_start": [20, 707, 878]}, "context": "Summary Reviewer 3\n\nA 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this case, the patients presenting symptom was breast pain.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In addition, her breast density was described as containing scattered areas of fibroglandular elements.  Her breasts were not particularly dense.  Breast tomosynthesis has not been shown to provide significant increased value in this clinical setting.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n\n\n", "id": "99d88dc08ed244e5a5f147ea352fb3ad", "question": "What is the background context in this case summary?", "title": "99d88dc08ed244e5a5f147ea352fb3ad", "sufficiency_score": 4}
+{"answers": {"text": ["A 64-year-old female enrollee has requested reimbursement for repair of cartilage in the left ankle joint performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.", "In this case, the lesion had remained symptomatic for over two years before the second surgery."], "answer_start": [19, 634]}, "context": "Summary Reviewer \n\nA 64-year-old female enrollee has requested reimbursement for repair of cartilage in the left ankle joint performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteochondral lesions of the talus occur in up to 70% of acute ankle sprains and fractures. These lesions have become increasingly recognized with the advancements in magnetic resonance imaging (MRI) scans. A fair number of these lesions can remain symptomatic and necessitate surgery. In this case, the lesion had remained symptomatic for over two years before the second surgery. Thus, additional surgery was needed. The type of surgery has included either reparative procedures, such as bone marrow stimulation, or replacement procedures, such as autologous osteochondral transplantation. Reparative procedures are generally indicated for smaller lesions, such as this one. The reparative techniques include debridement and bone marrow stimulation techniques, such as microdrilling and microfracture. Regenerative techniques include autologous osteochondral transplants utilized for larger lesions. A review of the current literature indicates drilling, microfracture and insertion of micronized cartilage and bone marrow aspirate concentrate appears to be a safe and effective treatment option for osteochondral lesions of the talus. The addition of bone marrow aspirate concentrate and micronized cartilage does not result in an increase in ankle or donor site morbidity. It is a well-tolerated therapy that significantly promotes healing and decreases revision rates for treatment of the osteochondral lesions when compared to debridement and microfracture alone. Therefore, repair of cartilage in the left ankle joint performed on 11/14/18 was medically necessary for the treatment of this patient.", "id": "efa08e647728462398a4d73f39c7df72", "question": "What is the background context in this case summary?", "title": "efa08e647728462398a4d73f39c7df72", "sufficiency_score": 4}
+{"answers": {"text": ["A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The medical evidence has not established whether therapy guided by following trough drug levels and drug antibodies is superior to routine good clinical care.  The data available are uncontrolled and come from retrospective analyses.  In general, for a patient failing therapy, there is a trend toward lower trough drug levels with or without the presence of antibody.  However, many patients fail therapy with a normal drug level for a variety of reasons.  All told, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other methods of evaluation.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "b3d9296ac03a4515b1cced973479e6c4", "question": "What is the background context in this case summary?", "title": "b3d9296ac03a4515b1cced973479e6c4", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nThe parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the clinical utility of chromosomal microarray (CMA) is well-established, and is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. Research continues to support the use of CMA testing in the evaluation of developmental delays and autism spectrum disorders. Recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "410d5265712b4ab5a0093b6152c850d8", "question": "What is the background context in this case summary?", "title": "410d5265712b4ab5a0093b6152c850d8", "sufficiency_score": 2}
+{"answers": {"text": ["A 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Documents critical to the review, such as a psychiatric assessment, interpretative summary, serial progress notes, longitudinal history of the illness burden and outcomes of specific evidence-based psychotherapies and non-pharmacologic interventions, were not presented.  The information provided, including the patients lengthy course of treatment with mood stabilizing and antipsychotic medications and poor tolerability of antidepressants, strongly suggests bipolar depression rather than a unilateral mood disorder and does not detail the influence of the patients psychiatric comorbid conditions.  Considering transcranial magnetic stimulation is indicated for the acute phase treatment of major depressive disorder at this time, and the safety and effectiveness of transcranial magnetic stimulation therapy has not been established for other psychiatric disorders, the medical necessity of the services at issue cannot be established.  All told, transcranial magnetic stimulation therapy from 6/30/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "6a0855e61d4945a7b80678fa5e72080a", "question": "What is the background context in this case summary?", "title": "6a0855e61d4945a7b80678fa5e72080a", "sufficiency_score": 2}
+{"answers": {"text": ["A 64-year-old female has requested reimbursement for DecisionDx-Melanoma assay provided on 3/21/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 64-year-old female has requested reimbursement for DecisionDx-Melanoma assay provided on 3/21/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on the DecisionDx-Melanoma assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. In sum, DecisionDx-Melanoma assay provided on 3/21/18 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n\n", "id": "9c1c23cf4a604b0a96f5cacc208f0a66", "question": "What is the background context in this case summary?", "title": "9c1c23cf4a604b0a96f5cacc208f0a66", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 13-year-old male enrollee has requested authorization and coverage for Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with inflammatory bowel disease, psoriasis and juvenile ankylosing spondylitis."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe parent of a 13-year-old male enrollee has requested authorization and coverage for Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with inflammatory bowel disease, psoriasis and juvenile ankylosing spondylitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. Cimzia is an anti-tumor necrosis factor medication which is indicated for the treatment of psoriasis, inflammatory bowel disease and ankylosing spondylitis/sacroiliitis. These diseases are the same in children and adults and respond to therapy similarly. Currently, there is an active trial being conducted, the Pediatric Arthritis Study of Certolizumab Pegol (PASCAL). This is a phase 3, multicenter, open-label study to assess the pharmacokinetics, safety, and efficacy of certolizumab pegol (Cimzia) in children and adolescents with moderately to severely active polyarticular-course juvenile idiopathic arthritis. In this patients case, Cimzia is a medically appropriate treatment option. Thus, Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications are medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "507383753249460096d835460acf9e32", "question": "What is the background context in this case summary?", "title": "507383753249460096d835460acf9e32", "sufficiency_score": 3}
+{"answers": {"text": ["An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.", "This patient has", "failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his obstructive sleep apnea."], "answer_start": [20, 429, 454]}, "context": "Summary Reviewer 2\n\nAn 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his obstructive sleep apnea. Multiple studies have demonstrated that hypoglossal nerve stimulation or Inspire airway stimulation improves health for people with obstructive sleep apnea with clinically significant decreases in observed mean apnea-hypopnea index and improvements in quality of life. The American Academy of Otolaryngology-Head and Neck Surgery considers aupper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy.a All told, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.\n\n\n", "id": "ffe53a463c504f03874dbe09af269bcf", "question": "What is the background context in this case summary?", "title": "ffe53a463c504f03874dbe09af269bcf", "sufficiency_score": 4}
+{"answers": {"text": ["A 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that surgical implantation of healthy cartilage cells (autologous chondrocyte implantation) is an alternative option for the treatment of large articular cartilage defects. Autologous chondrocyte implantation is primarily used to treat full-thickness cartilaginous defects of the distal femur by arthroscopically extracting healthy chondrocyte cells from the patients knee, culturing the cells, and implanting them back into an articular defect via an open surgical procedure. In general, autologous chondrocyte implantation is recommended as a second-line surgical option either after failure of initial arthroscopic repair or when a full-thickness articular cartilage defect is very large (2.5 cm2 or greater).  Autologous chondrocyte implantation should also be avoided in obese patients who have been shown to have no sustained improvement at two years. Worse outcomes have been reported in females with autologous chondrocyte implantation, especially in patients with patellar defects. Weak evidence has suggested some success with patellar autologous chondrocyte implantation, which remains off-label, but quality randomized controlled trials are lacking. In this patients case, the records noted a bipolar chondral lesion of the patellofemoral joint, which is a contraindication for autologous chondrocyte implantation. The failure rate of this procedure is high in this location. Thus, autologous chondrocyte implantation of the knee is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "c837299aecad4274b4c06817a91d4b61", "question": "What is the background context in this case summary?", "title": "c837299aecad4274b4c06817a91d4b61", "sufficiency_score": 3}
+{"answers": {"text": ["A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition.", "This patient has been treated with a variety of modalities, including beta-blocker therapy, fludrocortisone and pyridostigmine, but has some persistent symptomatology."], "answer_start": [20, 450]}, "context": "Summary Reviewer 1\n\nA 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the treatment of autonomic neuropathy can often involve multidisciplinary strategies, both from cardiovascular medicine as well as neurology. This patient has been treated with a variety of modalities, including beta-blocker therapy, fludrocortisone and pyridostigmine, but has some persistent symptomatology. There is the additional factor that there may be comorbidities to suggest autoimmune disorder as well. However, the use of intravenous immunoglobulin to treat autonomic dysfunction remains investigational. The study by Schofield is retrospective and only included 38 patients. There is a lack of support for the requested medication in this clinical setting. Therefore, Octagam infusions are not likely to be more beneficial than any available standard therapy.  \n\n\n", "id": "063569af1df74b0f89f0b73e123f2640", "question": "What is the background context in this case summary?", "title": "063569af1df74b0f89f0b73e123f2640", "sufficiency_score": 2}
+{"answers": {"text": ["A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found pertuzumab is a monoclonal antibody that targets HER2 positive breast cancer cells, similar to, but not exactly in the same way as trastuzumab.  In metastatic breast cancer, when used in combination with chemotherapy and trastuzumab, pertuzumab yields superior progression-free survival compared to treatment with Taxotere-Herceptin without pertuzumab.  Combining pertuzumab with Herceptin and chemotherapy also appears to be superior to the combination without pertuzumab in the neoadjuvant situation.  However, there is a lack of data to support the use of combining pertuzumab with trastuzumab in the adjuvant setting.  Therefore, the superior efficacy of pertuzumab injections from 8/18/15 forward has not been established.  Based upon the information set forth above, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "bb3103886e274bfb91b837bab8519f03", "question": "What is the background context in this case summary?", "title": "bb3103886e274bfb91b837bab8519f03", "sufficiency_score": 3}
+{"answers": {"text": ["A 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD)."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX reflux management system lower esophageal sphincter augmentation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "5f5df32ecc70494db7e4e46ba977006d", "question": "What is the background context in this case summary?", "title": "5f5df32ecc70494db7e4e46ba977006d", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 60-year-old female with a history of class 1 obesity complicated by dyslipidemia. The \nrecords available for review indicate that the patient had a body mass index (BMI) over 30 kg/m2 prior \nto beginning treatment with Wegovy.", "the issue is whether the \nrequested Wegovy solution auto-injector 0.25 mg/0.5 mL is medically necessary for the treatment of \nthis patient.", "In \nthis case, the patient has a history of class 1 obesity complicated by dyslipidemia. The records reflect \nthat the patient has attempted treatment with diet management and exercise without significant \nbenefit. Per the provider, the patient has contraindications or intolerances to several weight loss \nmedications.", "the patient has demonstrated prior weight loss success with \nWegovy."], "answer_start": [10, 288, 1216, 1659]}, "context": "Summary  \nThe patient is a 60-year-old female with a history of class 1 obesity complicated by dyslipidemia. The \nrecords available for review indicate that the patient had a body mass index (BMI) over 30 kg/m2 prior \nto beginning treatment with Wegovy. The physician reviewer found that the issue is whether the \nrequested Wegovy solution auto-injector 0.25 mg/0.5 mL is medically necessary for the treatment of \nthis patient. According to Gadde and colleagues, while lifestyle modification is recommended as the \ncornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty \nwith adherence as well as physiological and neurohormonal adaptation of the body in response to \nweight loss. There are multiple pharmacologic therapies available for weight management. Wegovy is a \nmember of a class of medications known as glucagon-like peptide 1 (GLP-1) analogs. As noted in the \nmedical literature, GLP-1 analogs have been shown to improve glycemic control, reduce body weight, \nand decrease cardiovascular risk (Knudsen and Lau). Studies have demonstrated Wegovys ability to \npromote weight loss via reduced appetite and energy intake and delayed gastric emptying (Cornell). In \nthis case, the patient has a history of class 1 obesity complicated by dyslipidemia. The records reflect \nthat the patient has attempted treatment with diet management and exercise without significant \nbenefit. Per the provider, the patient has contraindications or intolerances to several weight loss \nmedications. Wegovy has been shown to effectively promote weight loss for patients in conjunction \nwith diet and exercise. Furthermore, the patient has demonstrated prior weight loss success with \nWegovy. All told, the requested Wegovy solution auto-injector 0.25 mg/0.5 mL is medically necessary \nfor the treatment of this patient. ", "id": "ecb61264b42143d4aa2eeb191d1cde20", "question": "What is the background context in this case summary?", "title": "ecb61264b42143d4aa2eeb191d1cde20", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported \npain in her left knee that she rated at an eight out of a scale of ten. The patient has requested \nreimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this \nrequest and reported that the services at issue were not medically necessary.", "In this case, the \npatient reported pain at a level of eight out of ten that did not respond to a corticosteroid injection \non 3/17/22. The patient had tried and failed other conservative treatments."], "answer_start": [19, 1183]}, "context": "Summary Reviewer  \nThe patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported \npain in her left knee that she rated at an eight out of a scale of ten. The patient has requested \nreimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this \nrequest and reported that the services at issue were not medically necessary. This denial is the \nsubject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted \ndocumentation supports the medical necessity of the services at issue. Per the medical literature, \nalthough viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is \nnot known as to which individuals will benefit. The current evidence is limited, and guidelines \nfrom organizations such as the American Academy of Orthopedic Surgeons indicate that the \nevidence  is  not  conclusive.  In  light  of  the  foregoing,  viscosupplementation  can  only  be \nrecommended in individuals with a history of lasting benefit from prior injections, and in carefully \nselected cases where everything else has been tried, and the options are limited. In this case, the \npatient reported pain at a level of eight out of ten that did not respond to a corticosteroid injection \non 3/17/22. The patient had tried and failed other conservative treatments. Given the patients \nlimited options and based on the current medical literature, the services at issue were medically \nindicated. Therefore, Synvisc from 6/15/22 through 6/29/22 was medically necessary for the \ntreatment of this patient. \n ", "id": "bdff1d6268174de9afd03f8c45982e92", "question": "What is the background context in this case summary?", "title": "bdff1d6268174de9afd03f8c45982e92", "sufficiency_score": 4}
+{"answers": {"text": ["A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the \nultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at \nissue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy.", "In this case, notes dated 6/2/22 \nreported a body mass index of 28 kg/m2, the demise of a dichorionic twin at seven weeks, and the \nfinding of a uterine synechia."], "answer_start": [22, 1038]}, "context": "Summary Reviewer 1 \n \nA 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the \nultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at \nissue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. \nThe physician reviewer found that American Institute of Ultrasound Medicine (AIUM) notes that \ndetailed obstetric ultrasound examination is not intended to be the routine ultrasound examination \nperformed for all pregnancies. Rather, the AIUM notes that it is an indication-driven examination \nperformed for a known or suspected fetal anatomic abnormality, known fetal growth disorder, \ngenetic abnormality, or increased risk for a fetal anatomic or genetic abnormality or placenta \naccreta spectrum. The Society for Maternal-Fetal Medicine (SMFM) notes that the performance \nof the detailed fetal anatomic examination should be rare outside referral practices with special \nexpertise in the identification and diagnosis of fetal anomalies. In this case, notes dated 6/2/22 \nreported a body mass index of 28 kg/m2, the demise of a dichorionic twin at seven weeks, and the \nfinding of a uterine synechia. However, these are not indications that the more detailed fetal \nultrasound  at  issue  was  likely  to  be  beneficial  than  standard,  routine  ultrasound  screening \nTherefore, ultrasound and reading of the ultrasound on 8/2/22 was not likely to have been more \nbeneficial for evaluation of the patients condition than any available standard therapy. \n \n \n", "id": "8ee057743cbf4eb2b7261ca07b91f3b7", "question": "What is the background context in this case summary?", "title": "8ee057743cbf4eb2b7261ca07b91f3b7", "sufficiency_score": 4}
+{"answers": {"text": ["A 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this patients case.  The records do not demonstrate that a specific genetic condition is suspected by the requesting provider.  In the absence of a proposed diagnosis, there is insufficient evidence that this testing will change management or improve health for this patient.   In addition, given the early state of this technology, the implications of many genetic mutations are not currently known.  For these reasons, the requested services are not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "81968e2b3d314231bf4ffacb88bd98fb", "question": "What is the background context in this case summary?", "title": "81968e2b3d314231bf4ffacb88bd98fb", "sufficiency_score": 2}
+{"answers": {"text": ["A 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although DecisionDx Melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. For this reason, the DecisionDx Melanoma testing (CPT code 84999) performed on 1/23/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "a19d35d9ec6c424ea8a812445f79ffe1", "question": "What is the background context in this case summary?", "title": "a19d35d9ec6c424ea8a812445f79ffe1", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 2/06/13 through 5/03/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.", "In this case, the patient was struggling with the developmental stage of identity formation which was complicated by a formidable anxiety and affective burden coupled with an underdeveloped sense of self and substance use which fueled dysphoria and parent-child disharmony."], "answer_start": [20, 453]}, "context": "Summary Reviewer \n\n\nThe parent of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 2/06/13 through 5/03/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this case, the patient was struggling with the developmental stage of identity formation which was complicated by a formidable anxiety and affective burden coupled with an underdeveloped sense of self and substance use which fueled dysphoria and parent-child disharmony.  The documentation provided does not support the medical necessity of the services at issue during the disputed timeframe.  It appears as though the patient and his family had not pursued evidence-based treatments in a less restrictive setting during the episode of illness.  Such interventions include, but are not limited to, school-based services, psychotherapy, chemical dependency counseling, family therapy, parent training and pharmacotherapy.  Additionally, the medical records did not include a psychiatric evaluation, psychosocial assessment, history and physical examination, or integrated summary justifying the necessity of the placement as opposed to a lower level of care.  The discharge summary, psychological evaluation and initial treatment plan did not describe behaviors, symptomatologies, or treatment interventions that would typically require a 24-hour supervised setting.  In sum, the documentation submitted for review did not suggest that a less restrictive setting would have been insufficient.  All told, residential treatment provided from 2/06/13 through 5/03/13 was not medically necessary for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n\n", "id": "f7f83ba59308416995b828d5964b6905", "question": "What is the background context in this case summary?", "title": "f7f83ba59308416995b828d5964b6905", "sufficiency_score": 4}
+{"answers": {"text": ["A 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found the Decision Dx melanoma assay examines genes for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy in thin melanomas. However, the patients treatment would not likely change based on the results of the exam. There is a lack of medical literature to support its use in patients with thin melanomas to effect health outcomes. Given the lack of published data to support the use of gene expression profiling, the testing performed on 6/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n", "id": "e030fdf6972248cb93519af7e0bb86e2", "question": "What is the background context in this case summary?", "title": "e030fdf6972248cb93519af7e0bb86e2", "sufficiency_score": 3}
+{"answers": {"text": ["A 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition.", "There has been a diagnosis of peripheral motor polyneuropathy. Medical records from his neurologist describes muscular atrophy and weakness, diminished distal reflexes, and no upper motor neuron signs. Headaches and autonomic dysfunction are also described. He has had treatment with Radicava, which is indicated for treatment of amyotrophic lateral sclerosis."], "answer_start": [20, 481]}, "context": "Summary Reviewer 3\n\nA 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested medication. There has been a diagnosis of peripheral motor polyneuropathy. Medical records from his neurologist describes muscular atrophy and weakness, diminished distal reflexes, and no upper motor neuron signs. Headaches and autonomic dysfunction are also described. He has had treatment with Radicava, which is indicated for treatment of amyotrophic lateral sclerosis. The notes do not include electromyography/nerve conduction velocity studies or autoimmune studies. Based on the available records, the diagnosis is unclear. While motor neuropathy is commonly treated with intravenous immune globulin, there is a lack of evidence that intravenous immune globulin would be helpful for amyotrophic lateral sclerosis. Without a more distinct diagnosis, it is not possible to state that intravenous immune globulin is likely to be more effective than other therapies. Thus, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is not likely to be more beneficial than other treatment options.\n\n\n", "id": "a2ac5c794df348d7873f94cb9ac1ad9a", "question": "What is the background context in this case summary?", "title": "a2ac5c794df348d7873f94cb9ac1ad9a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 36year-old female with a history of low back and right lower extremity pain due to a disc herniation at L4-5.  The patient has requested reimbursement for anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.", "This patient has requested reimbursement for the surgery and two days of inpatient hospitalization."], "answer_start": [19, 1399]}, "context": "Summary Reviewer \n\nThe patient is a 36year-old female with a history of low back and right lower extremity pain due to a disc herniation at L4-5.  The patient has requested reimbursement for anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Phan and colleagues performed a meta-analysis of seven studies, including 181 patients who underwent anterior lumbar discectomy and fusion after primary discectomy had resulted in a recurrence of low back and leg pain, as in this patients case. The authors noted that there are certain advantages to the anterior approach. Repeat posterior approach for recurrent herniations may result in trauma to the spinal nerves and paraspinal muscles that is avoided in the anterior approach. Furthermore, the authors noted that the exposure allows for a comprehensive discectomy. In these 181 patients, there was significant improvement in the Oswestry Disability Index and Visual Analogue Scale (VAS) back and leg pain scores. The average length of hospital stay was 5.28 days. This patient has requested reimbursement for the surgery and two days of inpatient hospitalization. The authors concluded that anterior lumbar interbody fusion is a feasible approach for the treatment of recurrent lumbar disc herniations and demonstrates good results, with minimal complications. As such, in the presence of a recurrent herniation with chronic low back and leg pain, and failure of conservative treatment, the services at issue were medically indicated. Therefore, the anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization were medically necessary for the treatment of this patient. \n", "id": "6c67da0fe4d14f1c9296567152d857be", "question": "What is the background context in this case summary?", "title": "6c67da0fe4d14f1c9296567152d857be", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 13-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.", "This patient had a low annual growth velocity which indicated abnormal growth. His estimated adult height gradually declined to 66 inches", "His estimated adult height is below his genetic potential of 71.6 inches. Per the records, he failed growth hormone stimulation testing with a peak less than 10ng/mL"], "answer_start": [19, 422, 590]}, "context": "Summary Reviewer \n\nThe parent of a 13-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. This patient had a low annual growth velocity which indicated abnormal growth. His estimated adult height gradually declined to 66 inches, which indicates poor growth. His estimated adult height is below his genetic potential of 71.6 inches. Per the records, he failed growth hormone stimulation testing with a peak less than 10ng/mL, which indicates growth hormone deficiency in the setting of poor growth. Therefore, Humatrope 24 mg cartridge is medically necessary for the treatment of this patient.", "id": "fd8c739aa3564a0d8b7fad64736c8736", "question": "What is the background context in this case summary?", "title": "fd8c739aa3564a0d8b7fad64736c8736", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 44-year-old female who presented to the emergency department on 10/13/19 with complaints of abdominal pain status post dirt bike accident. At the time of presentation, her vital signs were stable, with a heart rate of 112 and normal oxygen saturations on room air.", "in this case, the patient was admitted in stable condition. Her pain was controlled with oral pain medications.", "Her vital signs were stable"], "answer_start": [19, 335, 501]}, "context": "Summary Reviewer \n\nThe patient is a 44-year-old female who presented to the emergency department on 10/13/19 with complaints of abdominal pain status post dirt bike accident. At the time of presentation, her vital signs were stable, with a heart rate of 112 and normal oxygen saturations on room air. The physician reviewer found that in this case, the patient was admitted in stable condition. Her pain was controlled with oral pain medications. She did not require any urgent surgery or procedures. Her vital signs were stable, and there was no evidence of hemodynamic instability or active bleeding. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting,\nwhen the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient admission provided from 10/13/19 through 10/14/19 was not medically necessary for the treatment of this patient.", "id": "a258f8c0591f4133a6caef61283d89de", "question": "What is the background context in this case summary?", "title": "a258f8c0591f4133a6caef61283d89de", "sufficiency_score": 4}
+{"answers": {"text": ["A 48-year-old female enrollee has requested reimbursement for laparoscopic gastric sleeve (CPT 43775) performed on 12/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees morbid obesity.", "This patient is an adult with morbid obesity.  Per the records, her body mass index was greater than 40 kg/m2 (it was 44.9 kg/m2). The patient documented prior dietary efforts and completed a multidisciplinary evaluation"], "answer_start": [20, 418]}, "context": "Summary Reviewer \n\n\nA 48-year-old female enrollee has requested reimbursement for laparoscopic gastric sleeve (CPT 43775) performed on 12/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patient is an adult with morbid obesity.  Per the records, her body mass index was greater than 40 kg/m2 (it was 44.9 kg/m2). The patient documented prior dietary efforts and completed a multidisciplinary evaluation that did not reveal any obvious medical, dietary or behavioral barriers to surgery. The patient met standard nationally accepted criteria for bariatric surgery.  The current medical evidence supports the services at issue in this clinical setting.  All told, laparoscopic gastric sleeve performed on 12/17/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n", "id": "0d6bd4aace034883b7e65d69d271fd1c", "question": "What is the background context in this case summary?", "title": "0d6bd4aace034883b7e65d69d271fd1c", "sufficiency_score": 4}
+{"answers": {"text": ["An 18-year-old female enrollee has requested reimbursement for mental health residential treatment from 7/17/17 through 9/16/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.", "The medical records indicate that the patient was not actively suicidal. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation and attempts.", "The patient has had some issues with level of functioning, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming.", "The patient did not have active medical problems and reported a history of mild cannabis use issues.", "The patient was noted to have interpersonal conflict with the family as a focus of treatment.", "the progress notes document that her family therapy sessions were productive and not adversarial.", "The patients parents were involved in treatment on a regular basis.", "The patient had good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. She had a history of residential treatment in the past", "The patient participated in therapy actively and was able to develop a positive relationship with clinicians.", "The parents worked actively and constructively with clinicians on a regular basis."], "answer_start": [19, 720, 1034, 1313, 1618, 1721, 1915, 2063, 2496, 2693]}, "context": "Summary Reviewer \n\nAn 18-year-old female enrollee has requested reimbursement for mental health residential treatment from 7/17/17 through 9/16/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation and attempts. In terms of functional status, the records support a score of 2. The patient has had some issues with level of functioning, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems and reported a history of mild cannabis use issues.  She did not describe continued cravings, and there was no documentation of withdrawal symptoms from substances. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family as a focus of treatment. However, the progress notes document that her family therapy sessions were productive and not adversarial. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. The patient had good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. She had a history of residential treatment in the past, and it is not clear that her symptoms resolved with past treatment efforts. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively and was able to develop a positive relationship with clinicians. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 17. This score correlates intensive outpatient services. Therefore, mental health residential treatment provided from 7/17/17 through 9/16/17 was not medically necessary for the treatment of this patient.", "id": "979e8a9874d24e4894e68f6b432500af", "question": "What is the background context in this case summary?", "title": "979e8a9874d24e4894e68f6b432500af", "sufficiency_score": 4}
+{"answers": {"text": ["A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found Currently, that there is a lack of clinical data in the medical literature to indicate the superior efficacy of the requested services when compared to conventional treatment options. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT).  A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. Also, the ASTRO emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials, (Allen, et al). Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer.  The patients previous history of treatment with radioactive iodine does not preclude the use of standard treatment with photons. Therefore, proton therapy is not likely to be more effective than standard therapy in the treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "0265737f2db24c858a041c92e42386ad", "question": "What is the background context in this case summary?", "title": "0265737f2db24c858a041c92e42386ad", "sufficiency_score": 3}
+{"answers": {"text": ["A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.", "in this case, the patient had severe dysphagia with an inability to tolerate solid food intake and a hiatal hernia, with upper gastrointestinal series showing reflux. Hernia repair surgery was being contemplated before the endoscopy with pH study."], "answer_start": [20, 470]}, "context": "Summary Reviewer 1\n\nA 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that in this case, the patient had severe dysphagia with an inability to tolerate solid food intake and a hiatal hernia, with upper gastrointestinal series showing reflux. Hernia repair surgery was being contemplated before the endoscopy with pH study. This is consistent with current medical literature, which recommends a pH study to evaluate esophageal motility before undergoing such a surgery. Additionally, dysphagia in the setting of dilated and angulated esophagus can be suggestive of achalasia, and warrants evaluation with impedance and with esophagogastroduodenoscopy. Furthermore, esophagogastroduodenoscopy is recommended for the evaluation of dysphagia. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was likely to have been more beneficial than any available standard therapy. \n\n", "id": "6fdea42ee31a4d62889fce48f50922de", "question": "What is the background context in this case summary?", "title": "6fdea42ee31a4d62889fce48f50922de", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old female enrollee has requested reimbursement for DecisionDX Melanoma gene expression assay performed on 12/23/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 60-year-old female enrollee has requested reimbursement for DecisionDX Melanoma gene expression assay performed on 12/23/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found there is a lack of high-grade scientific data to support the superior efficacy of the services at issue in this clinical setting. The DecisionDX Melanoma gene expression assay has not been clinically shown to add to the current standard of care for the evaluation of malignant melanoma. Therefore, the DecisionDX Melanoma gene expression assay performed on 12/23/15 was not likely to be more effective than standard treatment for the evaluation of this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "9ffeefe721cd413a8c0b37082bb961bb", "question": "What is the background context in this case summary?", "title": "9ffeefe721cd413a8c0b37082bb961bb", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a seven-year-old female enrollee has requested authorization and coverage for \nXeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested \nmedication is investigational for the treatment of the enrollees alopecia."], "answer_start": [22]}, "context": "Summary Reviewer 1 \n \nThe parent of a seven-year-old female enrollee has requested authorization and coverage for \nXeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested \nmedication is investigational for the treatment of the enrollees alopecia. The physician reviewer \nfound that the U.S. Food and Drug Administration (FDA) approves the use of one Janus kinase \n(JAK) inhibitor, Olumiant (generic name baricitinib), for the treatment of adult patients with \nsevere alopecia areata. Pediatric-onset alopecia areata, including alopecia universalis, tends to \nbe more severe and carries a worse prognosis than adult-onset disease. While there are no FDA \napproved treatments for alopecia areata in pediatric patients, current medical literature supports \nthe use of oral JAK inhibitors, such as Xeljanz, as resulting in an improvement of Severity of \nAlopecia Tool (SALT) scores. Kennedy Crispin and colleagues report that tofacitinib is a safe and \neffective treatment for severe alopecia areata. Toussi and colleagues note that alopecia areata \nhas substantial psychosocial impact on patients and results in reduced health-related quality of \nlife, which should be addressed as an active part of treatment. In this case, given the patients \nresponse to Xeljanz, including hair regrowth and improvement of psychiatric comorbidities, the \nrequested medication is likely to be more beneficial than the several other treatments that she \nhas already tried and failed. Therefore, Xeljanz 5 mg tablet is likely to be more beneficial for \ntreatment of the patients condition than any available standard therapy. \n \n \n", "id": "8c41eeada921465885939624145f947b", "question": "What is the background context in this case summary?", "title": "8c41eeada921465885939624145f947b", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 57-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland. The patient has requested authorization and coverage for intensity modulated radiation therapy image-guided radiation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 57-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland. The patient has requested authorization and coverage for intensity modulated radiation therapy image-guided radiation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the requested services are standard of care in this clinical setting. High-quality clinical outcomes published in the peer-reviewed medical literature have proven that aggressive consolidation of oligometastatic prostate cancer is associated with a significant improvement in chances for long-term survival. The high-quality prospective trial by Parker and colleagues supports such a benefit, as definitive radiotherapy improved failure-free survival. IMRT is widely employed nationwide for similar patients in this setting. Therefore, intensity modulated radiation therapy image-guided radiation is medically necessary for the treatment of this patient. ", "id": "e828d3fef3e6421e914ea7632300bcd1", "question": "What is the background context in this case summary?", "title": "e828d3fef3e6421e914ea7632300bcd1", "sufficiency_score": 3}
+{"answers": {"text": ["A 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.", "This patient presents with a history of chronic severe right ankle pain and swelling. Significant functional limitations are noted that interfere with activities of daily living. There is imaging evidence of a very large cystic osteochondral lesion of the right talus. She has failed long-term conservative management as well as operative intervention. She is not a candidate for microfracture surgery due to the size of the lesion."], "answer_start": [20, 936]}, "context": "Summary Reviewer 2\n\nA 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that current evidence-based medical literature supports the use of autologous chondrocyte implantation as a first-line treatment option for large articular cartilage defects. The literature supports treatment with bone marrow stimulation for lesions of smaller sizes, whereas treatment with autologous osteochondral transplantation may be utilized for larger or cystic lesions. The literature indicates that autologous chondrocyte implantation of the talus yields improvement in all parameters tested, with enduring long-term results in patients who have failed previous surgery for osteochondral lesions of the talus. This patient presents with a history of chronic severe right ankle pain and swelling. Significant functional limitations are noted that interfere with activities of daily living. There is imaging evidence of a very large cystic osteochondral lesion of the right talus. She has failed long-term conservative management as well as operative intervention. She is not a candidate for microfracture surgery due to the size of the lesion. Current evidence-based medical literature supports the use of autologous chondrocyte implantation in this clinical setting as a salvage procedure. In sum, autologous chondrocyte implantation is likely to be more beneficial than other treatment options.\n\n\n", "id": "fccada618ca149e38d6bd8ce019f5a6f", "question": "What is the background context in this case summary?", "title": "fccada618ca149e38d6bd8ce019f5a6f", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old female enrollee has requested reimbursement for cervical spine surgery performed on 7/25/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees neck pain and tingling in the upper extremities.", "This patient presented with persistent and worsening neck pain radiating down the left upper extremity, with tingling and weakness, and progressive right upper extremity symptoms. Associated symptoms included clumsiness and inability to grasp and hold objects. She was no longer able to work. Clinical examination findings evidenced C6 and C7 myotomal weakness", "evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted."], "answer_start": [20, 1351, 1858]}, "context": "Summary Reviewer \n\n\nA 55-year-old female enrollee has requested reimbursement for cervical spine surgery performed on 7/25/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees neck pain and tingling in the upper extremities.The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Davis and colleagues performed a prospective, randomized, controlled, multicenter clinical trial on two-level symptomatic degenerative disc disease. Their findings supported the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two-level anterior cervical discectomy and fusion. The U.S. Food and Drug Administration has approved the use of artificial disc replacement for skeletally mature patients for reconstruction of the disc from C3-C7 following discectomy at two contiguous levels for intractable radiculopathy (arm pain and/or neurologic deficit) with or without neck pain, or myelopathy due to abnormality localized to the level of the disc space and at least one of the following conditions confirmed by radiographic imaging: herniated nucleus pulposus, spondylosis (defined by the presence of osteophytes) and/or visible loss of disc height compared with adjacent levels. This patient presented with persistent and worsening neck pain radiating down the left upper extremity, with tingling and weakness, and progressive right upper extremity symptoms. Associated symptoms included clumsiness and inability to grasp and hold objects. She was no longer able to work. Clinical examination findings evidenced C6 and C7 myotomal weakness consistent with imaging evidence of nerve root compromise at the C5-C6 level and bilateral neural foraminal stenosis at the C6-C7 level. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. Evidence-based criteria were met to establish the medical necessity of this surgical intervention. Therefore, the cervical spine surgery performed on 7/25/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "7829bec8c3e94c0eabaee292a7a489c6", "question": "What is the background context in this case summary?", "title": "7829bec8c3e94c0eabaee292a7a489c6", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 51-year-old female who had a vaginal delivery in 2004 complicated by grade 4 episiotomy and Clostridium difficile on and off for six months. The patient has requested reimbursement for opium tincture 10 mg/mL provided on 2/18/20. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of this patient.", "The patient has been stabilized on opium tincture for several years. She has attempted several medical alternatives and has undergone sacral nerve stimulator."], "answer_start": [19, 926]}, "context": "Summary Reviewer \n\nThe patient is a 51-year-old female who had a vaginal delivery in 2004 complicated by grade 4 episiotomy and Clostridium difficile on and off for six months. The patient has requested reimbursement for opium tincture 10 mg/mL provided on 2/18/20. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of this patient. The physician reviewer found that the use of opium tincture is supported as medically necessary for the treatment of this patientas incontinence and diarrhea. American Society of Colon and Rectal Surgeons guidelines for the treatment of fecal incontinence state that medical management should be first-line therapy, and opioids result in decreased intestinal motility, decreased intestinal secretion, and increased absorption. Opiates are recommended as safe and effective for the treatment of chronic diarrhea. The patient has been stabilized on opium tincture for several years. She has attempted several medical alternatives and has undergone sacral nerve stimulator. There is sufficient support for the requested medication in this setting. Therefore, opium tincture 10 mg/mL provided on 2/18/20 was medically necessary for the treatment of this patient. ", "id": "f11159e331f6462d8059c81444eeccb5", "question": "What is the background context in this case summary?", "title": "f11159e331f6462d8059c81444eeccb5", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old female enrollee has requested reimbursement for left and right eye refraction surgery performed on 9/19/16 and 10/07/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollee, who has a history of blurred vision.", "The records show that the patient did have symptomatic cataracts"], "answer_start": [20, 481]}, "context": "Summary Reviewer \n\n\nA 54-year-old female enrollee has requested reimbursement for left and right eye refraction surgery performed on 9/19/16 and 10/07/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollee, who has a history of blurred vision. The physician reviewer found that the submitted submitted documentation supports the medical necessity of a portion of the services at issue. The records show that the patient did have symptomatic cataracts requiring surgery. The Health Insurers argument that the surgery was purely for refractive reasons was not substantiated upon reviewing the medical records. Thus, the portion of surgeries to treat cataract was medically necessary. The additional treatments of femtosecond laser and multifocal intraocular lens were for the purpose of refractive treatment and were not medically necessary. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.", "id": "25b117d5149946adb2912cbb0f0575aa", "question": "What is the background context in this case summary?", "title": "25b117d5149946adb2912cbb0f0575aa", "sufficiency_score": 3}
+{"answers": {"text": ["A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that when performing thrombophilia screening, while the probability of a positive assay is higher in patients with a history of thrombus, the information provided does not help to inform future management. Various professional organizations have published guidelines indicating that routine thrombophilia screening in patients presenting with thrombosis should not be performed. In this\ncase, results of the thrombophilia screen is not likely to justify an evidence-based modification of this patients management. Furthermore, the consulting provider indicated that the deep vein thrombosis was considered to be a provoked event. The medical evidence does not support thrombophilia screening in this setting. In sum, laboratory testing performed on 6/26/19 was not likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "14ff4d58a3504b8289dd87e34a9a17b4", "question": "What is the background context in this case summary?", "title": "14ff4d58a3504b8289dd87e34a9a17b4", "sufficiency_score": 1}
+{"answers": {"text": ["A 62-year-old male enrollee has requested authorization and coverage for proton beam therapy. \nThe  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  service  is \ninvestigational for the treatment of the enrollees prostate cancer."], "answer_start": [22]}, "context": "Summary Reviewer 3 \n \nA 62-year-old male enrollee has requested authorization and coverage for proton beam therapy. \nThe  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  service  is \ninvestigational for the treatment of the enrollees prostate cancer. The physician reviewer found \nthat in this clinical setting, the only justified use for proton therapy would be in a clinical trial. \nStandard radiation therapy for prostate cancer is with x-ray IMRT radiation therapy, which has \nbeen shown to carry no long-term significant side effects. There is a lack of evidence in current \nmedical literature showing improvement in terms of local control of the prostate cancer or for a \nsurvival benefit with the use of proton therapy. The NCCN guidelines note that photon or proton \nEBRT are both effective at achieving highly conformal radiotherapy with acceptable and similar \nbiochemical control and long-term side effect profiles. Takeda and colleagues reported a very \nlow  rate  of  grade  3  urine  toxicity,  which  is  not  life-threatening  and  does  not  require \nhospitalization, in patients with prostate cancer treated with IMRT and no in stances of grade 4 \ntoxicity. In a study regarding 15-year outcomes data for 301 patients with prostate cancer treated \nwith x-ray IMRT, Weg and colleagues observed grade 3 gastrointestinal toxicity in three patients \nand no instances of grade 4 toxicity. The Radiation Therapy Oncology Group (RTOG) protocol \nnotes that the small bowel can tolerate a maximum dose of 50 Gy, which is more than the typical \ndosage of 45 Gy in 2 gray equivalent dosage for EBRT treatment of elective lymph nodes for \nprostate cancer. In this case, the patient reported concern regarding the potential impact of ADT \ndue to his history of hypogonadism. In this clinical setting, the NCCN recommends brachytherapy \nand EBRT, noting that ADT is only optional in this setting. Therefore, proton beam therapy is not \nlikely to be more beneficial for treatment of the patients condition than any available standard \ntherapy. \n \n ", "id": "98e813905ad145149db63019e3cf16d8", "question": "What is the background context in this case summary?", "title": "98e813905ad145149db63019e3cf16d8", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 39-year-old female who underwent genetic testing during pregnancy.  Specifically, she underwent testing for the SMARCA4 gene mutation. The patient had a prior affected child with the SMARCA4 gene mutation leading to the child having Coffin-Siris syndrome. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nThe patient is a 39-year-old female who underwent genetic testing during pregnancy.  Specifically, she underwent testing for the SMARCA4 gene mutation. The patient had a prior affected child with the SMARCA4 gene mutation leading to the child having Coffin-Siris syndrome. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. Per the records, there is a higher chance than the general population that the fetus may have the gene mutation SMARCA4 leading to Coffin-Siris syndrome.  Since this patient already had a severely affected offspring, the information from this testing was important in making important medical decisions regarding the pregnancy. Thus, SMARCA4 gene mutation and chromosome testing performed on 8/14/17 were likely to be of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "93dd4cf11c8147cd853d589722c2bcca", "question": "What is the background context in this case summary?", "title": "93dd4cf11c8147cd853d589722c2bcca", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 49-year-old male with a history of acute trauma to the thigh resulting in a thigh compartment syndrome. He underwent an emergency fasciotomy; however, the submitted documentation indicates the treating surgeon was not familiar with post-surgical care. The record noted a 14-inch draining skin incision. The patient was transported by air ambulance from Florida to Dallas, Texas. The patient has requested reimbursement for air ambulance services provided on 11/25/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary.", "the record had noted that the patients vital signs were stable", "The patient had a 14-inch long draining wound and the submitted documentation indicates the initial surgeon was not familiar with current fasciotomy wound closure techniques.", "The patient could not utilize public transportation due to the need for maximum assistance with ambulation. His ambulation was limited to use of bathroom only with assistance. He required dressing changes by medical personnel with sterile precautions as needed to keep wound clean during transport."], "answer_start": [18, 2182, 1387, 1877]}, "context": "Summary Reviewer\n\nThe patient is a 49-year-old male with a history of acute trauma to the thigh resulting in a thigh compartment syndrome. He underwent an emergency fasciotomy; however, the submitted documentation indicates the treating surgeon was not familiar with post-surgical care. The record noted a 14-inch draining skin incision. The patient was transported by air ambulance from Florida to Dallas, Texas. The patient has requested reimbursement for air ambulance services provided on 11/25/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary. This denial is the subject of this appeal and determination.  There is sufficient support in the documentation and the medical literature for the medical necessity of the services at issue. Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time are also crucial for optimization of functional and aesthetic outcomes. The patient had a 14-inch long draining wound and the submitted documentation indicates the initial surgeon was not familiar with current fasciotomy wound closure techniques. Transfer by air ambulance to a tertiary care institution was needed in light of the 14-inch long draining open wound and the patients pain. There was an urgent need for wound management at a tertiary care center to prevent deep infection, facilitate healing, and prevent complications such as deep vein thrombosis. The patient could not utilize public transportation due to the need for maximum assistance with ambulation. His ambulation was limited to use of bathroom only with assistance. He required dressing changes by medical personnel with sterile precautions as needed to keep wound clean during transport. While the record had noted that the patients vital signs were stable, stable vitals do not mean a sudden change in vitals cannot take place at any moment due to bleeding from an open wound. The presence of emergency medical personnel was essential. Tertiary care in Dallas, Texas was chosen because it was near his home. His treatment in Orlando, Florida would have necessitated a prolonged stay for follow-up care and inability to use public transportation. As noted above, the surgeon in Florida was unfamiliar with vacuum assisted closure.  Vacuum assisted closure technique has one of the lowest complication rates. In sum, air ambulance services provided on 11/25/17 were medically necessary for treating this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n", "id": "f8b18f865a9f4963893dddba75b48751", "question": "What is the background context in this case summary?", "title": "f8b18f865a9f4963893dddba75b48751", "sufficiency_score": 4}
+{"answers": {"text": ["A 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition.", "this patient had an early stage melanoma."], "answer_start": [19, 309]}, "context": "Summary Reviewer \n\nA 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, CPT 84999 performed on 10/17/18 was not medically necessary for the evaluation of this patient.", "id": "8631278b30874bcf835d8fff107269b8", "question": "What is the background context in this case summary?", "title": "8631278b30874bcf835d8fff107269b8", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a 64-year-old male with a diagnosis of hypogonadism. His symptoms include decreased energy and libido, mood swings, sleepiness and changes in fat/muscles. His pre-treatment testosterone level was 208 in 2011. The patient has been treated with testosterone injections and Testopel. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nThe patient is a 64-year-old male with a diagnosis of hypogonadism. His symptoms include decreased energy and libido, mood swings, sleepiness and changes in fat/muscles. His pre-treatment testosterone level was 208 in 2011. The patient has been treated with testosterone injections and Testopel. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The use of Testopel is appropriate only for patients with an appropriate diagnosis of hypogonadism based on criteria recommended by national and international guidelines. Guidelines require measurement of two morning testosterone levels along with follicle-stimulating hormone/luteinizing hormone (FSH/LH) levels prior to initiation of therapy to identify the presence of and type of hypogonadism. In this case, the documentation submitted for review does not support that this was performed. In addition, patients who are on testosterone replacement should be monitored with laboratory work-up that includes testosterone, hematocrit, prostate-specific antigen (PSA), and lipid profile initially at frequent intervals and annually thereafter. Based on the clinical documentation submitted for review, the Testopel implants provided on 1/21/16 and 5/26/16 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "94784617a5cb424a907a22a5761eee1c", "question": "What is the background context in this case summary?", "title": "94784617a5cb424a907a22a5761eee1c", "sufficiency_score": 3}
+{"answers": {"text": ["A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  While autonomic testing can be useful in select cases where clear autonomic symptoms and findings have been documented, it should not be used in generic cases where a patient is noted to have pain.  In this case, the records do not clearly demonstrate marked autonomic findings or symptoms.  In the absence of this, autonomic testing has not been shown by clinical studies to statistically improve the management of patients.  The patient can be evaluated for treatable causes of peripheral neuropathies in the absence of the requested testing.  All told, autonomic nerve function testing performed on 3/26/15 was not likely to have been of greater benefit than other alternatives.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "a1506b8fd4db4839a8cbf178fcb7289f", "question": "What is the background context in this case summary?", "title": "a1506b8fd4db4839a8cbf178fcb7289f", "sufficiency_score": 2}
+{"answers": {"text": ["A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.", "The patients history is not well-documented"], "answer_start": [21, 406]}, "context": "Summary Reviewer 3\n\n\nA 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the superior efficacy of the services at issue has not been established.  The patients history is not well-documented and does not indicate features of neuropathy.  The examination was inadequate to discern if neuropathy was a realistic consideration. Electrodiagnostic test results were not submitted for review.  If small fiber neuropathy is within the differential, commonly such individuals would be assessed by a neurologist familiar with neuropathy, and undergo more detailed neurologic clinical examination.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n\n\n", "id": "e2b0827a47a7404da11a6f793852618e", "question": "What is the background context in this case summary?", "title": "e2b0827a47a7404da11a6f793852618e", "sufficiency_score": 2}
+{"answers": {"text": ["A 51-year-old male enrollee has requested authorization and coverage for Octagam intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees bilateral upper extremity weakness and atrophy.", "this patient developed progressive motor neuropathy", "the patients condition is active and he is losing axons."], "answer_start": [19, 405, 897]}, "context": "Summary Reviewer \n\nA 51-year-old male enrollee has requested authorization and coverage for Octagam intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees bilateral upper extremity weakness and atrophy.  The physician reviewer found the records provided for review demonstrate that this patient developed progressive motor neuropathy that could be related to a variant of lower motor neuron syndrome. However, a variant of chronic inflammatory demyelinating polyneuropathy (CIDP), multifocal motor neuropathy or inflammatory neuropathy cannot be excluded. Considering the fact that the disease is active and progressive, a short trial of IVIG as recommended by the provider is appropriate. If the patient has an inflammatory neuropathy, he may respond to IVIG. In addition, the patients condition is active and he is losing axons. Delaying IVIG treatment in inflammatory neuropathy may limit the patients response to immunotherapy. An IVIG trial may help support or exclude the diagnosis of CIDP variant. Given this support, the requested Octagam IVIG is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "4e7e52c95f26468c8c84a4aeb6c3bc16", "question": "What is the background context in this case summary?", "title": "4e7e52c95f26468c8c84a4aeb6c3bc16", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that the submitted records fails to demonstrate the superior efficacy of the requested services in this clinical setting. In this circumstance, while there is increasing evidence to suggest that patent foramen ovale device closure may more effective than medical therapy alone for select patients age 60 years or younger with a cryptogenic non-lacunar ischemic stroke who have a patent foramen ovale, the patients most likely to benefit are those with large right-to-left interatrial shunting and/or an associated atrial septal aneurysm, neither of which is documented in this patient. Based on the documentation, medical management with aspirin is most appropriate in this case. In sum, heart surgery (93580, percutaneous transcatheter closure of heart defect) is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n\n", "id": "62299e324679466da7ee5736ce7cf8b2", "question": "What is the background context in this case summary?", "title": "62299e324679466da7ee5736ce7cf8b2", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 64-year-old female who presented to the neurosurgery clinic after being diagnosed with a right carotid occlusion and high-grade stenosis of the left carotid artery.  She has a history of several transient ischemic attacks with complaints of dizziness as well as headaches and blurry vision. The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18.  The angiogram noted high-grade stenosis of the right vertebral artery is 70%, and a computed tomography (CT) perfusion revealed decreased blood flow to the right occipital lobe. During the postoperative examination, she continued with symptomatic dizziness, and the recommendation was made for right vertebral artery angioplasty with stenting.  The provider noted she is at increased risk for stroke should she become dehydrated or hypotensive given the carotid occlusion and stenosis of the right vertebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has been recommended to undergo a vertebral artery angioplasty due to vertebral artery occlusion.  The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18 and was noted to have a follow-up on 3/06/18 where she indicated she was doing well. She did complain of one episode of dizziness."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nThe patient is a 64-year-old female who presented to the neurosurgery clinic after being diagnosed with a right carotid occlusion and high-grade stenosis of the left carotid artery.  She has a history of several transient ischemic attacks with complaints of dizziness as well as headaches and blurry vision. The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18.  The angiogram noted high-grade stenosis of the right vertebral artery is 70%, and a computed tomography (CT) perfusion revealed decreased blood flow to the right occipital lobe. During the postoperative examination, she continued with symptomatic dizziness, and the recommendation was made for right vertebral artery angioplasty with stenting.  The provider noted she is at increased risk for stroke should she become dehydrated or hypotensive given the carotid occlusion and stenosis of the right vertebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has been recommended to undergo a vertebral artery angioplasty due to vertebral artery occlusion.  The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18 and was noted to have a follow-up on 3/06/18 where she indicated she was doing well. She did complain of one episode of dizziness. While treatment with the requested surgical intervention may be appropriate in certain situations, it does not appear this patient is an appropriate candidate. There is lack of documentation indicating that the stenosis continues to make the patient symptomatic.  The follow-up note indicated the patient was doing well and only had one episode of dizziness.  Given the above, the requested vertebral artery angioplasty is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n\n\n\n", "id": "0bcaf594d1f24e309de5ddfd40e778a9", "question": "What is the background context in this case summary?", "title": "0bcaf594d1f24e309de5ddfd40e778a9", "sufficiency_score": 4}
+{"answers": {"text": ["A  55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.", "this patient was staged as T1a, melanoma, with no mitoses seen."], "answer_start": [18, 572]}, "context": "Summary Reviewer  A  55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch and colleagues. There may be some further value in adding the mitotic rate to this system.  As per this system, this patient was staged as T1a, melanoma, with no mitoses seen. This would have an expected ten year survival of at least 88%.  There is no information in the records submitted as to whether she had sentinel node performed. DecisionDX, melanoma assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years).  It is not clear how DecisionDX data compares to the ten year data of the Balch determinations, and whether it can be used to make clinical practice decisions.  This is particularly in question in this patients case given her pathologic findings and excellent prognosis.  All told, DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more effective than other modalities for evaluating this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "7fc4f6bcd9a54281b8f6ed5895b3a28a", "question": "What is the background context in this case summary?", "title": "7fc4f6bcd9a54281b8f6ed5895b3a28a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions.", "He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.", "The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.", "He has insulin dependent diabetes mellitus. There was nothing in the notes to indicate that his blood sugars were unstable.", "He was unable to work due to COVID-19 restrictions and was financially dependent on his mother.", "The patientas mother participated in treatment.", "The patient has had emotional problems since childhood and has struggled with substance use.", "He had acceptance of his illness and was engaged in his treatment. He was motivated to get better."], "answer_start": [19, 1005, 1171, 1490, 1708, 1896, 2027, 2198]}, "context": "Summary Reviewer \n\nThe patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions. The physician reviewer found that 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.\nstressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.\nIn terms of risk of harm, the records support a score of 3. He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.\nWith regard to functional status, the records support a score of 3. The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.\nIn terms of comorbidity, the records support a score of 3. He has insulin dependent diabetes mellitus. There was nothing in the notes to indicate that his blood sugars were unstable.\nWith regard to level of stress of the recovery environment, the records support a score of 3. He was unable to work due to COVID-19 restrictions and was financially dependent on his mother.\nIn terms of level of support of the recovery environment, the records support a score of 2. The patientas mother participated in treatment.\nWith regard to resiliency and treatment history, the records support a score of 3. The patient has had emotional problems since childhood and has struggled with substance use.\nIn terms of engagement and recovery status, the records support a score of 2. He had acceptance of his illness and was engaged in his treatment. He was motivated to get better.\nThus, the records support a composite score of 19. Intensive outpatient program level of care was medically indicated. Therefore, intensive outpatient program services provided from 7/15/20 through 10/08/20 were medically necessary for the treatment of this patient.\n", "id": "b73571742e9c4bd6931f2543ec25d4ee", "question": "What is the background context in this case summary?", "title": "b73571742e9c4bd6931f2543ec25d4ee", "sufficiency_score": 2}
+{"answers": {"text": ["A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.", "This patient reported itching and discharge."], "answer_start": [20, 480]}, "context": "Summary Reviewer 3\n\nA 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patients symptoms and findings. This patient reported itching and discharge. The services performed in this patients case were clinically appropriate. Per the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin number 215, Although microscopy with Amsel criteria and Gram staining with Nugent scoring remain the preferred methods and the most cost-effective way to diagnosis bacterial vaginosis, some newer commercially available diagnostic tests show promise for use in the clinical setting and may be considered when microscopy is unavailable. Per the medical evidence, this single-swab multiplex test may be a promising alternative to microscopy. Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "120ff37b00fb4b5bae16ebde96c3312f", "question": "What is the background context in this case summary?", "title": "120ff37b00fb4b5bae16ebde96c3312f", "sufficiency_score": 2}
+{"answers": {"text": ["A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia.", "the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use."], "answer_start": [19, 477]}, "context": "Summary Reviewer 1\nA 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that there is support in the literature for the efficacy of the requested services in this clinical setting. Based on the overall documentation provided for review, the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use.  The requested Strattice (porcine biologic mesh) is used to reinforce the abdominal reconstruction provided by autologous tissue.  Strattice is a bioprosthetic porcine mesh. The medical literature indicates that bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination.  Patel and colleagues noted, Strattice is an effective adjunct to AWR (abdominal wall reconstruction) when used as reinforcement during CS (component separation) for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.  In summary, this patient has exhausted standard therapy and Strattice has been shown to provide benefit in abdominal wall reconstruction. As such, implantation of Strattice is likely to be superior to the standard options available for treatment of this patients medical condition.Therefore for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "80f6f045fd55488fb5fdee8fc43b2d39", "question": "What is the background context in this case summary?", "title": "80f6f045fd55488fb5fdee8fc43b2d39", "sufficiency_score": 4}
+{"answers": {"text": ["A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "a3e9bdfcce2540aa930f93d14695182b", "question": "What is the background context in this case summary?", "title": "a3e9bdfcce2540aa930f93d14695182b", "sufficiency_score": 3}
+{"answers": {"text": ["A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.", "In this patients case, her breasts have been described as extremely dense."], "answer_start": [21, 713]}, "context": "Summary Reviewer 3\n\n\nA 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis performed on 8/01/16 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "c702fb1cd0b841f4b3a660e63e502c83", "question": "What is the background context in this case summary?", "title": "c702fb1cd0b841f4b3a660e63e502c83", "sufficiency_score": 4}
+{"answers": {"text": ["A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that intractable lower urinary tract symptoms and painful bladder/urethral syndrome related to interstitial cystitis can be clinically difficult to treat. Treatment options often are limited and have variable results. Patients often receive multimodal treatment, including proceeding to secondary and tertiary treatment options. Percutaneous tibial nerve stimulation is considered as a tertiary treatment option for intractable lower urinary tract symptoms and painful bladder syndrome with urgency frequency syndrome. There is some support for the requested services in this clinical setting. Therefore, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.", "id": "2276574ba54840a8a0d544afbb026819", "question": "What is the background context in this case summary?", "title": "2276574ba54840a8a0d544afbb026819", "sufficiency_score": 3}
+{"answers": {"text": ["A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous \nbasivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating \nthat the requested services are considered investigational for treatment of the insureds chronic \nlow  back  pain.", "This \npatients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5", "the patients \nMRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral \nrecess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion \nand mild central canal stenosis."], "answer_start": [22, 792, 975]}, "context": "Summary Reviewer 1 \n \nA  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous \nbasivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating \nthat the requested services are considered investigational for treatment of the insureds chronic \nlow  back  pain.  The  physician  reviewer  found  that  according  to  the  U.S.  Food  and  Drug \nAdministration (FDA), intraosseous nerve ablation is intended to be used in conjunction with \nradiofrequency for the ablation of basivertebral nerves for the relief of chronic low back pain of \nat least six months duration that has not responded to at least six months of conservative care \nand is also accompanied by features such as disruption and fissuring of the endplate. This \npatients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5 that would \nmake the patient a good candidate for ablation of basivertebral nerves. However, the patients \nMRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral \nrecess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion \nand mild central canal stenosis. Thus, there are multiple plausible pathologic sources of low back \npain and finding the source of chronic lower back pain is clinically challenging (Tieppo Francio \nand Sayed). A small minority low back pain diagnoses can be attributed to an anatomical source. \nOverall, the medical evidence is insufficient to support a finding of spinal vertebral bodies as \nbeing the overwhelming primary generators of the patients chronic low back pain. Therefore, \nthe requested intraosseous basivertebral nerve ablation (CPT code 64628) is not likely to be more \nbeneficial than any other available standard treatments for the patients medical condition. \n \n", "id": "c52a1363da8241cea35fa6d22d590962", "question": "What is the background context in this case summary?", "title": "c52a1363da8241cea35fa6d22d590962", "sufficiency_score": 4}
+{"answers": {"text": ["A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous \nbasivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating \nthat the requested services are considered investigational for treatment of the insureds chronic \nlow back pain.", "This \npatient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results \ndemonstrated changes at disc space endplates L4-5. This patient has undergone more than six \nmonths of conservative treatment consisting of intradiscal steroid injection, home exercise and \nphysical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient \nand  durable  relief."], "answer_start": [22, 984]}, "context": "Summary Reviewer 3 \n \nA  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous \nbasivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating \nthat the requested services are considered investigational for treatment of the insureds chronic \nlow back pain. The physician reviewer found that basivertebral nerve ablation is a minimally \ninvasive outpatient procedure allowing for a quick recovery. The procedure is implant-free and \npreserves  spinal  integrity  by  negating  need  for  extensive  tissue  exposure  and  disruption. \nAdditionally, basivertebral nerve ablation fills a treatment gap for patients with chronic low back \npain and preserves future treatment options. In one study, patients with chronic low back pain \nwho underwent basivertebral nerve ablation reported significant improvement in pain and \nfunction with well documented long-term effectiveness and durability (Fischgrund, et al.). This \npatient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results \ndemonstrated changes at disc space endplates L4-5. This patient has undergone more than six \nmonths of conservative treatment consisting of intradiscal steroid injection, home exercise and \nphysical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient \nand  durable  relief.  This  patient  does  not  warrant  more  invasive  treatment,  such  as \ndecompression and fusions, as there are no reported severe symptoms of lumbar radiculopathy. \nGiven these findings the requested intraosseous basivertebral nerve ablation (CPT code 64628) \nis likely to be more beneficial than any other available standard treatments for the patients \nmedical condition. \n ", "id": "c1a18a2e2d844d7f9725ac828ac193bd", "question": "What is the background context in this case summary?", "title": "c1a18a2e2d844d7f9725ac828ac193bd", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health position statement states, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a There is sufficient support for the requested services in this patientas case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.", "id": "47b4954c2993429093f84036a8ba83e0", "question": "What is the background context in this case summary?", "title": "47b4954c2993429093f84036a8ba83e0", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).", "the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness."], "answer_start": [20, 360]}, "context": "Summary Reviewer \n\n\nThe parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).  The physician reviewer found the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness. The medical literature supports hospitalization for observation for cardiopulmonary monitoring for 23 hours after an ALTE in the majority of infants (Fu and Moon; McGovern and Smith). However, certain individuals can be discharged from the emergency department without hospitalization (Kahn and European Society for the Study and Prevention of Infant Death). Given that the patient was well-appearing at the time of presentation, had no further events during observation in the hospital, did not require specific interventions or extensive evaluation beyond observation, and was discharged home on the same day of admission, he met criteria for observation but not admission. Based upon the information provided and reviewed and the medical literature reviewed, the inpatient hospital level of care provided on 3/31/16 was not medically necessary for treatment of the patients medical condition. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "67682f99dcbe4d8c9870131eb910e337", "question": "What is the background context in this case summary?", "title": "67682f99dcbe4d8c9870131eb910e337", "sufficiency_score": 4}
+{"answers": {"text": ["A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.\n\n", "id": "03d69cbf98ab4151bd11539ffc3729e7", "question": "What is the background context in this case summary?", "title": "03d69cbf98ab4151bd11539ffc3729e7", "sufficiency_score": 3}
+{"answers": {"text": ["A 28-year-old female insured has requested authorization and coverage for intravenous (IV) \nGammagard. The Health Insurer has denied this request indicating that the requested treatment is \nconsidered investigational for the treatment of the insured's refractory relapsing polychondritis.", "In this case, the patient \npresents with relapsing polychondritis.", "the patient \nhas tried and failed treatment with multiple therapies from several classes of medications. The \nprovider has recommended a continuation of IVIG therapy"], "answer_start": [20, 1075, 1188]}, "context": "Summary Reviewer 3 \nA 28-year-old female insured has requested authorization and coverage for intravenous (IV) \nGammagard. The Health Insurer has denied this request indicating that the requested treatment is \nconsidered investigational for the treatment of the insured's refractory relapsing polychondritis. \nThe physician reviewer found that there is limited medical literature studying IVIG as a treatment \noption for patients with relapsing polychondritis. Relapsing polychondritis is a rare autoimmune \ndisorder, and official guidelines to utilize certain therapies are not likely to be available in the near \nfuture. However, for patients who have tried and failed treatment with multiple therapies from \nseveral classes of medications, IVIG is appropriate as the next-line treatment option. This is \nparticularly applicable when its efficacy has been established for a particular patient in keeping \nthe disease stable or in remission. According to one study by Lekpa and Chevalier, IVIG has been \nshown to be effective in some patients with relapsing polychondritis. In this case, the patient \npresents with relapsing polychondritis. The records provided for review indicate that the patient \nhas tried and failed treatment with multiple therapies from several classes of medications. The \nprovider has recommended a continuation of IVIG therapy which has already been shown to be \nthe most effective treatment option for this patient. All told, the requested IV Gammagard is likely \nto be more beneficial for the treatment of the patients condition than any available standard \ntherapy. \n \n ", "id": "5ee2bff0318a47fbaca7392f00c7f113", "question": "What is the background context in this case summary?", "title": "5ee2bff0318a47fbaca7392f00c7f113", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen (PSA) level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities, because many patients will not require therapy (i.e., surgery or radiation) and may be followed closely instead. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. The National Comprehensive Cancer Network guidelines also suggest the use of this test to better stratify such patients with localized disease. Thus, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.\n\n\n", "id": "4c249adecf4549f38a6499e10540bc3b", "question": "What is the background context in this case summary?", "title": "4c249adecf4549f38a6499e10540bc3b", "sufficiency_score": 3}
+{"answers": {"text": ["A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that there is a lack of medical literature supporting the service at issue in this clinical setting. Silverstein and colleagues studied intraoperative radiotherapy for early-stage breast cancer. The study revealed that intraoperative radiotherapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar. In addition, the American Society for Radiation Oncology (ASTRO) consensus guidelines recommended intraoperative radiation therapy for those with suitable criteria with invasive cancer, and not for patients with DCIS. Moreover, treatment with intraoperative radiation therapy is not the standard therapy for breast cancer. Given the lack of support in the peer-reviewed literature, the intraoperative radiation therapy performed on 7/19/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "f989ee4fbdfb419b89c36414afd86df6", "question": "What is the background context in this case summary?", "title": "f989ee4fbdfb419b89c36414afd86df6", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19.", "The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center.", "The records noted \nmoderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission."], "answer_start": [19, 532, 733]}, "context": "Summary Reviewer \n\nThe patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regards to risk of harm, the records support a score of 4. The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center. In terms of functional status, the records support a score of 3. The records noted \nmoderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission. With regard to comorbidity, the records support a score of 3 due to the physical manifestations of anorexia nervosa, including low weight and laboratory abnormalities, co-occurring with post-traumatic stress disorder, depression, and anxiety symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to discord with parents and recent transition back to the United States after a year of living abroad. With regard to level of support of the recovery environment, the records support a score of 3 due to parents ambivalence toward participating in treatment and lack of recent contact with the patient. In terms of treatment and recovery history, the records support a score of 4 due to the persistence of symptoms despite prior extensive treatment. With regard to engagement and recovery status, the records support a score of 3 due to poor insight and limited judgment. Thus, the patient has a composite score of 23. In this case, the records support medically monitored residential services. Therefore, eating disorder residential treatment center services from 1/23/20 forward were and are medically necessary for the treatment of this patient. \n\n", "id": "cfd99b0e9f0d4c08807a36a3dda60d70", "question": "What is the background context in this case summary?", "title": "cfd99b0e9f0d4c08807a36a3dda60d70", "sufficiency_score": 4}
+{"answers": {"text": ["A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the non-surgical treatment is the initial treatment of choice for symptomatic hallux valgus deformity. Shoe modification, padding and local application of ice to symptomatic bunion are reasonable initial conservative options. Orthotic devices to control documented biomechanical dysfunction may be considered as conservative or post-surgical options. Surgical treatment is recommended if there is no or little response to non-operative treatment after a six-month trial, or if initial response deteriorates. In general, once surgical criteria has been met, the surgical procedures to be performed are based on the location and the degree of deformity. The two most common radiographic measurement used to choose appropriate surgical procedures include the intermetatarsal angle (IMA) and the hallux valgus angle (HVA). For IMAs less than 13 degrees, distal osteotomy or soft tissue procedure alone are sufficient to correct the deformity. For IMAs greater than 13 degrees, a proximal osteotomy is recommended. There is a variety of osteotomies described to correct the IMA, including the scarf, and no procedure has proved superiority over the other. Regarding the HVA, angles less than 30 degrees can be treated with a distal soft tissue procedure, such as the modified McBride procedure, with or without a chevron osteotomy. For HVA greater than 40 degrees, metatarsophalangeal joint fusion is generally recommended.\nIn this patients case, operative criteria have been met. Based on the radiographs and the HVA and IMA measurements reported by the treating surgeon, appropriate surgical procedures were performed and are supported by published treatment guidelines for the treatment of symptomatic hallux valgus. In sum, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.\n\n\n", "id": "fa63063e0ddb40c8916d1e10bc9ac690", "question": "What is the background context in this case summary?", "title": "fa63063e0ddb40c8916d1e10bc9ac690", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region. The physician reviewer found that the provided documentation does not establish the medical necessity of the chiropractic services provided from 6/1/17 through 9/7/17. Specifically, the records do not objectively verify functional improvements with prior chiropractic therapy over eight weeks of care. As noted in the current medical literature and guidelines, the documentation should report objective functional improvement with chiropractic treatment to support an indication for future services. Accordingly, the chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17 were not medically necessary for treatment of this patients neck pain and low back pain. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "9f22ef31c4ec4688af47e2690bc88a83", "question": "What is the background context in this case summary?", "title": "9f22ef31c4ec4688af47e2690bc88a83", "sufficiency_score": 3}
+{"answers": {"text": ["A 55-year-old female enrollee has requested reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea.", "This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value.", "the patient was clinically stable after initial evaluation"], "answer_start": [19, 462, 834]}, "context": "Summary Reviewer \n\nA 55-year-old female enrollee has requested reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value. In this circumstance, a period of overnight observation without hospital admission is reasonable and appropriate to confirm no evidence of myocardial infarction with serial troponins prior to discharge. Since the patient was clinically stable after initial evaluation, with an anticipated length of stay of less than 48 hours or less than two midnights, hospital admission was not medically necessary. Based on the records, an observational level of stay would have been safe and effective. Thus, inpatient hospital services provided from 3/01/18 through 3/02/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "62c987f5537747bfb6be935239a158aa", "question": "What is the background context in this case summary?", "title": "62c987f5537747bfb6be935239a158aa", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.The physician reviewer found in this case, the medical records fail to indicate any diagnosis consistent with an IgG mediated food allergy to support an indication for the testing at issue. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated (Boyce, et al). The Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated (Sampson, et al). As such, IgG food testing is not considered the standard of care in this clinical setting (Sicherer and Teuber). Thus, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "10e56142635a40528f327074d1786865", "question": "What is the background context in this case summary?", "title": "10e56142635a40528f327074d1786865", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.  The physician reviewer found the use of food-specific IgG level testing has not been shown to improve health outcomes at long-term follow-up. There is data suggesting that this testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods (Beyer and Teuber). Thus, food-specific IgG should not be used as a tool to diagnose food allergy and the positive foods should not be eliminated from the diet based upon results of these tests (Lemon-Mule, et al; Savilahti, et al). The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens including egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95% predictive accuracy. In conclusion, the IgG food laboratory testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard of care.Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "66d01ac39bab4204bce2411dd015c266", "question": "What is the background context in this case summary?", "title": "66d01ac39bab4204bce2411dd015c266", "sufficiency_score": 3}
+{"answers": {"text": ["A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Skaane and colleagues noted the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues indicated integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 5/23/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "c81090bb105542229d55c8db1f5f7d60", "question": "What is the background context in this case summary?", "title": "c81090bb105542229d55c8db1f5f7d60", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including \non her palms and soles. The patient has requested authorization and coverage for Cosentyx two \npens 150 mg/ml pen injector. The Health Insurer has denied this request and reported that the \nrequested medication is not medically necessary for the treatment of this patient."], "answer_start": [19]}, "context": "Summary Reviewer  \nThe patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including \non her palms and soles. The patient has requested authorization and coverage for Cosentyx two \npens 150 mg/ml pen injector. The Health Insurer has denied this request and reported that the \nrequested medication is not medically necessary for the treatment of this patient. This denial is the \nsubject of this appeal and determination. The physician reviewer found Cosentyx is a U.S. Food \nand Drug Administration (FDA) approved medication for the treatment of psoriasis.  It receives \nan A rating from the American Academy of Dermatology and National Psoriasis Foundation \nguidelines of care. This medication has good safety and efficacy profiles. It is recommended as \ntreatment for chronic psoriasis by the American Academy of Dermatology and National Psoriasis \nFoundation. It has been shown in the FIXTURE study to be a safe and efficacious medication for \nthe treatment of psoriasis. The requested medication is medically indicated for the treatment of \nthis patients chronic psoriasis, psoriatic arthritis and hand and foot psoriasis. Therefore, Cosentyx \ntwo pens 150 mg/ml pen injector is medically necessary for the treatment of this patient.  \n ", "id": "9608583d58da499fb5363dd271157949", "question": "What is the background context in this case summary?", "title": "9608583d58da499fb5363dd271157949", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.", "The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics.", "The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged."], "answer_start": [20, 1114, 1482]}, "context": "Summary Reviewer \n\n\nA 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients symptoms on 12/1/16 did meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics. The medical records support a comprehensive history and medical decision making of high complexity to support CPT code 99285. The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged. All told, the emergency department services provided at Hoag Hospital on 12/1/16 were required on an emergent basis and include comprehensive history and medical decision making of high complexity to support CPT code 99285. Therefore, the Health Insurers denial should be overturned.", "id": "534b4ceda94a4333a9288005240f641a", "question": "What is the background context in this case summary?", "title": "534b4ceda94a4333a9288005240f641a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient does not have any chronic medical conditions that would cause vitamin D deficiency. She did not have any signs or symptoms of vitamin D toxicity or severe deficiency. Therefore, vitamin D testing performed on 7/30/19 was not medically necessary for the evaluation of this patient.", "id": "988682d6d68f441f981dbc08c95d6494", "question": "What is the background context in this case summary?", "title": "988682d6d68f441f981dbc08c95d6494", "sufficiency_score": 2}
+{"answers": {"text": ["A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  HE4 is used for the evaluation of an adnexal mass as a component of the Risk of Ovarian Malignancy Algorithm (ROMA). A ROMA score helps determine the likelihood that an adnexal mass is malignant and the need for referral to a gynecologic oncologist for surgery. This testing is considered a standard of care.  In sum, HE4 testing performed on 11/20/15 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "987ba862ff1e4052aef648599a32312c", "question": "What is the background context in this case summary?", "title": "987ba862ff1e4052aef648599a32312c", "sufficiency_score": 3}
+{"answers": {"text": ["A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.", "This patient has received Prolia."], "answer_start": [21, 422]}, "context": "Summary Reviewer 3\n\n\nA 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patient has received Prolia.  In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) scan is appropriate to monitor therapy.  The value of monitoring therapy with the use of biochemical markers of bone turnover is controversial.  This is a test that can be variable and subject to timing, dietary intake and lack of assay standardization.  In sum, collagen crosslink testing performed on 7/11/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n\n\n", "id": "6a26e01f768b430fabcba94008aa7820", "question": "What is the background context in this case summary?", "title": "6a26e01f768b430fabcba94008aa7820", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.", "This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy."], "answer_start": [19, 424]}, "context": "Summary Reviewer \n\nA 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy. Generally, standard breast reductions include a breast lift as an integral part of the procedure and would not be considered a separate procedure. Based on the documentation provided, this patient underwent a bilateral breast reduction and not solely a mastopexy. An additional mastopexy would not be considered as a separate procedure, but an integral portion to the breast reduction. Therefore, the Health Insurers denial was appropriate. Thus, mastopexy (CPT 19316) performed on 10/24/18 was not medically necessary for the treatment of this patient.", "id": "c03d6ffa634b4704a298dd9bc4551944", "question": "What is the background context in this case summary?", "title": "c03d6ffa634b4704a298dd9bc4551944", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy. The physician reviewer found that placement of a prophylactic defibrillator is not recommended until a period of time after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment (Russo, et al). Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Steinbeck, et al). A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. Therefore, the Life Vest provided from 6/10/15 through 7/10/15 has not been demonstrated by scientific literature as likely to have been more beneficial in treating this patients medical condition than standard alternatives. Based upon the information set forth above, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n", "id": "129da9e7d1864ab59f1b5af37c63954c", "question": "What is the background context in this case summary?", "title": "129da9e7d1864ab59f1b5af37c63954c", "sufficiency_score": 3}
+{"answers": {"text": ["A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. The physician reviewer found that the Oncotype DX test uses a reverse transcriptase polymerase chain reaction assay for 12 genes in an algorithm that can be used to help predict recurrence (OConnell, et al; Gray, et al). Despite this support, it has not been established whether adjuvant chemotherapy can obviate recurrence risk. Overall, the current data does not support use of the Oncotype DX as a predictive marker for response to adjuvant treatment (Benson and Hamilton; Gray, et al). As such, the National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend use of multi-gene assay panels to determine adjuvant therapy. All told, the Oncotype DX Colon Cancer Assay provided on 2/14/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "e890f1b3ffc4443ab7758f0c0c650180", "question": "What is the background context in this case summary?", "title": "e890f1b3ffc4443ab7758f0c0c650180", "sufficiency_score": 3}
+{"answers": {"text": ["A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression.", "The patient presented with significant risk of harm", "with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment", "and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity", "with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful", "as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive", "and she demonstrated moderate response to prior treatment", "The patient demonstrated positive engagement and recovery", "as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment."], "answer_start": [20, 576, 638, 958, 1105, 1316, 1455, 1524, 1592]}, "context": "Summary Reviewer \n\n\nA 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression. The physician reviewer found that applying the level of care utilization system (LOCUS) criteria, the inpatient mental health services provided from 11/7/17 to 12/6/17 were not medically necessary for treatment of this patients behavioral health issues. The patient presented with significant risk of harm (score 3) with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment (score 3) and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity (score 3) with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful (score 2) as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive (score 2) and she demonstrated moderate response to prior treatment (score 3). The patient demonstrated positive engagement and recovery (score 2) as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment. These findings give the patient a composite score of 18, which is consistent with intensive outpatient program (IOP) level of care. The patient continued to require treatment for her of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors, but this could have been safely and effectively provided in a less restrictive environment. Therefore, the services at issue were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "a6e8b9b3b5ec4eeb8b49e83abcf87958", "question": "What is the background context in this case summary?", "title": "a6e8b9b3b5ec4eeb8b49e83abcf87958", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health, Inc. (WPATH) states, Non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH notes, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The current medical evidence supports the requested services in this patients case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.\n", "id": "5ff9e6c9c19841ae9dead1fc261d147d", "question": "What is the background context in this case summary?", "title": "5ff9e6c9c19841ae9dead1fc261d147d", "sufficiency_score": 3}
+{"answers": {"text": ["A 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward. The Health Insurer has denied this request indicating that the medication dosage at issue was not and is not medically necessary for treatment of the enrollee who has been assessed with chronic pain syndrome.", "In this case, the patient was recently taking 135 MME per day."], "answer_start": [20, 1598]}, "context": "Summary Reviewer \n\n\nA 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward. The Health Insurer has denied this request indicating that the medication dosage at issue was not and is not medically necessary for treatment of the enrollee who has been assessed with chronic pain syndrome. The physician reviewer found that the medical literature states that dose escalation is not a long-term plan but a short-term plan for the treatment of tolerance. In the documentation available for review, there were no objective treatment goals for pain and function noted for the requested medication. In addition, several requirements for opioid prescribing have not been documented to be performed. Therefore, the need to use them as the primary medication treatment strategy for pain has not been established (Chou, et al). The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day or carefully justify a decision to titrate dosage to 90 or more MME per day. In this case, the patient was recently taking 135 MME per day. However, there is no submitted evidence based rationale given by the provider to support the potential long-term consequences with the continual increase in opioids. Risk and benefit analysis must be performed to justify the requested level of 90 MME per day. It is also reasonable to consider alternatives to opioids. Moreover, pure mu agonists are not considered evidence based treatments for fibromyalgia and the adverse effects of opioids in fibromyalgia patients are unknown. In addition, the submitted records do not mention the completion of behavior therapy despite much research to support its use. For all of these reasons, reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward has not been demonstrated as medically necessary for treatment of the patients medical condition. Therefore, based on the reasons stated above, the medication dosage at issue was not and is not medically necessary for the treatment of this patients medical condition. The Health Insurers denial should be upheld.", "id": "5b1180097e1245ed97e0ba0861a7c1f9", "question": "What is the background context in this case summary?", "title": "5b1180097e1245ed97e0ba0861a7c1f9", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.", "In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin."], "answer_start": [19, 993]}, "context": "Summary Reviewer \n\nThe patient is a 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. The randomized PURSUIT study showed that Simponi serum concentrations are proportional to dose, and higher Simponi concentration was associated with improved clinical outcomes. Studies have shown that dose escalation can recover response to therapy in a significant fraction of patients. One study showed recovery of response in 71% of ulcerative colitis patients undergoing Simponi dose escalation, and another demonstrated improvement in half of patients (Taxonera and Rodriguez, et al; Taxonera and Iborra, et al). In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin. Dose escalation can recover response and prevent complications, such as disease flare, hospitalization, toxic megacolon, and dysplasia with risk of colorectal cancer. Therefore, Simponi 100 mg every 21 days is medically necessary for the treatment of this patient. ", "id": "b3397d854552409e9038a0ce47036b15", "question": "What is the background context in this case summary?", "title": "b3397d854552409e9038a0ce47036b15", "sufficiency_score": 4}
+{"answers": {"text": ["A 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.", "On 5/27/17 admission, the patients symptoms prevented him from functioning properly.", "by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg.", "His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment."], "answer_start": [20, 554, 648, 1234]}, "context": "Summary Reviewer \n\n\nA 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the medical records provided for review do not support the medical necessity of the RTC services provided from 6/11/17 through 7/2/17 for treatment of this patients behavioral health issues. On 5/27/17 admission, the patients symptoms prevented him from functioning properly. However, by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg. Further, Clozaril titration does not require a RTC setting and can be performed in the outpatient setting. His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment. He no longer required 24-hour monitoring in the RTC setting, and could have continued treatment at IOP level of care. Thus, the RTC services provided from 6/11/17 through 7/2/17 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "90f6e8dd45f84956bad94a0a3b2098b2", "question": "What is the background context in this case summary?", "title": "90f6e8dd45f84956bad94a0a3b2098b2", "sufficiency_score": 4}
+{"answers": {"text": ["A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea.", "The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy."], "answer_start": [20, 422]}, "context": "Summary Reviewer 1\n\nA 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure therapy, anterior posterior collapse, no central apnea, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy. \n\n\n", "id": "373e783819a94daa9bd636a3bd5ba8cc", "question": "What is the background context in this case summary?", "title": "373e783819a94daa9bd636a3bd5ba8cc", "sufficiency_score": 4}
+{"answers": {"text": ["A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea.", "She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea."], "answer_start": [20, 414]}, "context": "Summary Reviewer 2\n\nA 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this patientas case. She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. The alternative, no treatment, may lead to potential harms, such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale scores.  The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.\n\n\n", "id": "ad7b258e6e5846bab2e5f9349dbbe65b", "question": "What is the background context in this case summary?", "title": "ad7b258e6e5846bab2e5f9349dbbe65b", "sufficiency_score": 4}
+{"answers": {"text": ["A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug."], "answer_start": [20, 760]}, "context": "Summary Reviewer 1\n\nA 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The U.S. Food and Drug Administration has approved the LINX device for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug. As such, he cannot be considered refractory to medical management. Given this patients excellent response and tolerance to conventional acid suppression medication and the attendant surgical risks of LINX implantation, the requested CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.\n\n\n", "id": "15161a09d52e4148b8b130b57e137d44", "question": "What is the background context in this case summary?", "title": "15161a09d52e4148b8b130b57e137d44", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted letters from the patient and provider were reviewed.  However, there is a lack of additional pertinent medical documentations, such as progress notes from the ordering provider.  The progress notes submitted are from a different provider which documented the diagnosis of mast cell disorder, chemical sensitivities and food allergy.  The only records from the ordering provider were testing records, which are insufficient to support the services at issue.  The submitted records do not support a covered indication for the services at issue.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "daf2a4bfb2ef475b97f3f40d819cd19a", "question": "What is the background context in this case summary?", "title": "daf2a4bfb2ef475b97f3f40d819cd19a", "sufficiency_score": 2}
+{"answers": {"text": ["The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nThe parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Allergen immunotherapy is a long-term treatment that decreases symptoms for many people with allergic rhinitis, allergic asthma, conjunctivitis or stinging insect allergy.  Allergy shots decrease sensitivity to allergens and often lead to lasting relief of allergy symptoms even after treatment is stopped.  Indications for allergen immunotherapy include allergic asthma and rhinitis, conjunctivitis, as well as venom-induced anaphylaxis.  In this patients case, the records do not support the services at issue.  Without a diagnosis of asthma, rhinitis, conjunctivitis or anaphylaxis, the services at issue cannot be recommended.  In sum, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 were not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "4ae3d22661874a64b2a1c418a93019f5", "question": "What is the background context in this case summary?", "title": "4ae3d22661874a64b2a1c418a93019f5", "sufficiency_score": 2}
+{"answers": {"text": ["A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.", "this patient had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor."], "answer_start": [20, 325]}, "context": "Summary Reviewer 2\n\nA 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. The role of DecisionDx-Melanoma testing for recurrent node positive disease has not been established. In sum, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.\n\n\n", "id": "856d224833ac4144bbf0dac605df9810", "question": "What is the background context in this case summary?", "title": "856d224833ac4144bbf0dac605df9810", "sufficiency_score": 4}
+{"answers": {"text": ["A 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. "], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that antibodies to adalimumab (ADA) are present in a substantial number of patients treated with adalimumab, and in some patients there may be a correlation between the level of these antibodies and clinical response. However, there are technical factors relating to the use of different assay methods across studies, and it has not yet been established whether the use of threshold level aid in the discrimination of response to adalimumab. There are patients who do not respond to adalimumab (primary non responders), and patients who appear to lose their response to adalimumab over a period of time (secondary non responders). However, some evidence suggests that low serum drug levels and/or the presence of drug antibodies to may play a role in primary or secondary response failures. Menting and colleagues noted that patients with no ADA formation in the first 24 weeks of treatment have little chance of it in the following 24 weeks. The presence of ADA is strongly correlated with adalimumab concentration. Standard alternatives to Anser ADA testing, in patients like this patient, include shortening the interval between doses, increasing the dose, or switching to a different agent. At this time, the peer-reviewed medical literature does not support the use of the Anser ADA test as performed on 10/13/14 as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n", "id": "e05ba2f49c794dbbb035dde072cc1b3b", "question": "What is the background context in this case summary?", "title": "e05ba2f49c794dbbb035dde072cc1b3b", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer. "], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Turner and colleagues reported that treatment with Ibrance and Faslodex is approved for ER positive metastatic disease. The authors reported that among patients with hormone receptor positive metastatic breast cancer who had progression of disease during prior endocrine therapy, Ibrance combined with Faslodex resulted in longer progression-free survival than Faslodex alone. Given this support, the requested Ibrance 100 mg is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n\n", "id": "403cd33ffa1e41d7a3ac9bfa9791bdae", "question": "What is the background context in this case summary?", "title": "403cd33ffa1e41d7a3ac9bfa9791bdae", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nThe parent of a five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay. The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the request for genetic testing is medically necessary for evaluation of the patients medical condition. The clinical utility of CMA is well established in the peer-reviewed literature and is considered a first-line genetic test for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). CMA technology has been shown to provide clinically actionable information. The study by Coulter and colleagues demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, and specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Current data suggest that many clinically significant genetic changes can impact neurodevelopment without associated anatomic departures. For the reasons provided, the request for genetic testing has been established as medically necessary for evaluation of the patients medical condition. Therefore, the requested testing is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.", "id": "eceee3ca537a4034a23a72bf072604a6", "question": "What is the background context in this case summary?", "title": "eceee3ca537a4034a23a72bf072604a6", "sufficiency_score": 3}
+{"answers": {"text": ["A 42-year-old female enrollee has requested authorization and coverage for disc fusion. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.", "this patients", "degenerative disc disease with a 4 mm protrusion at L5-S1", "did not respond to nonoperative treatment."], "answer_start": [19, 1122, 1157, 1220]}, "context": "Summary Reviewer \n\nA 42-year-old female enrollee has requested authorization and coverage for disc fusion. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested anterior lumbar interbody fusion procedure is likely to be beneficial for this patients severely symptomatic degenerative disc disease with a 4 mm protrusion at L5-S1 that did not respond to nonoperative treatment. Therefore, the requested 63077, 22558 and 22845 are medically necessary for the treatment of this patient.", "id": "05e541da746346908bdc21ceaf0377f8", "question": "What is the background context in this case summary?", "title": "05e541da746346908bdc21ceaf0377f8", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is an 11-year-old female with short stature. The patientas parent has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.", "This patient was growing along the 5th percentile from age 4 years and was subsequently started on growth hormone therapy. She has a good IGF-1 generation on growth hormone treatment. This patient exhibited signs of growth failure before the growth hormone treatment was started. Per the submitted documentation, she had a good response to growth hormone therapy in terms of growth velocity."], "answer_start": [19, 427]}, "context": "Summary Reviewer \n\nThe patient is an 11-year-old female with short stature. The patientas parent has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient was growing along the 5th percentile from age 4 years and was subsequently started on growth hormone therapy. She has a good IGF-1 generation on growth hormone treatment. This patient exhibited signs of growth failure before the growth hormone treatment was started. Per the submitted documentation, she had a good response to growth hormone therapy in terms of growth velocity. Continuation of growth hormone therapy is medically appropriate in this case. Therefore, Nutropin AQ Nuspin is medically necessary for the treatment of this patient.", "id": "7405b736145e4f7dbc69477522177466", "question": "What is the background context in this case summary?", "title": "7405b736145e4f7dbc69477522177466", "sufficiency_score": 4}
+{"answers": {"text": ["A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that fecal calprotectin, elaborated by neutrophils, is elevated when there is inflammation within the lumen of the gastrointestinal tract. In the setting of post-operative Crohns, a progressive rise is usually indicative of disease recurrence. Following serial measurements is a reasonably strategy rather than subjecting the patient to serial colonoscopy exams to assess disease activity. Performance of serial post-operative fecal calprotectin levels can be considered a standard of care strategy. Accordingly, the laboratory services (CPT code 83993) performed on 10/5/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "f4a9adc483ad430aa0bc2c1ebba566e8", "question": "What is the background context in this case summary?", "title": "f4a9adc483ad430aa0bc2c1ebba566e8", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, CPT code 84999 performed on 1/12/17 was not likely to have been more efficacious than other available methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "c2c972772a814d998ec475cd84c960b0", "question": "What is the background context in this case summary?", "title": "c2c972772a814d998ec475cd84c960b0", "sufficiency_score": 2}
+{"answers": {"text": ["A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the proposed procedure has been studied for over a decade, and the peer-reviewed literature supports the benefit of the procedure. Scaglioni and colleagues performed a systematic review of lymphovenous anastomosis for the treatment of lymphedema. The authors noted, aAlthough the studies included in this review showed great heterogeneity, lymphovenous anastomosis surgery revealed both objective and subjective improvements in most patients.a Thomas and colleagues noted, aThe findings suggest that the real impact of living with lymphedema is much more challenging than previously identified. The findings suggest that lymphovenous anastomosis can give a future of greater choice for some of its recipients, but further research should explore longer-term benefits. Lymphovenous anastomosis could offer hope to some people with lymphedema, but a realistic expectation is essential.a There is sufficient support for the requested services in this clinical setting. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy. \n\n\n\n\n", "id": "4b87c0702ba9473fa1634784427146cb", "question": "What is the background context in this case summary?", "title": "4b87c0702ba9473fa1634784427146cb", "sufficiency_score": 3}
+{"answers": {"text": ["A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.", "In this case, the patient has had a history of chronic low back pain that has persisted for several years, which has been refractory to multiple modes of standard care."], "answer_start": [20, 1062]}, "context": "Summary Reviewer 3\n\nA 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Fischgrund and colleagues performed a randomized controlled trial regarding the two-year clinical outcomes for chronic low back pain patients treated with radiofrequency ablation of the basivertebral nerve. The authors noted, aBasivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of chronic low back pain in a patient population that typically has few effective treatment options.a Lorio and colleagues concluded, aThe procedure is supported by level 1 evidence including two randomized controlled trials demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies.a In this case, the patient has had a history of chronic low back pain that has persisted for several years, which has been refractory to multiple modes of standard care. Based on the available medical records for review and the current studies, the requested services are likely to be superior over other treatment options. Thus, destruction of intraosseous basivertebral nerve is likely to be more beneficial than any available standard therapy.\n", "id": "94f8672ea27d412883b6d05722449ff1", "question": "What is the background context in this case summary?", "title": "94f8672ea27d412883b6d05722449ff1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 67-year-old male who presented in 2021 with a prostate-specific antigen (PSA) \nlevel of 5.64. The patient has requested authorization and coverage for proton beam therapy. "], "answer_start": [19]}, "context": "Summary Reviewer  \nThe patient is a 67-year-old male who presented in 2021 with a prostate-specific antigen (PSA) \nlevel of 5.64. The patient has requested authorization and coverage for proton beam therapy. \nThe physician reviewer found that the submitted documentation fails to demonstrate the \nmedical necessity of the requested services. There is a lack of strong medical evidence to \nsuggest that treatment with proton beam therapy is associated with a clinical benefit compared \nto standard treatment. Currently, there is insufficient clinical data to discern whether treatment \nwith proton beam radiation offers a clinical benefit compared to conventional radiation therapy \ntechniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent \nmulti-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The \nauthors compared groups receiving hypofractionated radiation proton therapy and intensity \nmodulated radiation therapy with photons. This analysis found no significant difference in \ngastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found \nno difference in disease control between the two modalities. The American Society of Radiation \nOncology (ASTRO) Model Policy stated, Proton beam therapy for primary treatment of \nprostate cancer should only be performed within the context of a prospective clinical trial or \nregistry. At the present time, ASTRO believes the comparative efficacy evidence of proton \nbeam therapy with other prostate cancer treatments is still being developed, and thus the role \nof proton beam therapy for localized prostate cancer within the current availability of \ntreatment options remains unclear. The National Comprehensive Cancer Network guidelines \nendorse the position statement by ASTRO and state that no clear benefit of proton beam \ntherapy has been demonstrated over standard treatment with photons and intensity \nmodulated radiation therapy technique. Therefore, proton beam therapy is not medically \nnecessary for the treatment of this patient. \n ", "id": "671cfeaa88824876813dd00d0388d8a7", "question": "What is the background context in this case summary?", "title": "671cfeaa88824876813dd00d0388d8a7", "sufficiency_score": 3}
+{"answers": {"text": ["A 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.", "In this case, the patient has chronic low back pain that has not responded to at least six months of conservative care. The patient has had multiple treatments, including lumbar epidural steroid injections, medial branch blocks, aquatic therapy, massage therapy, home exercise program, stretching, cryotherapy, transforaminal epidural steroid injection, chiropractic manipulation and medication management. There are also Type II Modic changes in the lumbar spine at the L3-4 and L4-5 levels."], "answer_start": [20, 357]}, "context": "Summary Reviewer 2\n\nA 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is evidence-based support for this procedure. In this case, the patient has chronic low back pain that has not responded to at least six months of conservative care. The patient has had multiple treatments, including lumbar epidural steroid injections, medial branch blocks, aquatic therapy, massage therapy, home exercise program, stretching, cryotherapy, transforaminal epidural steroid injection, chiropractic manipulation and medication management. There are also Type II Modic changes in the lumbar spine at the L3-4 and L4-5 levels. There is sufficient evidence-based support for the requested services. There has been sufficient, documented, detailed, comprehensive and reasonable treatment provided prior to this request. Therefore, the requested spine procedure is likely to be more beneficial for the treatment of the patientas medical condition than any available standard therapy.\n\n\n", "id": "daf6d114f557428da3137fff6c48de2c", "question": "What is the background context in this case summary?", "title": "daf6d114f557428da3137fff6c48de2c", "sufficiency_score": 4}
+{"answers": {"text": ["A 44-year-old female enrollee has requested reimbursement for monitored anesthesia care provided on 7/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 44-year-old female enrollee has requested reimbursement for monitored anesthesia care provided on 7/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care provided on 7/17/15 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "94b9fe334d404038ab494349aed99261", "question": "What is the background context in this case summary?", "title": "94b9fe334d404038ab494349aed99261", "sufficiency_score": 2}
+{"answers": {"text": ["A 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis.", "This patient has been taking Tymlos."], "answer_start": [20, 423]}, "context": "Summary Reviewer 2\n\nA 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. This patient has been taking Tymlos. In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) is appropriate at the end of the two-year treatment to assess the patients response to therapy. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision making is controversial. The test performed can be variable and subject to timing, dietary intake as well as lack of assay standardization. In sum, collagen crosslinks testing performed on 11/18/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "12809722f72c43a68c892be896c7073b", "question": "What is the background context in this case summary?", "title": "12809722f72c43a68c892be896c7073b", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a three-year-old female who was transported by air ambulance from Childrens Hospital in Centennial, Colorado (CHCC) to Childrens Hospital in Millard, Nebraska (CHMC) on 6/30/15. The patient was born with a congenital diaphragmatic hernia on 1/29/15. She was intubated at birth. The patient underwent several surgeries. She remained with severe pulmonary hypertension. Multiple attempts to wean the child from the ventilator failed. It was determined that the patient no longer required the services of a level IV neonatal intensive care unit (NICU). The decision was made to transfer the patient to a level III NICU in Nebraska to be closer to her home. The ambulance was scheduled in advance on 6/29/15. The transport was initiated on 6/30/15, and no adverse events occurred during transport. The Health Insurer has denied reimbursement for air ambulance services provided on 6/30/15. Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient."], "answer_start": [18]}, "context": "Summary Reviewer\n\nThe patient is a three-year-old female who was transported by air ambulance from Childrens Hospital in Centennial, Colorado (CHCC) to Childrens Hospital in Millard, Nebraska (CHMC) on 6/30/15. The patient was born with a congenital diaphragmatic hernia on 1/29/15. She was intubated at birth. The patient underwent several surgeries. She remained with severe pulmonary hypertension. Multiple attempts to wean the child from the ventilator failed. It was determined that the patient no longer required the services of a level IV neonatal intensive care unit (NICU). The decision was made to transfer the patient to a level III NICU in Nebraska to be closer to her home. The ambulance was scheduled in advance on 6/29/15. The transport was initiated on 6/30/15, and no adverse events occurred during transport. The Health Insurer has denied reimbursement for air ambulance services provided on 6/30/15. Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  Air ambulance services are considered medically necessary under certain circumstances. These circumstances include: the patients condition is such that any other means of transport would be medically contraindicated, the patients condition is such that the time necessary for transport by land poses a threat to the patients health, and the patient is transported to the nearest hospital with appropriate facilities for treatment. All of these criteria must be met in order for air ambulance transport to be medically necessary. In this case, the patient was being transferred from a level IV NICU to a level III NICU, a lower level of care. This transfer was planned in advance, not completed emergently. The patient was transferred to another state in order to be closer to home. There are other NICU facilities closer to CHCC than CHMC. All told, air ambulance services provided on 6/30/15 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n", "id": "4e84316888d646188fcd38d6488ab9a1", "question": "What is the background context in this case summary?", "title": "4e84316888d646188fcd38d6488ab9a1", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 15-year-old female enrollee has requested authorization and coverage for an insulin pump (T-Slim). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.", "In this case, the patient has a history of widely fluctuating blood glucose levels before meals, glycemic control that is suboptimal on a multi-dose insulin injection regimen, and variations in her daily activity schedule and eating plan", "the patient and her family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have attempted to comply with dietary recommendations.", "the patients previously prescribed OmniPod pump was never fully functional.", "the OmniPod malfunctioned in this patient after a trial of a few months, as the patient experienced significant adverse skin reactions at the sites of the adhesive tape, making it impossible for her to continue to wear the pump. In addition, due to the nature of her active lifestyle, the pump dislodged too often to make it a viable tool to deliver insulin, and her glycemic control worsened due to unpredictable insulin delivery."], "answer_start": [20, 413, 1433, 1732, 1906]}, "context": "Summary Reviewer \n\n\nThe parent of a 15-year-old female enrollee has requested authorization and coverage for an insulin pump (T-Slim). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation establishes the medical necessity of the requested services. In this case, the patient has a history of widely fluctuating blood glucose levels before meals, glycemic control that is suboptimal on a multi-dose insulin injection regimen, and variations in her daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to maintain glycemic control and prevent severe hypoglycemia. Several studies in the peer-reviewed literature have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes. Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents (Battelino; Plotnick, et al; Saha, et al). Finally, this patients caregivers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. Specifically, the patient and her family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have attempted to comply with dietary recommendations. Pump therapy is medically necessary for treatment of this patients diabetes. Furthermore, the patients previously prescribed OmniPod pump was never fully functional. Although there was no mechanical failure of the OmniPod and it is not out of warranty, in effect, the OmniPod malfunctioned in this patient after a trial of a few months, as the patient experienced significant adverse skin reactions at the sites of the adhesive tape, making it impossible for her to continue to wear the pump. In addition, due to the nature of her active lifestyle, the pump dislodged too often to make it a viable tool to deliver insulin, and her glycemic control worsened due to unpredictable insulin delivery. The T-Slim pump delivers insulin via a catheter inserted under the skin instead of a pod; the insertion site is much smaller and does not require as much adhesive tape to stay in place. In addition, the thin catheter in the T-Slim is less likely to dislodge with vigorous physical activity than the pod in the OmniPod system. Thus, transition to the T-Slim pump is medically necessary based on the history of adverse reaction to the OmniPod. Moreover, the T-Slim pump has been shown to have an easy-to-read screen and reduced error rates and training time compared to other insulin pumps (Schaeffer, et al). Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. \n\n\n", "id": "56cf7688cc2844fa9426b1ed99c41d04", "question": "What is the background context in this case summary?", "title": "56cf7688cc2844fa9426b1ed99c41d04", "sufficiency_score": 4}
+{"answers": {"text": ["A 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST)."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST). The physician reviewer found that the malignant peripheral nerve sheath tumors (MPNST) are an uncommon but devastating tumor of peripheral nerve. About 22 to 50 percent of MPNSTs occur in patients with neurofibromatosis type 1 (NF1). Having a NF1 mutation adds information for prognosis and aids in follow-up decision making. FoundationOne offers the advantage of testing for NF1 mutations as well as others that may help guide therapeutic decision making should the patient progress. FoundationOne testing is likely to be more beneficial than not testing and not knowing the prognosis of the patient. In sum, FoundationOne testing performed on 4/7/15 was likely to have been more effective over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "1d11fe293ca94bc6b087050b8c477ab6", "question": "What is the background context in this case summary?", "title": "1d11fe293ca94bc6b087050b8c477ab6", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA)."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA). The physician reviewer found THE testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. Several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed patients considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. In this case, the patient has low-risk localized prostate cancer and the testing at issue was indicated to assist with improve decision-making. All told, the Oncotype DX testing provided on 9/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "51058c75cd5348e79cce28340ba4073a", "question": "What is the background context in this case summary?", "title": "51058c75cd5348e79cce28340ba4073a", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a four-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe parent of a four-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that Ataxia is an uncommon finding in children with a large number of causes. Genetic etiology can often be identified, particularly in those with early age of onset, family history of ataxia, or consanguineous parents. In this childs case, the very early age of onset indicated a high probability of an underlying genetic cause. Studies of whole exome sequencing (WES), which is more comprehensive than the panel requested here, have shown rates of identification of underlying genetic etiology ranging from 21% to 69%, depending on age and family history of those included. The rate of positive WES in 21% of adults with ataxia suggests a significant likelihood of finding a diagnosis for this child, either by panel test or by WES. Many authors currently recommend WES either as a follow-up test to non-diagnostic ataxia panel genetic testing, or as an initial molecular test due to its comprehensiveness. Specific treatments do exist for some hereditary ataxias, and more clinical trials and therapies are anticipated, increasing the benefits of confirming a molecular diagnosis. The current medical evidence supports genetic testing in this clinical setting. Therefore, the requested genetic testing is medically necessary for the evaluation of this patient.", "id": "718eb4cb81be431c9f9490a1b4a31656", "question": "What is the background context in this case summary?", "title": "718eb4cb81be431c9f9490a1b4a31656", "sufficiency_score": 2}
+{"answers": {"text": ["A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. There are no widely accepted clinical studies demonstrating that treatment strategies directed at advanced lipoprotein testing parameters will improve clinical outcomes in individuals with dyslipidemias. Clinical trial data to date does not support the superiority of measurement of such parameters beyond what is known from a basic lipid panel in assessing treatment. This was also the conclusion of the American College of Cardiology/American Heart Association 2013 guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation. \n\n\n", "id": "e069e6f2a7ae482bbe108ef76b8119d1", "question": "What is the background context in this case summary?", "title": "e069e6f2a7ae482bbe108ef76b8119d1", "sufficiency_score": 2}
+{"answers": {"text": ["A 26-year-old male enrollee has requested authorization and coverage for the LINX reflux management system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).", "In this patients case, the records reflect that he has undergone", "pre-operative assessment and that he has GERD based on pH recording.", "neither his radiographic studies in 2011 nor 2015 evidenced gastroesophageal reflux."], "answer_start": [21, 1363, 1441, 1519]}, "context": "Summary Reviewer 1\n\n\nA 26-year-old male enrollee has requested authorization and coverage for the LINX reflux management system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).   The physician reviewer found according to peer-reviewed published literature, there is only one lower esophageal sphincter (LES) augmentation device designed for the treatment of GERD at this time.  The LINX device has been approved for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. Two post-approval studies are designed to evaluate the long-term effectiveness of the device and incidence of adverse events; however, comparative studies with other anti-reflux surgeries are still needed. While there is some medical literature in support of the use of the LINX device for patients with GERD, appropriate patient selection is crucial before anti-reflux procedures. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. In this patients case, the records reflect that he has undergone much of this pre-operative assessment and that he has GERD based on pH recording. However, neither his radiographic studies in 2011 nor 2015 evidenced gastroesophageal reflux. As such, he cannot be considered medically refractory given the intermittency of documented reflux. Also, implantation of LINX in this clinical setting must be approached with caution given the patients charted complaint of dysphagia.  As such, the LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "83d04bc0697f4e38ab1b07225611cd4b", "question": "What is the background context in this case summary?", "title": "83d04bc0697f4e38ab1b07225611cd4b", "sufficiency_score": 4}
+{"answers": {"text": ["A 30-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 7/04/18 through 7/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.", "The patients abuse of alcohol was impairing his daily routine and contributing to significant impairment across multiple domains of functionality.", "the patient completed an uncomplicated detoxification.  He was maintaining sobriety and was motivated for recovery. His girlfriend was supportive. He had safe housing.", "the patient had no history of chemical dependency treatment", "he had no impairment in memory, concentration or thought processing.", "the patient had improved with the treatment intervention. He was autonomous and was maintaining motivation for sobriety.", "he had not failed a less restrictive treatment course during the episode of illness."], "answer_start": [19, 457, 652, 1007, 2121, 2198, 2328]}, "context": "Summary Reviewer \n\nA 30-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 7/04/18 through 7/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. The patients abuse of alcohol was impairing his daily routine and contributing to significant impairment across multiple domains of functionality. As such, specialty care was indicated. However, the patient completed an uncomplicated detoxification.  He was maintaining sobriety and was motivated for recovery. His girlfriend was supportive. He had safe housing. Despite his comorbid obsessive-compulsive disorder, the patient did not have a psychiatric condition or medical illness that required placement at the residential level of care. Further, the patient had no history of chemical dependency treatment, such as sponsored community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment.  This is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that similarly comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time. With that said, discharge on a federal holiday would have incurred a needless gap in treatment and thus would have been inappropriate. The extra day also afforded opportunity to address his severe craving, as it appears that acamprosate was added the following day. On 7/05/18, the patients craving was mild. There was no mention of medication intolerability or non-adherence. His appearance was appropriate, and he had no impairment in memory, concentration or thought processing. In sum, the patient had improved with the treatment intervention. He was autonomous and was maintaining motivation for sobriety. Further, he had not failed a less restrictive treatment course during the episode of illness. As such, the substance abuse residential treatment services at issue were no longer medically necessary as of 7/05/18. Thus, substance use residential treatment provided on 7/04/18 was medically necessary, but not thereafter. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned. ", "id": "2e43351fc8cc46cfbd3da9d0ec67c67d", "question": "What is the background context in this case summary?", "title": "2e43351fc8cc46cfbd3da9d0ec67c67d", "sufficiency_score": 4}
+{"answers": {"text": ["A 41-year-old male enrollee has requested authorization and coverage for rituximab injections 100 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pretibial myxedema."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 41-year-old male enrollee has requested authorization and coverage for rituximab injections 100 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pretibial myxedema. The physician reviewer found that the use of rituximab for ocular related findings associated with Graves disease is supported by peer-reviewed medical literature. However, there is a paucity of large, controlled studies demonstrating the safety and efficacy of rituximab for treatment of pretibial myxedema (Heyes, et al; Ferreira-Hermosillo, et al). As this patient does not have any documented ocular related findings associated with Graves disease, the requested rituximab injections 100 mg are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "5cf1bd409fe241b5a8a3e1f6d0f81d1e", "question": "What is the background context in this case summary?", "title": "5cf1bd409fe241b5a8a3e1f6d0f81d1e", "sufficiency_score": 3}
+{"answers": {"text": ["the records document that this patient \npresents with a history of primary melanoma of the cervix with an erythroblastic oncogene B \n(ERBB)2 V777L mutation. The patients provider has recommended treatment with Tukysa.", "The patient is a 53-year-old female with a history of primary melanoma of the cervix with an \nerythroblastic oncogene B (ERBB)2 V777L mutation. In a letter dated 12/13/22, the provider \nreported that the patient was diagnosed in April 2022. The records noted that the patient had \nundergone initial treatment with four cycles of ipilimumab with nivolumab. The Health Insurer \nhas denied the requested medication as not medically necessary."], "answer_start": [546, 10]}, "context": "Summary  \nThe patient is a 53-year-old female with a history of primary melanoma of the cervix with an \nerythroblastic oncogene B (ERBB)2 V777L mutation. In a letter dated 12/13/22, the provider \nreported that the patient was diagnosed in April 2022. The records noted that the patient had \nundergone initial treatment with four cycles of ipilimumab with nivolumab. The Health Insurer \nhas denied the requested medication as not medically necessary. This denial is the subject of this \nappeal and determination. The physician reviewer found that the records document that this patient \npresents with a history of primary melanoma of the cervix with an erythroblastic oncogene B \n(ERBB)2 V777L mutation. The patients provider has recommended treatment with Tukysa. Per \nthe  National  Comprehensive  Cancer  Network  (NCCN)  guidelines  for  melanoma,  mucosal \nmelanoma should be treated as diseases distinct from cutaneous melanoma, with care tailored to \nthe individual patient. The U.S. Food and Drug Administration (FDA) has approved Tukysa for \nthe treatment of patients with HER2 positive breast cancer or HER2 positive colon cancer, to be \ntaken in combination with other agents. However, there is a lack of FDA approved indication or \nsupport for use of Tukysa for use as monotherapy in the treatment of this patients cancer. Strickler \nand colleagues reported that studies are ongoing to evaluate the efficacy of Tukysa as monotherapy \nand to validate the reported findings from their trial. Overall, there is a lack of data to suggest that \nTukysa as single agent therapy is safe and effective in this patients clinical setting. All told, the \nrequested Tukysa (tucatinib) 150 mg #120/30 days is not medically necessary for treatment of this \npatient.  \n ", "id": "f7a36cde08094e0f8f2a72b247f041b1", "question": "What is the background context in this case summary?", "title": "f7a36cde08094e0f8f2a72b247f041b1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 46-year-old female with severe cervical spondylosis with progressive involvement of C5-6 and C6-7 levels and associated radiculopathy. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nThe patient is a 46-year-old female with severe cervical spondylosis with progressive involvement of C5-6 and C6-7 levels and associated radiculopathy. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. Cervical disc arthroplasty has been approved by the US Food and Drug Administration (FDA) and has been demonstrated preserve some motion and provide decreased incidence of adjacent level disease when compared with anterior cervical discectomy and fusion. The need for revision surgery is also less than anterior cervical discectomy and fusion (Gao, et al; Wu, et al; Radcliff, et al). For these reasons, the cervical artificial discectomy performed on 4/13/17 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the surgery at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "6f8cab2fe038471d80198a0487aef0ad", "question": "What is the background context in this case summary?", "title": "6f8cab2fe038471d80198a0487aef0ad", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 49-year-old male with a history of chronic low back pain. On 7/30/20, the records noted that the patient has a displaced lumbar disc and left lumbar radiculitis.", "In this case, the patient has a", "diagnosis of generalized anxiety disorder for which he is receiving medical treatment. The provider notes stated that the patient would undergo a lumbar epidural steroid injection but would require sedation because of a fear of needles. There is documentation from 2/16/18 showing that the patient suffered a severe case of vasovagal response during a lumbar medial branch block that was completed under local anesthetic only. He has a confirmed diagnosis of anxiety and known needle phobia which would make it difficult for him to undergo the epidural injection while remaining motionless. He also has a history of vasovagal response to previous injections done under local anesthetic only."], "answer_start": [19, 1363, 1405]}, "context": "Summary Reviewer \n\nThe patient is a 49-year-old male with a history of chronic low back pain. On 7/30/20, the records noted that the patient has a displaced lumbar disc and left lumbar radiculitis. The physician reviewer found that the 2019 American Society of Interventional Pain Physicians (ASIPP) guidelines for use of sedation during routine pain management injections states, aGiven that patients undergoing pain procedures typically are anxious and in pain, mild to moderate sedation is acceptable for many patients.a The guidelines further state, aDeeper sedation should only be undertaken in the presence of anesthesia providers and for patients who have high anxiety, complex pharmacotherapy, or a low pain threshold when undergoing more painful interventional pain procedures. In special cases, the risk of patient movement during a procedure resulting in potential inadvertent injury may justify a deeper anesthetic state.a\nThe American Society of Anesthesiologists also published a statement regarding the use of sedation for pain management injections and concluded, aSignificant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services.a\nIn this case, the patient has a confirmed diagnosis of generalized anxiety disorder for which he is receiving medical treatment. The provider notes stated that the patient would undergo a lumbar epidural steroid injection but would require sedation because of a fear of needles. There is documentation from 2/16/18 showing that the patient suffered a severe case of vasovagal response during a lumbar medial branch block that was completed under local anesthetic only. He has a confirmed diagnosis of anxiety and known needle phobia which would make it difficult for him to undergo the epidural injection while remaining motionless. He also has a history of vasovagal response to previous injections done under local anesthetic only. Based on the medical records for review and current national guidelines, the request for monitored anesthesia care for the lumbar epidural steroid injection was medically indicated. Therefore, anesthesia for diagnostic or therapeutic nerve blocks and injections provided on 7/30/20 was medically necessary for the treatment of this patient.", "id": "1e1a4240ee684bad9ad0bc5012c25bc0", "question": "What is the background context in this case summary?", "title": "1e1a4240ee684bad9ad0bc5012c25bc0", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 23-year-old male who underwent septorhinoplasty, bilateral inferior turbinoplasty, and submucous resection of the nasal septum on 3/11/20. The patient has requested reimbursement for nasal surgery performed on 3/11/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary and were not reconstructive in nature.", "Symptoms of nasal obstruction were fluctuating, with allergic rhinitis present seasonally from August through September.", "Symptoms of breathing obstruction were poor sleeping and waking with a dry mouth.", "The prior history of medical management included self-managed use of Claritin and Afrin.", "Nasal deviation was mild", "aThis patientas complaints for nasal surgery were not sleeping well and waking with a dry mouth. He has allergic rhinitis, a risk factor for obstructive sleep apnea syndrome. His nasal symptoms fluctuate seasonally"], "answer_start": [19, 748, 1001, 1154, 1378, 2372]}, "context": "Summary Reviewer \n\nThe patient is a 23-year-old male who underwent septorhinoplasty, bilateral inferior turbinoplasty, and submucous resection of the nasal septum on 3/11/20. The patient has requested reimbursement for nasal surgery performed on 3/11/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary and were not reconstructive in nature. The physician reviewer found that while the provider reported simply that there was a severely deviated nasal septum, no further information was received for review. There is no physical description of the reported nasal deviation from either speculum view or from the performed nasal endoscopy. No imaging of the nasal septum was performed. Symptoms of nasal obstruction were fluctuating, with allergic rhinitis present seasonally from August through September. Fluctuating symptoms of nasal obstruction due to allergy are not diagnostic of a physical functional deformity of the nasal septum. Symptoms of breathing obstruction were poor sleeping and waking with a dry mouth. No symptoms of daytime breathing obstruction were received for review. The prior history of medical management included self-managed use of Claritin and Afrin. No documented history of attempted medical management of breathing obstruction, including the use of Flonase, was received for review. Nasal deviation was mild on the photographs received for review. Gottlieb and Punjabi stated that the most common presenting symptom of OSA is excessive sleepiness. In a study of internal nasal dimensions and obstructive sleep apnea syndrome (OSAS), Trindade and colleagues stated, aThere were no significant differences in the cross-sectional areas and nasal volumes between individuals with primary snoring-mild obstructive sleep apnea syndrome and moderate-severe obstructive sleep apnea syndrome. Differently to the raised hypothesis, our results suggest that there is no association between internal nasal dimensions and severity of obstructive sleep apnea syndrome.a Cao and colleagues stated, aThe co-existence of allergic rhinitis (AR) and obstructive sleep apnea (OSA) is a common phenomenon in clinical practice. AR has long been considered a risk factor for OSAaPatients with AR were more likely to become habitual snorers and had increasing risk of SDB (sleep disordered breathing).aThis patientas complaints for nasal surgery were not sleeping well and waking with a dry mouth. He has allergic rhinitis, a risk factor for obstructive sleep apnea syndrome. His nasal symptoms fluctuate seasonally and do not reflect a fixed nasal airway deformity. There is no history of medical treatment for allergic rhinitis, including the use of Flonase. There are no objective physical findings reported to support a diagnosis of a severely functionally deviated nasal septum. Photographs received for review do not document nasal deviation to a functionally significant extent to cause nasal breathing obstruction. Based on the medical history received for review, septorhinoplasty, bilateral inferior turbinoplasty, and submucous resection of the nasal septum were not medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The medical history received for review does not support that the patient has an abnormal structure of the body. There is a lack of medical history and physical findings to support a diagnosis of functional nasal airway obstruction. The California reconstructive surgery statute does not apply to this patient. Therefore, nasal surgery performed on 3/11/20 was not reconstructive in nature.\n", "id": "4eedfae23b3e4df98c23a085b24f75ca", "question": "What is the background context in this case summary?", "title": "4eedfae23b3e4df98c23a085b24f75ca", "sufficiency_score": 4}
+{"answers": {"text": ["A 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata. The physician reviewer found that Alopecia areata is autoimmune in nature and brings psychological manifestations as well as physical. The use of Xeljanz has shown some promise, with better results than any other available standard treatment, other than maybe long-term oral steroids, which are limited by their side effects. In this clinical setting, Xeljanz is likely to offer this patient the safest option to treat her ongoing disease. In sum, Xeljanz 5 mg are likely to be of greater benefit than other treatment modalities. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "8e088ee6e82c471891fe3416124b1d66", "question": "What is the background context in this case summary?", "title": "8e088ee6e82c471891fe3416124b1d66", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "This patient is being treated for lumbar spinal stenosis with neurogenic claudication."], "answer_start": [20, 730]}, "context": "Summary Reviewer 2\n\nA 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that interspinous spacers were developed to avoid the risks of a traditional laminectomy via a less invasive technique that is reversible. The device is placed percutaneously in the interspinous space with minimal disruption of the spinal anatomy. The goal is to limit extension of the spine, minimizing the effects of spinal degeneration and enlarging the spinal canal and neural foramina area. This patient is being treated for lumbar spinal stenosis with neurogenic claudication. While there are many interspinous devices on the market, none have high quality research to demonstrate superiority over the current standard of care, simple decompression. The use of an interspinous spacer for spinal stenosis as a minimally invasive, stand-alone procedure has shown high failure and complication rates.  Until data exists that demonstrate noninferiority of these devices to the current gold standard treatment, simple decompression, the use of the requested device as a standalone procedure should be considered investigational for the treatment of the patients condition. In sum, the requested surgical insertion of an interspinous process spacer is not likely to be more beneficial than other available standard therapy.\n\n\n", "id": "8f3cc24d5495405c83cd0e706c079811", "question": "What is the background context in this case summary?", "title": "8f3cc24d5495405c83cd0e706c079811", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "this patient had a long history of neurogenic claudication. He has failed conservative treatment for over six months, including nonsteroidal anti-inflammatory drugs, opioids, physical therapy, epidural steroid injections, and bracing. His provider has recommended minimally invasive interspinous process spacer using the Superion device."], "answer_start": [20, 339]}, "context": "Summary Reviewer 3\n\nA 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a long history of neurogenic claudication. He has failed conservative treatment for over six months, including nonsteroidal anti-inflammatory drugs, opioids, physical therapy, epidural steroid injections, and bracing. His provider has recommended minimally invasive interspinous process spacer using the Superion device. Nunley and colleagues presented a four-year follow-up of 89 patients who underwent the procedure for spinal stenosis. At four years after the procedure, 75 of 89 patients with Superion (84.3%) demonstrated clinical success in terms of back and leg pain. The minimally invasive implantation procedure of the Superion device provided relief of symptoms of intermittent neurogenic claudication in these patients with moderate lumbar spinal stenosis. The second article referenced is a five-year follow-up and indicated that 75 percent of these patients continued to do well and did not require any other treatment such as an open decompression/fusion procedure. Thus, the requested surgical insertion of an interspinous process spacer is likely to be more beneficial than other available standard therapy.\n\n\n", "id": "6a16816f382c4dce998bd4dfd70311b5", "question": "What is the background context in this case summary?", "title": "6a16816f382c4dce998bd4dfd70311b5", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is an 80-year-old male with a history of psoriatic arthritis and osteoarthritis of both \nknees with associated chronic bilateral knee pain. The patient has requested reimbursement for \nhyaluronan injections (Synvisc-One) performed on 9/09/21.", "In this case, the medical records dated 9/09/21 state that the patient had \nreceived Synvisc-One injections into both knees in the past with good results."], "answer_start": [21, 1192]}, "context": "Summary Reviewer  \n \nThe patient is an 80-year-old male with a history of psoriatic arthritis and osteoarthritis of both \nknees with associated chronic bilateral knee pain. The patient has requested reimbursement for \nhyaluronan injections (Synvisc-One) performed on 9/09/21. The physician reviewer found that \nan exhaustive review of the current medical literature pertaining to viscosupplementation \nreveals mixed results. Evidence from eight systematic reviews and six randomized controlled \ntrials indicates that although viscosupplementation may relieve knee pain in some individuals \nwith osteoarthritis, it is not known as to which individuals will benefit. Different studies have \ntried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make \nit more effective. Guidelines from organizations such as the American Academy of Orthopedic \nSurgeons  indicate  that  the  evidence  is  not  conclusive.  In  light  of  the  foregoing, \nviscosupplementation can only be recommended in individuals with a history of lasting benefit \nfrom prior injections and in carefully selected cases where everything else has been tried and the \noptions are limited. In this case, the medical records dated 9/09/21 state that the patient had \nreceived Synvisc-One injections into both knees in the past with good results. Therefore, he \npresented with recurrent bilateral knee pain for additional injections. There is sufficient support \nfor the services at issue in this clinical setting. Therefore, hyaluronan injections (Synvisc-One) \nperformed on 9/09/21 were medically necessary for the treatment of this patient. \n ", "id": "1a05fe3f06304b768ef8980fa5885b72", "question": "What is the background context in this case summary?", "title": "1a05fe3f06304b768ef8980fa5885b72", "sufficiency_score": 4}
+{"answers": {"text": ["A 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD)."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Sheu and colleagues in Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval (Bauer, et al). One peer reviewed journal published a letter stating that there are 11 reports of endoscopically confirmed LINX erosion through the esophagus in the publicly-accessible U.S. Food and Drug Administration (FDA) Adverse Events database (Bielefeldt, et al). Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al in Surgical Endoscopy). The currently available peer reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). All told, the requested endoscopic anti-reflux procedure (LINX) is not likely to be more beneficial than the standard methods of treating this patients medical condition. Therefore, for the reasons stated above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n", "id": "6c45c0bb69d8445aa35614b94ab08feb", "question": "What is the background context in this case summary?", "title": "6c45c0bb69d8445aa35614b94ab08feb", "sufficiency_score": 3}
+{"answers": {"text": ["A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed medical literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 7/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "8281a640c756451db7027bf0f49df10c", "question": "What is the background context in this case summary?", "title": "8281a640c756451db7027bf0f49df10c", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 15-year-old male with a history of short stature. Per the submitted documentation, he underwent growth hormone stimulation testing in 2010, which showed that he was sufficient in growth hormone production. In March 2016, the predicted adult height was calculated to be 62.5 with the chronological age of 12 years and bone age of 12 years 6 months. The mid-parental height is 68.5. The records noted pretreatment growth velocity of 4.8 cm per year, which was low.  He was started on growth hormone therapy on 5/11/16 due to growth failure or low growth velocity and poor height prediction. The patients parent has requested coverage for Nutropin AQ. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of this patient.", "This patient had improvement in growth velocity to 7.6 cm per year. This patient meets the criteria for idiopathic short stature. He was prescribed growth hormone therapy and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects."], "answer_start": [18, 1266]}, "context": "Summary Reviewer\n\nThe patient is a 15-year-old male with a history of short stature. Per the submitted documentation, he underwent growth hormone stimulation testing in 2010, which showed that he was sufficient in growth hormone production. In March 2016, the predicted adult height was calculated to be 62.5 with the chronological age of 12 years and bone age of 12 years 6 months. The mid-parental height is 68.5. The records noted pretreatment growth velocity of 4.8 cm per year, which was low.  He was started on growth hormone therapy on 5/11/16 due to growth failure or low growth velocity and poor height prediction. The patients parent has requested coverage for Nutropin AQ. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender. This patient had improvement in growth velocity to 7.6 cm per year. This patient meets the criteria for idiopathic short stature. He was prescribed growth hormone therapy and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. The medical evidence supports the requested medication in this clinical setting. Thus, Nutropin AQ is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n\n", "id": "0e104f074bf84f61b24acf9df20b1460", "question": "What is the background context in this case summary?", "title": "0e104f074bf84f61b24acf9df20b1460", "sufficiency_score": 4}
+{"answers": {"text": ["A 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Optune therapy (E0766) from 6/19/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees glioblastoma multiforme."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Optune therapy (E0766) from 6/19/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees glioblastoma multiforme. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. Optune (Novo-TTF) is a novel portable medical device which is worn on the scalp and generates low-intensity alternating electric fields. This was initially approved for use in the treatment of glioblastoma in 2011. Stupp and colleagues demonstrated that Optune is less toxic than Temodar, with the same overall survival statistics. The advantage of the combination of Optune with Temodar was reaffirmed in the review by Taphoorn and colleagues. All told, Optune therapy (E0766) from 6/19/18 forward was and is medically necessary for the treatment of this patient. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "8ce2ba8c299e4580a74a64ca565d8d5e", "question": "What is the background context in this case summary?", "title": "8ce2ba8c299e4580a74a64ca565d8d5e", "sufficiency_score": 3}
+{"answers": {"text": ["A 31-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine, cervical spine, and pelvis. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees back and neck pain."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 31-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine, cervical spine, and pelvis. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees back and neck pain. The physician reviewer found that the records provided for review do not support the medical necessity of the requested MRI studies. The physical examination on 5/16/18 does not detail which muscles are weak or hypotonic. In addition, the neurological examination was limited and the note of prior physical therapy does not include details as to duration, evaluation or outcome. Moreover, there are no laboratory values in the chart to support an indication for an inflammatory process such as sacroiliitis. All told, there is a lack of documentation supporting the medical necessity for MRI of the lumbar spine, cervical spine, and pelvis for evaluation of this patients medical condition. Based on the foregoing discussion, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.", "id": "2bbeb8411dd74a228f6b5ccfdf6e0766", "question": "What is the background context in this case summary?", "title": "2bbeb8411dd74a228f6b5ccfdf6e0766", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that FoundationOne assay explores possible mutations in 324 genes, as well as certain other abnormalities, in an individualas cancer cells. At this time, there is a lack of convincing evidence that therapy that is determined by the assay is superior to that which an oncologist would recommend from the literature and experience. Finding a mutation does not guarantee that a treatment directed at that will be effective. It has been estimated that the percentage of patients who would benefit from using the assay to select therapy is quite small. The National Comprehensive Cancer Network guidelines for treatment of ovarian cancer does not recommend using such an assay in the selection of therapy. Therefore, laboratory services provided on 8/15/19 were not likely to have been more beneficial than other available standard therapy. \n\n\n", "id": "db57b7b4c8054cf782c98e170875220e", "question": "What is the background context in this case summary?", "title": "db57b7b4c8054cf782c98e170875220e", "sufficiency_score": 1}
+{"answers": {"text": ["A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation.", "She is alternating mammography/ultrasound with MRI every six months. Due to pregnancy and subsequent breastfeeding, she was unable to obtain her annual screening MRI, which would have been due February 2017.", "This patient has a known BRCA1 gene mutation"], "answer_start": [20, 1052, 924]}, "context": "Summary Reviewer 3\n\nA 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that contrast-enhanced breast MRI is more sensitive for the detection of breast cancer in the high risk population than both mammography and ultrasound. Screening breast MRI is recommended in women with BRCA gene mutations, their untested first-degree relatives, and women with a lifetime risk of greater than 20%. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. A common screening protocol is alternating MRI with mammography/ultrasound every six months. This patient has a known BRCA1 gene mutation and is therefore considered one of the highest risk populations for breast cancer. She is alternating mammography/ultrasound with MRI every six months. Due to pregnancy and subsequent breastfeeding, she was unable to obtain her annual screening MRI, which would have been due February 2017. Therefore, MRI was appropriately performed in January 2018 after the cessation of breastfeeding, according to her screening schedule. Thus, bilateral breast MRI performed on 1/28/18 was likely to have been of more efficacious than other modalities for evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned. \n\n\n", "id": "ccfb99baa7d24ae8b54bcd59a5f82190", "question": "What is the background context in this case summary?", "title": "ccfb99baa7d24ae8b54bcd59a5f82190", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is  a  27-year-old male who was  admitted  for  hospitalization  on  8/13/21  after \npresenting  with  progressively  worsening  abdominal  pain  with  vomiting.  The  patient  has \nrequested reimbursement for inpatient admission (hospital treatment services) from 8/13/21 \nthrough 8/15/21.", "In this case, the patient was hemodynamically stable and \nafebrile at admission. After treatment in the emergency department, the patients symptoms of \npain and vomiting improved.", "He \nwas treated with a nasogastric tube for a short time but able to tolerate oral nutrition shortly \nafter  admission."], "answer_start": [19, 915, 1257]}, "context": "Summary Reviewer  \nThe patient is  a  27-year-old male who was  admitted  for  hospitalization  on  8/13/21  after \npresenting  with  progressively  worsening  abdominal  pain  with  vomiting.  The  patient  has \nrequested reimbursement for inpatient admission (hospital treatment services) from 8/13/21 \nthrough 8/15/21. The physician reviewer found that at issue is whether inpatient admission \n(hospital treatment services) from 8/13/21 through 8/15/21 was medically necessary for the \ntreatment of this patient. The submitted documentation does not support the medical necessity \nof the services at issue. Inpatient care may be necessary when a patients signs, symptoms, and \ngeneral medical condition can only be managed safely in an acute inpatient setting, when a \npatient requires diagnostic studies in an inpatient setting, or when it is necessary for the patient \nto remain in an acute inpatient setting. In this case, the patient was hemodynamically stable and \nafebrile at admission. After treatment in the emergency department, the patients symptoms of \npain and vomiting improved. The records did not indicate that the patient required any urgent \nprocedures or surgical intervention. He did not have any significant electrolyte disturbances. He \nwas treated with a nasogastric tube for a short time but able to tolerate oral nutrition shortly \nafter  admission.  His  symptoms  improved  quickly  with  treatment  and  he  did  not  have \ncomplications. Given that this patient was in stable condition at admission and could have been \ntreated at a lower level of care, the services at issue were not medically indicated. Therefore, \ninpatient  admission  (hospital  treatment  services)  from  8/13/21  through  8/15/21  was  not \nmedically necessary for the treatment of this patient. \n \n ", "id": "bd1b143425584f8b9590965038837578", "question": "What is the background context in this case summary?", "title": "bd1b143425584f8b9590965038837578", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma. "], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found the most important considerations in the use of bronchial thermoplasty are the proper selection of patients and ensuring an experienced qualified provider is performing the procedure. Bronchial thermoplasty has adequate data on long-term safety and effectiveness in patients with asthma in terms of demonstrating improvement in symptoms and reduction in exacerbations. On the basis of daily symptoms, frequent rescue medication use, interference with daily activities and frequent exacerbations, this patient meets criteria for severe persistent asthma. However, there is not adequate information provided to determine two important considerations in the treatment of asthma. First, the records do not document that alternate diagnoses have been ruled out. The appearance of infiltrates and adenopathy on the computed tomography (CT) may indicate a secondary cause of wheezing. Secondly, there was not information provided to exclude other asthma therapies such as omalizumab or mepolizumab based on IgE levels or eosinophil counts. All told, there is a lack of documentation supporting the requested bronchial thermoplasty as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "2dc47c1276194071a137fca4e0b7467b", "question": "What is the background context in this case summary?", "title": "2dc47c1276194071a137fca4e0b7467b", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old male enrollee has requested reimbursement for long term acute care provided from 10/30/18 through 1/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.", "the patient required hemodialysis, nutrition via a feeding tube and continued wound care"], "answer_start": [19, 2032]}, "context": "Summary Reviewer \n\nA 62-year-old male enrollee has requested reimbursement for long term acute care provided from 10/30/18 through 1/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support. Long-term acute care hospitals offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day. The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care (e.g., ventilator-dependent). The long-term acute care hospital setting is considered when the patients need for nursing and rehabilitative services are such that only an inpatient long-term acute care hospital setting can meet the requirements, and the expected length of stay is greater than 25 days. In this case, the documentation does not support that the patient required complex medical treatment (e.g., multiple and prolonged intravenous therapies; monitoring of significantly medically active conditions requiring clinical assessment six or more times a day; multiple and frequent intervention of at least six or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above; and the need for specialized high-tech equipment like cardiac monitors, on-site dialysis, or surgical suites) as of 10/30/18. The patient did not require services at the long-term acute care hospital setting that were not available at the acute care hospital or the skilled nursing facility. The requested treatments were not medically necessary at the long-term acute care hospital level of care from 10/30/18 through 1/10/19. Although the patient required hemodialysis, nutrition via a feeding tube and continued wound care, he was medically stable as of 10/30/18 and could have received services at a lower level of care. Therefore, long-term acute care provided from 10/30/18 through 1/11/19 was not medically necessary for the treatment of this patient.", "id": "8b9cbe645c3747a0bf3469abeaf9fb1a", "question": "What is the background context in this case summary?", "title": "8b9cbe645c3747a0bf3469abeaf9fb1a", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a 45-year-old female with a history of atopic dermatitis. The patient states that she \nstopped treatment with Dupixent after experiencing a disruption in treatment from September to \nNovember 2022. The patient has requested continued treatment with Dupixent. The Health Insurer \nhas denied the requested treatment as not medically necessary for the treatment of the patients \nmedical condition.", "The \nrecords provided for review document that the patient has severe atopic dermatitis and atopic \nneurodermatitis, with 20% BSA involvement. The provider noted that the patient has tried and \nfailed treatment with topical steroids, antibiotics, and tacrolimus. The patient has previously \nundergone treatment with Dupixent with significant relief of symptoms."], "answer_start": [10, 1168]}, "context": "Summary  \nThe patient is a 45-year-old female with a history of atopic dermatitis. The patient states that she \nstopped treatment with Dupixent after experiencing a disruption in treatment from September to \nNovember 2022. The patient has requested continued treatment with Dupixent. The Health Insurer \nhas denied the requested treatment as not medically necessary for the treatment of the patients \nmedical condition. This denial is the subject of this appeal and determination. The physician \nreviewer found that the U.S. Food and Drug Administration (FDA) has approved Dupixent for the \ntreatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately \ncontrolled with topical therapies. A recent consensus article on atopic dermatitis by Boguniewicz \nand colleagues defined moderate-to-severe atopic dermatitis as more than 10% BSA involvement \nand/or involvement of highly visible areas or those important for function and significantly \nimpaired quality of life. On review of the current medical literature, Dupixent has the highest-\nquality clinical trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). The \nrecords provided for review document that the patient has severe atopic dermatitis and atopic \nneurodermatitis, with 20% BSA involvement. The provider noted that the patient has tried and \nfailed treatment with topical steroids, antibiotics, and tacrolimus. The patient has previously \nundergone treatment with Dupixent with significant relief of symptoms. Given these findings, the \nrequested Dupixent 300 mg/2 mL, four pens per 28 days is medically necessary for the treatment \nof this patient. \n \n ", "id": "b5e938f09bd64e17ac20f6d78d6c3719", "question": "What is the background context in this case summary?", "title": "b5e938f09bd64e17ac20f6d78d6c3719", "sufficiency_score": 4}
+{"answers": {"text": ["A 49-year-old female enrollee has requested authorization and coverage for breast susceptibility gene (BRCA) testing.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 49-year-old female enrollee has requested authorization and coverage for breast susceptibility gene (BRCA) testing.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found BRCA mutations are associated with a high incidence of both breast and ovarian cancer. Being BRCA positive has several implications for measures to be considered by the patient.  With regards to breast cancer, she can consider more intense screening with magnetic resonance imaging or even bilateral mastectomies.  With regards to ovarian cancer, it is recommended that such women have bilateral salpingo-oophorectomy at the appropriate age.  Thus BRCA is a genetic test of great potential importance and value.  However, there is a lack of support for the requested services in this patients case.  U.S. Preventative Services Task Force indicates that testing is recommended for women who have a family history including three or more first-degree or second-degree relatives with breast cancer, regardless of age of their diagnosis.  Additionally, there is support for BRCA testing for patients who have a close relative diagnosed with breast cancer under the age of 50.  None of these criteria appear to apply to this patient.  All told, the requested breast susceptibility gene (BRCA) testing is not medically indicated for the evaluation of this patient.  Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "9ecc9c5e8a2c484097b3534411b01bf3", "question": "What is the background context in this case summary?", "title": "9ecc9c5e8a2c484097b3534411b01bf3", "sufficiency_score": 2}
+{"answers": {"text": ["A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found that currently, there is a paucity of proven significant health or functional benefits of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry for use in this clinical setting. There have been a number of case reports and series providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury are lacking. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially retard or reverse muscle atrophy in paralyzed muscle, there is no proven significant health or functional benefit of this achievement in patients with spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide any other clinically or functionally relevant benefit. Passive cycling may be an option to provide passive range of motion therapy to prevent contractures or mitigate spasticity, but this is considered a custodial use of the device (Reichenfelser, et al). The other purported benefits of passive cycling have not been sufficiently investigated to allow conclusions related to clinically relevant outcomes. To date, the limited available data provide mixed results regarding health measures. Given that the RT300 FES cycle is not active exercise and not an appropriate substitute for active exercise, its use in this patients care was not indicated. Thus, the RT300 FES cycle provided on 2/10/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "4f2876b517534523b2c32c8c6858d465", "question": "What is the background context in this case summary?", "title": "4f2876b517534523b2c32c8c6858d465", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found the RT300 FES is a primary at-home internet linked and remote-clinician monitored intervention for patients with spinal cord injury (SCI) that provides intense electrical stimulation to intact peripheral nerves below the level of the SCI to evoke muscle contractions. Physical activities, like FES, that provide adequate stress to bone, can play a role in the improvement in bone mineral density with the possible prevention or reduction of osteoporosis and a decrease in fractures, two disabling and costly conditions for persons with paralysis due to SCI (Dolbow, et al). In addition, Fazio noted that repeated use of FES can lead to sensorimotor improvements as well as cortical reorganization, changes that cannot be accomplished with passive range of motion alone due to lack of sensory or motor input or activation of motor units, which is essential for motor relearning and neuromuscular reeducation. Thus, the intended in-home use of the RT300 FES cycle will help to remove many of the physical barriers to exercise which is a key factor in promoting regular physical activity in the SCI patient. For these reasons, the RT300 FES cycle provided on 2/10/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the equipment at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "977f7dcf487c479ba727751c190dba89", "question": "What is the background context in this case summary?", "title": "977f7dcf487c479ba727751c190dba89", "sufficiency_score": 3}
+{"answers": {"text": ["A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination", "In this particular patient, her breasts have been described as extremely dense."], "answer_start": [20, 697]}, "context": "Summary Reviewer 3\n\nA 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breasts have been described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on 3/22/16 was likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned\n\n\n\n\n", "id": "f0f99f6f2b3e410f9aee6c60d97de111", "question": "What is the background context in this case summary?", "title": "f0f99f6f2b3e410f9aee6c60d97de111", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer.", "In this patient with a rising PSA after radical prostatectomy, the possibility of subtle skeletal metastatic disease is possible"], "answer_start": [20, 1071]}, "context": "Summary Reviewer 1\n\nA 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based upon the recommendations of the National Oncologic PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its guidelines concerning coverage for PET scans in patients with solid tumors allowing up to three scans in each patient for diagnosis, staging and surveillance. While the use of this compound has proven to be of use in prostate cancer, the re-approval of 18F-NaF as a pharmaceutical has proven of greater benefit to patients with rising PSA levels where bone metastases are possible. The reason is the proven marked increased sensitivity of the technique compared to standard technetium bone scans in the detection and localization of skeletal metastatic deposits. In this patient with a rising PSA after radical prostatectomy, the possibility of subtle skeletal metastatic disease is possible and the requested 18F-NaF PET/CT scan is the most sensitive means with which to evaluate this patient.  Based upon the information set forth above, I have determined the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "a66fa4eed8e24b73bbed06230cd82a28", "question": "What is the background context in this case summary?", "title": "a66fa4eed8e24b73bbed06230cd82a28", "sufficiency_score": 4}
+{"answers": {"text": ["A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma testing for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "69fe01225b02478eb4e67cc2a069bb99", "question": "What is the background context in this case summary?", "title": "69fe01225b02478eb4e67cc2a069bb99", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from \n1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service \nat issue was investigational for the treatment of the enrollees hereditary hemochromatosis.", "In this case, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron \nsaturation over 85%."], "answer_start": [22, 783]}, "context": "Summary Reviewer 2 \n \nA 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from \n1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service \nat issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The \nphysician reviewer found that therapeutic phlebotomy is the preferred approach to removing \niron in patients with hereditary hemochromatosis because it is highly effective and relatively \ndevoid of toxicities. In this case, phlebotomy was indicated as the records noted a biopsy proven \niron overload. While there is a range of ferritin and iron saturation goals, the recommended \nferritin goal is 30 to 150 ng/mL and the recommended iron saturation goal is greater than 20%. \nIn this case, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron \nsaturation over 85%. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely \nto have been more beneficial for treatment of the enrollee's condition than any available \nstandard therapy. \n \n \n", "id": "70cbdef719904e73b1ef8ea0ede6c64b", "question": "What is the background context in this case summary?", "title": "70cbdef719904e73b1ef8ea0ede6c64b", "sufficiency_score": 4}
+{"answers": {"text": ["A 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.", "The patients physical examination and lumbar magnetic resonance imaging (MRI) do not show evidence of lumbar radiculopathy/radiculitis."], "answer_start": [19, 414]}, "context": "Summary Reviewer \n\nA 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patients physical examination and lumbar magnetic resonance imaging (MRI) do not show evidence of lumbar radiculopathy/radiculitis.  The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis.  The patients chronic pain condition is not consistent with such a diagnosis.  There is a lack of support for the requested services in this clinical setting.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "925ae103ce344a059f825f5f37ddfeb2", "question": "What is the background context in this case summary?", "title": "925ae103ce344a059f825f5f37ddfeb2", "sufficiency_score": 2}
+{"answers": {"text": ["The parent of a 16-year-old male enrollee has requested reimbursement for immunoassay for \nanalyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise \nspecified and adalimumab on 8/6/21. The Health Insurer has denied this request indicating that the \nservice and medication at issue were investigational for the treatment of the enrollees ulcerative \ncolitis.", "In this case, the patient had \nsymptoms of active ulcerative colitis despite being on Humira.", "he was at risk for complications from ulcerative colitis such as toxic megacolon, \nhospitalization, need for surgery, or colonic dysplasia leading to colorectal cancer."], "answer_start": [22, 587, 1786]}, "context": "Summary Reviewer 3 \n \nThe parent of a 16-year-old male enrollee has requested reimbursement for immunoassay for \nanalyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise \nspecified and adalimumab on 8/6/21. The Health Insurer has denied this request indicating that the \nservice and medication at issue were investigational for the treatment of the enrollees ulcerative \ncolitis. The physician reviewer found that the use of testing for Humira drug levels and anti-Humira \nantibody levels is supported by guidelines in this clinical setting. In this case, the patient had \nsymptoms of active ulcerative colitis despite being on Humira. The American Gastroenterological \nAssociation (AGA) guideline on therapeutic drug monitoring in inflammatory bowel disease \nsuggests reactive therapeutic drug monitoring to guide treatment changes in adults with active \ninflammatory bowel disease treated with anti-TNF agents. The guideline suggests target trough \nconcentrations of 7.5 mg/mL for adalimumab. Drug concentration and anti-drug antibody levels \nshould be checked if there is a loss of response to an anti-TNF medication such as Humira, \nallowing for a subsequent change in management including a switch within drug classes, assessing \nfor inflammation, or increasing the dose. The AGA guidelines for the management of ulcerative \ncolitis also recommend drug level testing, noting that the patient with nonresponse or loss of \nresponse to therapy should be assessed with therapeutic drug monitoring to identify the reason for \nlack of response and whether to optimize the existing therapy or to select an alternate therapy. In \nthis case, given that the patients symptoms that were consistent with active or uncontrolled \nulcerative colitis, he was at risk for complications from ulcerative colitis such as toxic megacolon, \nhospitalization, need for surgery, or colonic dysplasia leading to colorectal cancer. In this clinical \nsetting,  testing  for  Humira  drug  level  and  anti-Humira  antibody  level  was  appropriate  per \nguidelines for the assessment of whether the patients Humira dose should be increased or changed \nto an alternative therapy. As the guidelines do not recommend any alternative therapy, the testing \nat issue was likely to have been more beneficial than a standard approach of changing Humira to \nanother therapy, which could be ineffective and result in entirely uncontrolled disease and severe \ncomplications such as hospitalization, surgery, and toxic megacolon. Therefore, immunoassay for \nanalyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise \nspecified, and adalimumab on 8/6/21 was likely to have been more beneficial for treatment of the \npatient's condition than any available standard therapy. \n \n ", "id": "5a347686f13d42ad813d60d5f95b2f6c", "question": "What is the background context in this case summary?", "title": "5a347686f13d42ad813d60d5f95b2f6c", "sufficiency_score": 4}
+{"answers": {"text": ["A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain.", "In this case, the patient presents with chronic left hip/buttocks pain with significant functional limitation. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Clinical exam findings have documented significant tenderness at the SI joint with six positive SI joint provocative tests. There is radiographic evidence of bilateral joint arthrosis with joint space narrowing. There is no imaging evidence of lumbosacral spine neural compression pathology. Multiple bilateral SI joint injections have produced 90% pain relief."], "answer_start": [21, 1931]}, "context": "Summary Reviewer 1\n\n\nA 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based peer-reviewed literature support SI joint fusion in this clinical setting. Polly and colleagues concluded in their study that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. The authors noted that pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. The criteria include: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. In this case, the patient presents with chronic left hip/buttocks pain with significant functional limitation. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Clinical exam findings have documented significant tenderness at the SI joint with six positive SI joint provocative tests. There is radiographic evidence of bilateral joint arthrosis with joint space narrowing. There is no imaging evidence of lumbosacral spine neural compression pathology. Multiple bilateral SI joint injections have produced 90% pain relief. The peer-reviewed supports the requested SI joint fusion as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy in this clinical setting. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "94f69a5c289740329f2cadcd140c1c04", "question": "What is the background context in this case summary?", "title": "94f69a5c289740329f2cadcd140c1c04", "sufficiency_score": 4}
+{"answers": {"text": ["A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain.", "She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions.", "the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan."], "answer_start": [21, 775, 989]}, "context": "Summary Reviewer 2\n\n\nA 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the North American Spine Societys recommendations include that percutaneous sacroiliac joint fusion should only be considered when all inclusion criteria have been met. The authors state that due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan. This patient meets all NASS criteria for the proposed surgery. For these reasons, sacroiliac joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "71bdbe9b026947788e358e9d090f15b0", "question": "What is the background context in this case summary?", "title": "71bdbe9b026947788e358e9d090f15b0", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.", "the patient presents with a long history of migraine headaches dating to childhood. The records indicate that before starting Botox she had a baseline headache frequency of 16 to 24 per month", "the patient has had a marked improvement documented with Botox treatments for more than 10 years."], "answer_start": [19, 511, 777]}, "context": "Summary Reviewer 2\nA 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that ongoing Botox treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with a long history of migraine headaches dating to childhood. The records indicate that before starting Botox she had a baseline headache frequency of 16 to 24 per month, which is consistent with the diagnosis of chronic migraine. In addition, the patient has had a marked improvement documented with Botox treatments for more than 10 years. In sum, Botox treatment for chronic migraine is indicated for this patient and ongoing treatments are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "a5337336cd9443819a80c9690135422c", "question": "What is the background context in this case summary?", "title": "a5337336cd9443819a80c9690135422c", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 47-year-old female who has requested authorization and coverage for Neulasta. She underwent chemotherapy for breast cancer. The patient has requested authorization and coverage for Neulasta. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 47-year-old female who has requested authorization and coverage for Neulasta. She underwent chemotherapy for breast cancer. The patient has requested authorization and coverage for Neulasta. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Neulasta has been approved by the U.S. Food and Drug Administration to decrease the incidence of infection (as manifested by febrile neutropenia) in patients with non-myeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. The combination of Adriamycin and cyclophosphamide carries a high risk of neutropenic fever. The standard of care is administration in a dose dense fashion every two weeks with growth factor support with Neulasta. Therefore, Neulasta is medically necessary for the treatment of this patient. \n\n", "id": "83d62c1a6bda4694b70ca2c2b05f2a8a", "question": "What is the background context in this case summary?", "title": "83d62c1a6bda4694b70ca2c2b05f2a8a", "sufficiency_score": 3}
+{"answers": {"text": ["A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "this patient had a recent transient ischemic attack while flying on an airplane. He was evaluated and has no other reason for transient ischemic attack other than the patent foramen ovale."], "answer_start": [20, 321]}, "context": "Summary Reviewer 1\n\nA 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a recent transient ischemic attack while flying on an airplane. He was evaluated and has no other reason for transient ischemic attack other than the patent foramen ovale. In addition, the development of the transient ischemic attack symptoms while flying a high altitude makes the patent foramen ovale an even more likely etiology of the symptoms as right heart pressures increase at high altitudes, and the risk of transient deep vein thrombosis is higher as well. This combination (occult deep vein thrombosis with elevated right heart pressures because of lower air pressures) makes the likelihood of paradoxical embolism from increased right to left shunting significantly higher in the setting of a large patent foramen ovale. This adds further credence to the clinical suspicion of the patent foramen ovale being the culprit pathology of the transient ischemic attack in this case. Recent data and meta-analyses suggest that patent foramen ovale closure prevents recurrent crytogenic stroke better than medical therapy alone in patients with no other suspected cause of the stroke and likely transient ischemic attacks as well. Therefore, patent foramen ovale closure is likely to be more beneficial than any available standard therapy.\n\n\n", "id": "03bb630273064038ab2169903d2de4bd", "question": "What is the background context in this case summary?", "title": "03bb630273064038ab2169903d2de4bd", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan."], "answer_start": [20, 321]}, "context": "Summary Reviewer 2\n\nA 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan. In patients with transient ischemic attacks and patent foramen ovales, transcatheter closure has been demonstrated to be of mild benefit only in younger patients without another potential source of transient ischemic attack, such as hypertensive urgency, and mainly in patients with transient ischemic attacks despite antiplatelet medication. This patient does not fit those criteria since there is another potential source and his age is greater than 60. In sum, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.\n\n\n", "id": "5f3e998da89c4656a5f1a46c4c38e40c", "question": "What is the background context in this case summary?", "title": "5f3e998da89c4656a5f1a46c4c38e40c", "sufficiency_score": 4}
+{"answers": {"text": ["A 56-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty for obstructive sleep apnea.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.", "This patient has mild obstructive sleep apnea and snoring.  It is noted that his obstructive sleep apnea is severe when in the supine position."], "answer_start": [20, 437]}, "context": "Summary Reviewer \n\n\nA 56-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty for obstructive sleep apnea.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has mild obstructive sleep apnea and snoring.  It is noted that his obstructive sleep apnea is severe when in the supine position.  There is no documentation of retropalatal obstruction or of redundant palatal soft tissue.  While uvulopalatopharyngoplasty is a common surgical procedure for treatment of obstructive sleep apnea, its success rate as a stand-alone surgery is low.  Its success rate in conjunction with nasal surgery is not much greater.  The fact that apnea-hypopnea index is greater when in the supine position does not determine that there is retropalatal airway obstruction.  All told, the requested uvulopalatopharyngoplasty is not medically indicated for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "1b4ac13725964037ad3d53af8f0e1830", "question": "What is the background context in this case summary?", "title": "1b4ac13725964037ad3d53af8f0e1830", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse.", "this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services."], "answer_start": [20, 372]}, "context": "Summary Reviewer \n\n\nA 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services. Evidence-based medical guidelines support hospitalization for parental narcotics and inability to manage basic activities of daily living at home, and additionally support a three-day best practice length of stay following vertebroplasty. Continued inpatient stay is supported until acceptable patient status for the next level of care is achieved, including pain is adequately managed on oral medications, and activity levels are at baseline or acceptable. Therefore, inpatient hospitalization provided from 3/31/17 through 4/07/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "8230657a0f9f468587e9b57576e9ca94", "question": "What is the background context in this case summary?", "title": "8230657a0f9f468587e9b57576e9ca94", "sufficiency_score": 4}
+{"answers": {"text": ["A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis.", "In this patients case, she had a recent colonoscopy showing endoscopic healing, and she had no complaints relative to her colitis."], "answer_start": [20, 994]}, "context": "Summary Reviewer 1\n\nA 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in tissue samples, body fluids, and stools, making it a potentially valuable marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. An additional potential role of fecal calprotectin is in the monitoring of patients with colitis to predict whether they are going to have a disease flare and to distinguish in symptomatic patients whether the symptoms are due to inflammation or to functional disease. In this patients case, she had a recent colonoscopy showing endoscopic healing, and she had no complaints relative to her colitis. There is a lack of support for the services at issue in this setting. Thus, fecal calprotectin testing performed on 11/22/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n", "id": "73af0a7605394e25baab9c49719e857d", "question": "What is the background context in this case summary?", "title": "73af0a7605394e25baab9c49719e857d", "sufficiency_score": 4}
+{"answers": {"text": ["A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis.", "In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy."], "answer_start": [20, 926]}, "context": "Summary Reviewer 3\n\nA 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that the use of fecal calprotectin is supported for management of patients with ulcerative colitis to prevent invasive interventions such as colonoscopy. A randomized, prospective, controlled trial by Lasson and colleagues evaluating patients with ulcerative colitis showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Costa and colleagues showed that unlike in Crohns disease, fecal calprotectin was sensitive and specific for prediction of relapse in ulcerative colitis, making it a useful tool for non-invasive monitoring. In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy. For these reasons, fecal calprotectin testing performed on 11/22/17 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "71e3affbe56842b0a628c9c16aecd240", "question": "What is the background context in this case summary?", "title": "71e3affbe56842b0a628c9c16aecd240", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.", "In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease.", "She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis."], "answer_start": [19, 849, 1180]}, "context": "Summary Reviewer \n\nThe patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, in established rheumatoid arthritis, aIf disease activity remains moderate or high despite DMARD monotherapy, the recommendation is to use combination traditional DMARDs or add a tumor necrosis factor inhibitor (TNFi) or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone.a In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease. It is therefore appropriate to consider TNFi therapy in this case based on the guidelines. She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, Enbrel SureClick is medically necessary for the treatment of this patient.\n", "id": "d6bbf78bda734e9e9f16b22f71239e03", "question": "What is the background context in this case summary?", "title": "d6bbf78bda734e9e9f16b22f71239e03", "sufficiency_score": 4}
+{"answers": {"text": ["A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that the use of the advanced lipoprotein testing with measurement of low density lipoprotein (LDL) cholesterol particle numbers remains controversial. While some providers have advocated for its use, the American College of Cardiology (ACC) guidelines do not support its use, recommending instead standard risk assessment protocols and standard lipid profile testing (Stone, et al). The ACC moved away from specific target goals of LDL in their most recent guidelines, based on review of outcome studies. Lloyd-Jones and colleagues provided an expert consensus update from the ACC and it does not mention the use of advanced lipid testing. Overall, the guidelines do not establish a strong recommendation for use of the advanced lipid profiles at this time. Thus, the blood testing provided on 1/17/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "fa896d2c163a4ddca916664a0a16e780", "question": "What is the background context in this case summary?", "title": "fa896d2c163a4ddca916664a0a16e780", "sufficiency_score": 2}
+{"answers": {"text": ["A 24-year-old female enrollee has requested authorization and coverage for lower esophageal \nmyotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health \nPlan has denied this request indicating that the requested service is investigational for the \ntreatment of the enrollees medical condition."], "answer_start": [22]}, "context": "Summary Reviewer 1 \n \nA 24-year-old female enrollee has requested authorization and coverage for lower esophageal \nmyotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health \nPlan has denied this request indicating that the requested service is investigational for the \ntreatment of the enrollees medical condition. The physician reviewer found  that there is \nsufficient  support  for  the  requested  service  in  this  clinical  setting.  The  American \nGastroenterological Association best-practice guideline states that if the expertise is available, \nPOEM should be considered as treatment option comparable with laparoscopic Heller myotomy \nfor any of the achalasia syndromes. The American Society for Gastrointestinal Endoscopy has \nrecently published a statement based on available evidence, stating that POEM is a potential \nattractive option for the treatment of achalasia that offers a minimally invasive endoscopic \napproach to myotomy with the potential for a durable response to therapy. Clinical studies and \ntrials  have  shown  comparable  efficacy  with  surgery  when  expertise  in  POEM  is  available. \nHowever,  despite  comparable  efficacy,  POEM  is  significantly  less  invasive  than  surgical \nintervention, resulting in less postoperative pain and a more rapid recovery. In this patient with \nsymptoms including dysphagia and regurgitation, as well as failure of pneumatic dilation, the use \nof POEM is supported by current medical literature and guidelines. Therefore, lower esophageal \nmyotomy, transoral POEM and one inpatient day is likely to be more beneficial than any available \nstandard therapy. \n \n", "id": "a7fedb38ef6b4c73bf6ee6b5a56d4a02", "question": "What is the background context in this case summary?", "title": "a7fedb38ef6b4c73bf6ee6b5a56d4a02", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.", "the patient had small intestinal bacterial overgrowth."], "answer_start": [19, 311]}, "context": "Summary Reviewer \n\nA 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient had small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication has been shown to have greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. Moraru and colleagues performed a prospective trial of patients with irritable bowel syndrome and small intestinal bacterial overgrowth. The authors found that 86% responded to Xifaxan, and symptoms were reduced as well. Xifaxan is effective for the treatment of constipation-predominant irritable bowel syndrome. In this case, while antispasmodic medications may address irritable bowel syndrome, they would not be expected to improve small intestinal bacterial overgrowth. Anti-diarrheal medications would not be appropriate in the use of constipation. Therefore, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients small intestinal bacterial overgrowth in the setting of irritable bowel syndrome.", "id": "2da4f196509f487ba1cb04d9de9d8bd8", "question": "What is the background context in this case summary?", "title": "2da4f196509f487ba1cb04d9de9d8bd8", "sufficiency_score": 3}
+{"answers": {"text": ["A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that the DecisionDX is a study of 15 to 31 genes in a patients melanoma cells.  It has been used to classify the individuals melanoma as having either a high or low risk of metastasis.  It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors.  However, it is particularly useful in the analysis of uveal melanoma and has been validated in several studies.  Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis.  This testing has become a standard in many ocular cancer centers.  Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy.  Therefore, DecisionDX-UM assay performed on 5/09/16 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "05389752e63d4bb19f48ac5c13b900b0", "question": "What is the background context in this case summary?", "title": "05389752e63d4bb19f48ac5c13b900b0", "sufficiency_score": 3}
+{"answers": {"text": ["A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery.", "the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability"], "answer_start": [20, 1037]}, "context": "Summary Reviewer 1\n\nA 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the criteria for sacroiliac joint fusion have not been met in this patients case. The patients records do not include documentation of failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest; physical therapy; or sacroiliac joint steroid injection must be reported. Moreover, there must be evidence that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Thus, although the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability, the patient has not adequately satisfied all of the ISASS criteria. All told, the requested sacroiliac joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "4a34dddfc36444a3bdad2bd8a27ba8ca", "question": "What is the background context in this case summary?", "title": "4a34dddfc36444a3bdad2bd8a27ba8ca", "sufficiency_score": 4}
+{"answers": {"text": ["A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in the cells of an individuals melanoma. It then classifies the melanoma based on the five-year risk of metastases. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients having sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the clinical value of the assay. It is not known how the five-year DecisionDx-Melanoma data compares and relates to the 10-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma class can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "f3d3ecedc4904f549a9ba0f299639cfd", "question": "What is the background context in this case summary?", "title": "f3d3ecedc4904f549a9ba0f299639cfd", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.", "she is noted to be a daily tobacco user and notes she will quit nicotine"], "answer_start": [19, 1647]}, "context": "Summary Reviewer \n\nThe patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.  The physician reviewer found that Bydon and colleagues noted, aA trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.a Chan and colleagues stated, aPatients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.a  In this patientas case, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to requested surgery to include (but not limited to) physical therapy measures. In addition, she is noted to be a daily tobacco user and notes she will quit nicotine; however, follow-up documentation does not indicate this has been completed. The provided imaging studies, including the dynamic x-rays from 8/10/21, do not corroborate movement/instability at the requested level, and detailed documentation is not evident regarding potential impending/inevitable temporary intraoperative instability. There is a lack of support for the requested services in this clinical setting. Therefore, the requested spinal surgery is not medically necessary for the treatment of this patient. \n\n", "id": "33ac3e0fdb1a4ede99a8fc216c511382", "question": "What is the background context in this case summary?", "title": "33ac3e0fdb1a4ede99a8fc216c511382", "sufficiency_score": 3}
+{"answers": {"text": ["A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition."], "answer_start": [22]}, "context": "Summary Reviewer 2\n\n\n\nA 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that management of ulcerative colitis using infliximab antibody testing has not been standardized, and recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed (Kornbluth, et al). In addition, the use of infliximab antibody testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). Based on the clinical literature, the infliximab antibody testing performed on 3/30/15 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n", "id": "1d22cca832384a84a6e596ae3348c537", "question": "What is the background context in this case summary?", "title": "1d22cca832384a84a6e596ae3348c537", "sufficiency_score": 2}
+{"answers": {"text": ["A 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.", "In this case, the patient was admitted in stable condition with new onset atrial fibrillation", "At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.", "the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened."], "answer_start": [20, 744, 892, 1273]}, "context": "Summary Reviewer \n\n\nA 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition with new onset atrial fibrillation and could have been treated at a lower level of care. At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.  Given the patients recent arrhythmia and need for anticoagulation, the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened.  Given the potential for cardiac complications, acute inpatient medical admission from 12/22/16 through 12/24/16 was medically necessary. However, inpatient hospital stay from 12/20/16 through 12/21/16 was not medically necessary for the treatment of this patient. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.", "id": "2b6dc53db8434992a6ed505001740782", "question": "What is the background context in this case summary?", "title": "2b6dc53db8434992a6ed505001740782", "sufficiency_score": 4}
+{"answers": {"text": ["A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [19]}, "context": "Summary Reviewer 3\nA 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that polymerase chain reaction testing has been compared to traditional testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it results in significantly higher sensitivity and negative predictive value than clinical diagnosis or clinical testing.  The test was also superior for detecting more than one cause for vaginitis. The medical evidence supports polymerase chain reaction testing as a means of accurate detection which allows for appropriate treatment. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.\n", "id": "ff8cad023e9942b3ba27057aab65a491", "question": "What is the background context in this case summary?", "title": "ff8cad023e9942b3ba27057aab65a491", "sufficiency_score": 1}
+{"answers": {"text": ["A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation.", "Based on the documentation submitted for review, the patient presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials."], "answer_start": [20, 528]}, "context": "Summary Reviewer 2\n\nA 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the surgical services performed on 7/10/13 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials. Since the patient continued to have significant symptoms in spite of attempts at rate control and rhythm control a second atrial fibrillation ablation procedure in this clinical setting was reasonable and medically appropriate and considered the standard of care in the medical community. The highest success in preventing atrial fibrillation with ablation is in those patients with paroxysmal (as opposed to persistent) atrial fibrillation (January, et al). Also, cryoablation has favorable results compared to radiofrequency ablation (Packer, et al). Given that the repeat ablation procedure performed on 7/10/13 was clinically indicated to relieve symptoms and is the standard of care in the medical community, the surgical services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "8ee8c41a15c64eff8bcece95de379433", "question": "What is the background context in this case summary?", "title": "8ee8c41a15c64eff8bcece95de379433", "sufficiency_score": 4}
+{"answers": {"text": ["A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health \nInsurer has denied this request and reported that the requested service is investigational for the \ntreatment of the enrollee."], "answer_start": [22]}, "context": "Summary Reviewer 1 \n \nA 51-year-old female enrollee has requested authorization and coverage for Botox. The Health \nInsurer has denied this request and reported that the requested service is investigational for the \ntreatment of the enrollee. The physician reviewer found that Temporomandibular joint disorders \nusually present with symptoms and signs such as pain, mandibular movement, dysfunction, or \njoint sounds. Bruxism is characterized by teeth grinding. Botulinum toxin A (Botox) is a biologic \ntoxin which inhibits skeletal muscle through hindering the production of acetylcholine in the \nnerve endings. The use of Botox for treatment of temporomandibular joint disorders and bruxism \nis not consistent with U.S. Food and Drug Administration (FDA) indications. While there are \nreports of the clinical use of Botox for the treatment of temporomandibular joint disorders and \nbruxism, the clinical evidence in current medical literature is insufficient to demonstrate the \nclinical efficacy of Botox in the treatment of temporomandibular joint disorders and bruxism or \nthat it is more beneficial than standard therapies including the use of occlusal devices, NSAIDs, \nand physical therapy. Therefore, Botox is not likely to be more beneficial for treatment of the \npatients condition than any available standard therapy. \n \n", "id": "6bc891a2502b40b280462e98ebf3ce0f", "question": "What is the background context in this case summary?", "title": "6bc891a2502b40b280462e98ebf3ce0f", "sufficiency_score": 2}
+{"answers": {"text": ["A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.", "at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease.", "the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission"], "answer_start": [19, 360, 869]}, "context": "Summary Reviewer \n\nA 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease. Given these risk factors and the severity of his infection and wounds, it was reasonable to admit him to a telemetry level of care for 24 hours. The initial 24 hours is sufficient time to check serial echocardiogram and cardiac enzymes and have a cardiology consultation. Furthermore, the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission, and after monitoring and serial enzymes/echocardiograms, he could have been treated at a lower level of care from 5/25/18 through 5/30/18. Therefore, inpatient stay at telemetry level of care provided from 5/23/18 through 5/24/18 was medically necessary for the treatment of this patient. The records fail to demonstrate the medical necessity of inpatient stay at telemetry level of care provided from 5/25/18 through 5/30/18.", "id": "16d905ff5c6b458abf3ff8fc2f06c4ae", "question": "What is the background context in this case summary?", "title": "16d905ff5c6b458abf3ff8fc2f06c4ae", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nThe patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  The medical evidence has not demonstrated the superior efficacy of the device at issue in this patients case. There is a lack of support for an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in this clinical setting. Implantable cardioverter defibrillator placement can be undertaken 90 days after a percutaneous coronary intervention/stenting procedure if the ejection fraction remains below 35 percent or 40 days after a myocardial infarction if there is no intervention and the ejection fraction remains below 35 percent.  There is lack of support for the device at issue in this case. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment modalities. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "49088243a20e44159b80161ec7ae5731", "question": "What is the background context in this case summary?", "title": "49088243a20e44159b80161ec7ae5731", "sufficiency_score": 4}
+{"answers": {"text": ["A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The U.S. Food and Drug Administration (FDA) has approved the Watchman device. The Watchman device is an appropriate alternative in patients who are deemed to be at prohibitively high bleeding risk while on long-term anticoagulation, such as is documented with this patient. The requested services are likely to be more beneficial than the alternative of long-term anticoagulation in this patient with a documented high risk of recurrent bleeding. In sum, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "1a4077fb175d43c2a0d58b90d46376be", "question": "What is the background context in this case summary?", "title": "1a4077fb175d43c2a0d58b90d46376be", "sufficiency_score": 3}
+{"answers": {"text": ["A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that the Watchman device is an effective and relatively safe option for patients with atrial fibrillation who require but cannot take long-term anticoagulation. However, this patient underwent successful atrial fibrillation ablation with no documented recurrence of atrial fibrillation when the device had been regularly interrogated. Therefore, long-term anticoagulation would not be indicated to justify the need for a Watchman device. Thus, the superior efficacy of the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) has not been demonstrated. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "0cc8ee32ec0a4d869e968c081128f681", "question": "What is the background context in this case summary?", "title": "0cc8ee32ec0a4d869e968c081128f681", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 16-year-old female who has a history of a left knee anterior cruciate ligament reconstruction with a quadriceps tendon autograft in September 2018. The patientas parent has requested authorization and coverage for physical therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.", "In the current case, the patient underwent a right knee ACL reconstruction with quadriceps autograft, as well as medial and lateral meniscus repairs in early March 2020. Postoperatively, she had a slow recovery of her range of motion but ultimately gained full extension and functional flexion. She had complaints with various activities such as walking on uneven surfaces", "the patient has not fully recovered from her right knee surgery"], "answer_start": [19, 2677, 3185]}, "context": "Summary Reviewer \n\nThe patient is a 16-year-old female who has a history of a left knee anterior cruciate ligament reconstruction with a quadriceps tendon autograft in September 2018. The patientas parent has requested authorization and coverage for physical therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the literature related to rehabilitation after anterior cruciate ligament (ACL) reconstruction supports early weight bearing, early range of motion exercise, and closed kinetic chain activities. The early rehabilitation process should be monitored closely to protect against graft failure and other complications. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months. Rehabilitation following ACL reconstruction, overall, can require a prolonged period of time. The entire rehabilitation process following ACL reconstruction, however, does not requires a formal therapy setting. Home-based programs have been shown to result in similar long-term outcomes to more clinically supervised programs, particularly for the recreational sports participant. The rehabilitation process can be more complicated, however, particularly for return to activities placing significant stress on the knee. Regaining higher level neuromuscular control of core muscles and optimizing other biomechanics factors are important to improve functional outcomes and mitigate risk of re-injury of the repaired ACL, as well as contralateral knee injury. Assessment and treatment of the injured knee, as well as the addressing of potentially disadvantageous compensatory biomechanics is appropriate for a comprehensive rehabilitation program following ACL repair. Ultimately, each rehabilitation program needs to be reviewed on an individual basis, depending on the specific functional needs in each case. Therapy protocols after meniscal repair typically call for avoiding weight bearing and excessive range of motion in the early postoperative period. There is, however, no clear evidence-based consensus on optimal protocols, as accelerated and more aggressive programs have also been shown to have benefit, particularly when meniscal repairs are performed in association with an ACL reconstruction. In any case, a period of supervised formal therapy following meniscal repair is warranted to initiate the program, followed by a transition to self-directed exercises when possible and appropriate. In the current case, the patient underwent a right knee ACL reconstruction with quadriceps autograft, as well as medial and lateral meniscus repairs in early March 2020. Postoperatively, she had a slow recovery of her range of motion but ultimately gained full extension and functional flexion. She had complaints with various activities such as walking on uneven surfaces, but there are no indications that she has any limitations with her mobility-related activities of daily living at that time. Although the patient has not fully recovered from her right knee surgery, the medical necessity of the requested additional 24 therapy visits is not established. There are no exercises that she is performing in the formal therapy setting that could not be performed independently or substituted with independent exercise. There are no indications that she is unable to do an appropriate home exercise program. At this stage many months postoperatively, and with full knee extension already established long ago, there is no benefit of ongoing formal manual therapy over stretching and use of self-applied modalities (e.g., foam rollers) that can be performed independently. She will have a guarded prognosis with respect to future injuries if she continues to participate in activities and sports such as soccer, but the additionally proposed therapy in question is not expected to marginally improve her risk profile. Therefore, the requested physical therapy is not medically necessary for the treatment of this patient. ", "id": "935034953db64346a660469cecd10e83", "question": "What is the background context in this case summary?", "title": "935034953db64346a660469cecd10e83", "sufficiency_score": 4}
+{"answers": {"text": ["A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma test is an attempt to determine risk of recurrence for early stage melanoma. However, the treatment protocol for follow up of melanoma patients is summarized in the National Comprehensive Cancer Network (NCCN) guidelines. These guidelines note there is a lack of data to support using adjuvant therapy based on DecisionDx testing results. The follow up of melanoma patients is not tailored to each patient risk of recurrence, but rather is global to all patients with melanoma. Given these findings, the DecisionDx testing performed on 4/28/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n", "id": "14b31c34ca4e43d8853c8ea29c55a7da", "question": "What is the background context in this case summary?", "title": "14b31c34ca4e43d8853c8ea29c55a7da", "sufficiency_score": 3}
+{"answers": {"text": ["A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism.", "In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules."], "answer_start": [20, 1288]}, "context": "Summary Reviewer 2\n\nA 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found that in the medical literature, Eslamy and Ziessman noted that the clinical diagnosis of primary hyperparathyroidism is based largely on serum laboratory test results, as patients often are asymptomatic. Given that approximately 90% of cases are due to a single parathyroid adenoma, the procedure of choice is the selective surgical excision of the hyperfunctioning parathyroid gland after its preoperative identification and localization at radiologic imaging. The authors noted that SPECT, when combined with CT, is particularly helpful for preoperative localization: The three-dimensional functional information from SPECT is fused with the anatomic information obtained from CT. In addition, knowledge of the anatomy and embryologic development of the parathyroid glands and the pathophysiology of primary hyperparathyroidism aid in the identification and localization of hyperfunctioning glands. In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules. In this clinical setting, the minimally invasive parathyroidectomy procedure is the standard of care. Medical literature supports the use of SPECT/CT scan for the preoperative localization of the tumor. As such, the SPECT scan of parathyroid gland provided on 7/19/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "672b2bddfbc44507ba88f50f1c517a9a", "question": "What is the background context in this case summary?", "title": "672b2bddfbc44507ba88f50f1c517a9a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 38-year-old female with a history of chronic left hip pain in the groin related to CAM type femoroacetabular impingement, with a small pincer and associated tear of the anterior-superior labrum. The patient has requested reimbursement for hip arthroscopy performed on 12/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.", "In this patientas case, the procedures performed at the time of hip arthroscopy", "included arthroscopic surgery on her left hip consisting of acetabular rim trimming, repair of the labral tear, femoral osteochondroplasty, and capsular plication. The operative report describes the deformity that was corrected. Physical therapy was not helping at three months"], "answer_start": [19, 990, 1125]}, "context": "Summary Reviewer \n\nThe patient is a 38-year-old female with a history of chronic left hip pain in the groin related to CAM type femoroacetabular impingement, with a small pincer and associated tear of the anterior-superior labrum. The patient has requested reimbursement for hip arthroscopy performed on 12/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Femoroacetabular impingement is a common condition among young adults. Griffin and colleagues compared physical therapy and surgery for management of this condition. Among 348 participants, 171 participants were treated with hip arthroscopy and 177 were treated with hip physical therapy. Both treatments improved the quality of life. However, hip arthroscopy resulted in greater improvement than physical therapy. In this patientas case, the procedures performed at the time of hip arthroscopy were appropriate and are known to be beneficial. These included arthroscopic surgery on her left hip consisting of acetabular rim trimming, repair of the labral tear, femoral osteochondroplasty, and capsular plication. The operative report describes the deformity that was corrected. Physical therapy was not helping at three months, and surgery was medically indicated. Therefore, hip arthroscopy performed on 12/03/19 was medically necessary for the treatment of this patient. ", "id": "6aca523e20194d24a2d6cf5e02dfb36a", "question": "What is the background context in this case summary?", "title": "6aca523e20194d24a2d6cf5e02dfb36a", "sufficiency_score": 4}
+{"answers": {"text": ["A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Knowledge of the patients MTHFR status does not impact her care during pregnancy. All pregnant patients are advised to have adequate folic acid intake to prevent neural tube defects.  There is no recommended treatment during pregnancy for a known mutation in the MTHFR gene. Thus, the superior efficacy of CPT code 81291 performed on 10/11/17 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n\n", "id": "edf2205ca99248b683b8503e7f56c045", "question": "What is the background context in this case summary?", "title": "edf2205ca99248b683b8503e7f56c045", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 1/22/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees overactive bladder.", "the records document that this patient has a diagnosis of refractory overactive bladder. She has failed multiple second- and third-line therapies and is not a candidate for certain therapies including sacral neuromodulation as noted by the provider. She has responded to PTNS.", "this patient has been treated with multiple second- and third-line therapies and is not a candidate for sacral neuromodulation"], "answer_start": [20, 405, 1724]}, "context": "Summary Reviewer \n\n\nA 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 1/22/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees overactive bladder.   The physician reviewer found the records document that this patient has a diagnosis of refractory overactive bladder. She has failed multiple second- and third-line therapies and is not a candidate for certain therapies including sacral neuromodulation as noted by the provider. She has responded to PTNS. Continued treatment with PTNS is medically necessary, and a nationally accepted standard of care for this patient. The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. Evidence from multiple randomized placebo-controlled trials supports the safety and clinical efficacy of PTNS. The available 12- to 36-month evidence appears consistent with maintained efficacy in relieving symptoms of overactive bladder (OAB) and urinary voiding dysfunction. The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) guidelines support use of PTNS as third-line treatment in a carefully selected patient population with overactive bladder. Given that this patient has been treated with multiple second- and third-line therapies and is not a candidate for sacral neuromodulation, the PTNS provided from 1/22/16 forward was and is medically necessary for treatment of this patients refractory overactive bladder. Based on the foregoing discussion, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. \n\n\n", "id": "c7242e4101284e7196eeca0d971c2e8c", "question": "What is the background context in this case summary?", "title": "c7242e4101284e7196eeca0d971c2e8c", "sufficiency_score": 4}
+{"answers": {"text": ["A 43-year-old female enrollee has requested authorization and coverage for breast reduction mammoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic macromastia.", "The patient has well documented symptoms for macromastia and medical treatments have not improved her symptoms.", "In this patients case, the records document that she has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia."], "answer_start": [20, 396, 2232]}, "context": "Summary Reviewer \n\n\nA 43-year-old female enrollee has requested authorization and coverage for breast reduction mammoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic macromastia. The physician reviewer found that Breast reduction surgery is medically necessary in this patients case. The patient has well documented symptoms for macromastia and medical treatments have not improved her symptoms. The medical literature indicates that symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for treatment of this condition. Additionally, nonoperative treatments are not likely to improve pain. Instead, the evidence appears to support that surgery may be the most effective treatment for symptomatic relief.  Collins and Kerrigan report that data from the BRAVO (Breast Reduction Assessment Value and Outcomes) study, which prospectively followed 243 patients with symptomatic macromastia, found that nonoperative treatment options did not provide lasting relief from pain. The authors noted  Breast hypertrophy has a significant impact on womens health status and quality of life as measured by validated and widely used self-report instruments including the SF-36, MPQ, MBSRQ, and EuroQol. In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms. In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms. A 2014 study by Strong and Hall-Findlay concluded, We found that reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments. This adds further weight to the argument that patients should not be denied access to the surgery based on arbitrary volume restrictions. We advocate freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient. In this patients case, the records document that she has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Breast reduction is a treatment that has been proven effective and curative for symptomatic macromastia. Evidence based peer reviewed studies confirm the benefits of breast reduction surgery for individuals with upper torso pain due to breast hypertrophy. As such, nonoperative treatments are unlikely to improve this patients pain. Therefore, the breast reduction mammoplasty is medically necessary for the treatment of this patients medical condition.\nTherefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n", "id": "255895a1269c4dbbb07bc63a446e29b0", "question": "What is the background context in this case summary?", "title": "255895a1269c4dbbb07bc63a446e29b0", "sufficiency_score": 4}
+{"answers": {"text": ["A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that for patients with localized endometrial cancer, if the patient has elevated CA-125 at the time of initial diagnosis, then current National Comprehensive Cancer Network guidelines recommend serial testing of serum CA-125 for recurrence monitoring.  Multiple other serum proteins expressed by endometrial cancer are currently being investigated as possible markers for recurrent disease, including human epididymis protein 4 (HE4). Secreted HE4 has been extensively studied as a serum biomarker for proposed uses for either screening, detection of recurrence or monitoring of therapeutic response for ovarian cancer. Secreted HE4 is also associated with endometrial cancer, and continues to be studied as a potential biomarker for differentiating between malignant and benign pelvic masses, screening for malignancy, prognosis, recurrence detection, and therapeutic response. However, it is not currently accepted as a standard of care for patients with endometrial cancer. The study by Abbink and colleagues compared HE4 to the standard of care marker CA-125. Although the authors indicated the possibility of superior performance of HE4 compared to CA-125 for detection of recurrence in patients with endometrial cancer, they also noted that a future prospective study on a larger cohort of patients with endometrial cancer is needed to affirm the preoperative value of serum HE4 and the use of HE4 in routine follow-up. At this time, the superior efficacy of the services at issue has not been established. Thus, HE4 testing performed on 9/20/18 was not likely to have been more effective than other methods of evaluating this patient.\n\n\n", "id": "22301aa6ac654f779c06edae388a11c2", "question": "What is the background context in this case summary?", "title": "22301aa6ac654f779c06edae388a11c2", "sufficiency_score": 3}
+{"answers": {"text": ["A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.", "The patient has a history of high-risk HPV genotype 16."], "answer_start": [20, 476]}, "context": "Summary Reviewer 1\n\nA 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The patient has a history of high-risk HPV genotype 16. She has not been consistent with her follow-up. Recent changes in the American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines have moved to a risk-based assessment for the management of cervical cancer screening. HPV testing is the preferred manner of assessing risk. In this case, because data is missing, the guideline algorithm recommends clinical judgment. Therefore, HPV testing performed on 9/29/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.\n\n", "id": "14fde610b0494b24a5bc731942420f3a", "question": "What is the background context in this case summary?", "title": "14fde610b0494b24a5bc731942420f3a", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.", "In this patients case, her breasts were not described as particularly dense.", "she had a questionable area of developing new architectural distortion in one breast."], "answer_start": [20, 709, 796]}, "context": "Summary Reviewer 1\n\nA 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that the Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were not described as particularly dense.  However, she had a questionable area of developing new architectural distortion in one breast.  In this setting, breast tomosynthesis is valuable in separating out overlapping structures and possibly demonstrating an otherwise occult mass.  Thus, breast tomosynthesis performed on 8/04/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "d3d1f27207d04d3eaae0229e3fa52eb5", "question": "What is the background context in this case summary?", "title": "d3d1f27207d04d3eaae0229e3fa52eb5", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that the current medical literature supports the service at issue in this patients case.  Per Skaane and colleague, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Therefore, breast tomosynthesis performed on 8/04/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "04c6bd76d27d45b4b1fe99411f2718bf", "question": "What is the background context in this case summary?", "title": "04c6bd76d27d45b4b1fe99411f2718bf", "sufficiency_score": 3}
+{"answers": {"text": ["A 24-year-old male enrollee has requested authorization and coverage for cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical space and Depuy Synthes Stim-line instrumentation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.", "this patient presents with progressively worsening and severe neck, right shoulder/arm, and mid-back pain with associated headaches. Signs and symptoms have been reportedly consistent with possible cervical myelopathy, including hand clumsiness and hyperreflexia. His pain is interfering with sleep and activities of daily living. There is imaging evidence of a significant anterior osteophyte at the C5 level with history of superior endplate fracture, and degenerative changes at C4/5 without focal neural compression. There is discogram evidence of severe concordant pain at C4/5. Detailed evidence of a recent comprehensive nonoperative treatment protocol trial and failure has been submitted. The records suggest a history of dysphagia with recent improvement following discogram."], "answer_start": [19, 423]}, "context": "Summary Reviewer \n\nA 24-year-old male enrollee has requested authorization and coverage for cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical space and Depuy Synthes Stim-line instrumentation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with progressively worsening and severe neck, right shoulder/arm, and mid-back pain with associated headaches. Signs and symptoms have been reportedly consistent with possible cervical myelopathy, including hand clumsiness and hyperreflexia. His pain is interfering with sleep and activities of daily living. There is imaging evidence of a significant anterior osteophyte at the C5 level with history of superior endplate fracture, and degenerative changes at C4/5 without focal neural compression. There is discogram evidence of severe concordant pain at C4/5. Detailed evidence of a recent comprehensive nonoperative treatment protocol trial and failure has been submitted. The records suggest a history of dysphagia with recent improvement following discogram. Given the persistence of significantly abnormal findings, severe pain and functional limitations, imaging findings of cervical spondylosis with concordant findings at C4/5, and exhaustion of conservative treatment, surgical intervention is medically indicated and supported by evidence-based medical criteria. Therefore, the requested cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical spacer and Depuy Synthes Slim-line instrumentation is medically necessary for the treatment of this patient.", "id": "215e79d6bf574ba49c6cc1ae52ade6ff", "question": "What is the background context in this case summary?", "title": "215e79d6bf574ba49c6cc1ae52ade6ff", "sufficiency_score": 4}
+{"answers": {"text": ["A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available. The medical evidence has demonstrated that corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, there was a lack of treatment options available to slow or halt disease progression. In sum, corneal collagen crosslinking performed on 9/04/18 was likely to have been of greater benefit than other treatment options.\n\n\n", "id": "a27bf7f398154ee0ba049ac3b0baa7a6", "question": "What is the background context in this case summary?", "title": "a27bf7f398154ee0ba049ac3b0baa7a6", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction.", "the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk."], "answer_start": [19, 332]}, "context": "Summary Reviewer \n\nThe patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction. The physician reviewer found that the DIEP flap was for breast reconstruction and was medically necessary. However, the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk. This code is used in the setting of ventral hernia repair or for repair of wide diastasis recti. The medical records do not support this code in this patientas case. Based on the submitted medical records, there was no ventral hernia repair or repair of wide diastasis recti reported. Per the submitted records, no abdominal weakness or hernia was reported as being present to require a separation of parts repair. Therefore, 15734-59-62 and 15734-62 performed on 7/01/19 were not medically necessary for the treatment of this patient.\n", "id": "809cbfe706574173bb9bce3af0283d3f", "question": "What is the background context in this case summary?", "title": "809cbfe706574173bb9bce3af0283d3f", "sufficiency_score": 3}
+{"answers": {"text": ["A 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules.", "This patients biopsy was suspicious for follicular lesion of undetermined significance."], "answer_start": [21, 419]}, "context": "Summary Reviewer 2\n\n\nA 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that there is sufficient support for the Afirma gene test performed on 7/5/16 in this clinical setting. This patients biopsy was suspicious for follicular lesion of undetermined significance. The Afirma testing was suspicious, and a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "4d08ea5c9b644ad3a7c4dd27fba07587", "question": "What is the background context in this case summary?", "title": "4d08ea5c9b644ad3a7c4dd27fba07587", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder.", "he Health Insurer has authorized 25 hours per week of ABA services. ", "n this case, the patient demonstrates delays in social, cognitive, adaptive and executive functioning deficits and continues to demonstrate maladaptive behaviors of aggression, physical stereotypy and perseveration. "], "answer_start": [20, 370, 688]}, "context": "Summary Reviewer \n\n\nThe parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found the Health Insurer has authorized 25 hours per week of ABA services. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes (Roane et al; Myers et al). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient demonstrates delays in social, cognitive, adaptive and executive functioning deficits and continues to demonstrate maladaptive behaviors of aggression, physical stereotypy and perseveration. In this clinical setting, 40 hours per week of ABA therapy is medically necessary for treatment of the patients medical condition. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n", "id": "81161d0626224418a86101b0e8aa0f12", "question": "What is the background context in this case summary?", "title": "81161d0626224418a86101b0e8aa0f12", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 54-year-old female with a family history of a sister who died from ovarian cancer, father with colon cancer, and grandmother with possible primary peritoneal cancer. The patient was noted to have a 1 cm ovarian cyst with no concerning features. Her uterus was noted to be normal. The patients evaluation included detailed genetic consultation and testing. The testing did not show any high risk mutations. As a result, the genetic counselor did not place the patient in a high risk category for gynecologic malignancies. The patient has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary. The patient has elected to undergo a prophylactic hysterectomy and bilateral salpingo-oophorectomy due to her family history."], "answer_start": [18]}, "context": "Summary Reviewer\n\nThe patient is a 54-year-old female with a family history of a sister who died from ovarian cancer, father with colon cancer, and grandmother with possible primary peritoneal cancer. The patient was noted to have a 1 cm ovarian cyst with no concerning features. Her uterus was noted to be normal. The patients evaluation included detailed genetic consultation and testing. The testing did not show any high risk mutations. As a result, the genetic counselor did not place the patient in a high risk category for gynecologic malignancies. The patient has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary. The patient has elected to undergo a prophylactic hysterectomy and bilateral salpingo-oophorectomy due to her family history. However, genetic counseling and testing do not place her in a high risk category for epithelial ovarian cancer, fallopian tube cancer or uterine cancer. Current recommendations reserve risk reducing surgery for patients in the highest risk categories with genetic mutations such as BRCA1, BRCA 2 and Lynch syndrome. Based on the patients family history and genetic testing results, she does not have a strong clinical indication for surgical cancer prophylaxis. Accordingly, the requested hysterectomy is not medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n", "id": "fa660c7f611348f9984fad17db183e25", "question": "What is the background context in this case summary?", "title": "fa660c7f611348f9984fad17db183e25", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nThe parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found in general, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-TNF agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser IFX testing. In this patients case, the medical records submitted for review do not support acute loss of therapeutic response nor acute disease flare. There are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. In addition, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. In sum, the testing at issue was not clinically indicated and not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "1b93f8670b584552a2386c0590fab2a3", "question": "What is the background context in this case summary?", "title": "1b93f8670b584552a2386c0590fab2a3", "sufficiency_score": 3}
+{"answers": {"text": ["A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the molecular pathology testing provided on 4/14/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers (Brose, et al; Thompson and Easton). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers (Liede, et al; Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed (Umar, et al). However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extracolonic tumors in Lynch syndrome are endometrial, ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral cancers. This patients family history is suggestive of a breast/ovarian cancer syndrome. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Therefore, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "902a75937a7b4fcf8e9fdfd0afea5f87", "question": "What is the background context in this case summary?", "title": "902a75937a7b4fcf8e9fdfd0afea5f87", "sufficiency_score": 3}
+{"answers": {"text": ["A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found that on the information provided, it appears that the TMS is being used for maintenance or continuation purposes, which is consistent with an investigational application.  A typical course of TMS consists of 30 to 40 sessions spanning four to six weeks.  For patients who respond well to TMS, clinical improvement is usually maintained with psychotherapy and psychotropic medication.  Although small studies are demonstrating good tolerability and clinical efficacy of TMS therapy for treatment courses lasting years at a time, according to the summary of TMS treatment recommendations authored by Perera and colleagues, The standard parameter setprovided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established.  In other words, at this time there is a lack of well-designed and adequately-powered controlled studies showing the benefit of longer courses of TMS therapy.  Therefore, the superior efficacy of maintenance TMS therapy as compared to other available standard therapy, such as ongoing pharmacotherapy, psychotherapy and electroconvulsive therapy, has not been established.  Based upon the information set forth above, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "0f72ab9b76044ce698289add33c32868", "question": "What is the background context in this case summary?", "title": "0f72ab9b76044ce698289add33c32868", "sufficiency_score": 3}
+{"answers": {"text": ["A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder.", "this patient received 36 treatments prior to the Health Insurers denial.", "in this case, the patient did show an initial response to TMS treatment.   The records indicate that the patients symptoms had improved during the initial TMS treatment period."], "answer_start": [21, 399, 716]}, "context": "Summary Reviewer 3\n\n\nA 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found this patient received 36 treatments prior to the Health Insurers denial.  At this time, the literature on TMS is not clear on whether maintenance treatment is an evidence-based treatment.  The literature indicates that continued treatment can and should occur if an initial response to TMS is not apparent.  However, in this case, the patient did show an initial response to TMS treatment.   The records indicate that the patients symptoms had improved during the initial TMS treatment period.  Since the patient showed benefit from acute/initial TMS treatments and given the lack of evidence for maintenance TMS treatments, the superior effectiveness of the services at issue has not been established.  Based upon the information set forth above, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "107a3e58b6e54d65a881d910cae080da", "question": "What is the background context in this case summary?", "title": "107a3e58b6e54d65a881d910cae080da", "sufficiency_score": 4}
+{"answers": {"text": ["A 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis.", "the patient does not have systematic lupus erythematosus, rather she carries a low titer double stranded deoxyribonucleic acid (dsdna) antibody which is being monitored."], "answer_start": [21, 611]}, "context": "Summary Reviewer 2\n\n\nA 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that Enbrel is appropriate for this patients diagnosis of ankylosing spondylitis. However, if the patient does have systematic lupus erythematosus, than it is not suggested to use Enbrel or other anti-tumor necrosis factor (TNF) agents as these drugs can trigger lupus. Given the presentation in the records, the patient does not have systematic lupus erythematosus, rather she carries a low titer double stranded deoxyribonucleic acid (dsdna) antibody which is being monitored. Thus, the requested Enbrel is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n", "id": "eaea762e8d9b4af083c11d313b186b59", "question": "What is the background context in this case summary?", "title": "eaea762e8d9b4af083c11d313b186b59", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis.", "In this case, the patient has multiple skin conditions including lichen planus, herpes simplex virus, and atopy, and she has been diagnosed with rheumatoid arthritis."], "answer_start": [20, 1381]}, "context": "Summary Reviewer 2\n\nA 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found the varicella-zoster virus causes two clinically distinct forms of infection.  Herpes zoster is related to reactivation of varicella-zoster virus infection and is characterized by a painful, unilateral vesicular eruption in a dermatomal distribution. The herpes zoster vaccination can decrease the risk of developing herpes zoster and post-herpetic neuralgia associated with infection.  The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all patients 60 years of age or older, including patients who report a previous episode of zoster and patients with chronic medical conditions (such as chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless those conditions are contraindications. In clinical practice, the vaccine is recommended for patients between 50 and 59 who are receiving low-level immunosuppressive therapy or are expected to receive high-level immunosuppressive therapy or for patients that would have difficulty tolerating a zoster infection. In this case, the patient has multiple skin conditions including lichen planus, herpes simplex virus, and atopy, and she has been diagnosed with rheumatoid arthritis. Rheumatoid arthritis is treated with immunosuppressive medications that would leave the patient vulnerable to infections. Given this patients rheumatoid arthritis and skin conditions, it was appropriate to vaccinate this patient. Therefore, the shingles vaccine performed on 2/06/17 was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "84af371a96fa4f82a18d15d5b013bf68", "question": "What is the background context in this case summary?", "title": "84af371a96fa4f82a18d15d5b013bf68", "sufficiency_score": 4}
+{"answers": {"text": ["A 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that there is a lack of evidence based literature that show the efficacy of genetic testing in evaluating patients  diagnosed with bipolar disorders or ADHD. There is very limited clinical justification, based on substantial medical research, to endorse genetic screening tests prior to attempting another medication for treatment of ADHD, bipolar disorder, or personality disorders.  Specifically, the standard of care for treatment of these disorders would be to continue to trial or prescribe stimulant medication. This method of prescribing medication would produce similar outcomes when compared to awaiting genetic testing results in this patients case.  In sum, cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and SNP variants for chromosomal abnormalities administered on 3/16/16 were not likely to have been more effective than the standard options available for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "69f6409999a94641bfac6ad9a727d32a", "question": "What is the background context in this case summary?", "title": "69f6409999a94641bfac6ad9a727d32a", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 28-year-old female with a history of severe persistent eosinophilic asthma. She has requested authorization and coverage for Fasenra Pen.", "The submitted documentation indicates that the patient has severe persistent asthma and has required several courses of oral steroids for uncontrolled asthma symptoms. The patient has been using Symbicort and Breztri, and she continues to have episodes of asthma flare-ups. Her blood eosinophil count in end of August 2021 was greater than 150 cell/ml. The provider attested that she will continue to use inhaled corticosteroids Symbicort in conjunction with Fasenra therapy."], "answer_start": [19, 447]}, "context": "Summary Reviewer \n\nThe patient is a 28-year-old female with a history of severe persistent eosinophilic asthma. She has requested authorization and coverage for Fasenra Pen. The physician reviewer found that Benralizumab (Fasenra) is a cytotoxic monoclonal antibody directed against IL-5 receptor alpha that is approved by the U.S. Food and Drug Administration (FDA) as add-on therapy in patients with severe asthma and an eosinophilic phenotype. The submitted documentation indicates that the patient has severe persistent asthma and has required several courses of oral steroids for uncontrolled asthma symptoms. The patient has been using Symbicort and Breztri, and she continues to have episodes of asthma flare-ups. Her blood eosinophil count in end of August 2021 was greater than 150 cell/ml. The provider attested that she will continue to use inhaled corticosteroids Symbicort in conjunction with Fasenra therapy. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested Fasenra Pen is medically necessary for the treatment of this patient. ", "id": "0074025d048d4732b748a2c5f89904d6", "question": "What is the background context in this case summary?", "title": "0074025d048d4732b748a2c5f89904d6", "sufficiency_score": 4}
+{"answers": {"text": ["A 25-year-old male enrollee has requested reimbursement for substance abuse residential treatment services provided from 7/22/17 through 8/3/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance and alcohol abuse.", "the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive.", "He was motivated and working the program. He was cooperative and participating in his treatment plan.", "the patient continued to require further treatment to develop and solidify coping skills"], "answer_start": [20, 373, 934, 1045]}, "context": "Summary Reviewer \n\n\nA 25-year-old male enrollee has requested reimbursement for substance abuse residential treatment services provided from 7/22/17 through 8/3/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance and alcohol abuse. The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He had no comorbid medical conditions and he was psychiatrically stable. His medications could have been managed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and working the program. He was cooperative and participating in his treatment plan. Although the patient continued to require further treatment to develop and solidify coping skills, this did not require the residential structure. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. Thus, as of 7/22/17, the patient no longer met the criteria for residential level of care. Accordingly, the substance abuse residential treatment services provided from 7/22/17 through 8/3/17 were not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "e439e600fca34b29b5ee496117db976f", "question": "What is the background context in this case summary?", "title": "e439e600fca34b29b5ee496117db976f", "sufficiency_score": 4}
+{"answers": {"text": ["A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition.", "in this case, the patient has already been treated with eight different antidepressants, with at least three different pharmacodynamic strategies, and has not had a good response."], "answer_start": [21, 696]}, "context": "Summary Reviewer 1\n\n\nA 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature suggests that continued research is still necessary to develop clear guidelines for the usage of pharmacogenetics testing. Therefore, pharmacogenetics testing is not considered the standard treatment. However, in this case, the patient has already been treated with eight different antidepressants, with at least three different pharmacodynamic strategies, and has not had a good response. Given that she has failed the standard treatments that are available, the pharmacogenetics testing was medically reasonable in this clinical setting. The genetic testing has the potential to guide the providers decisions to medications that will be better tolerated and more effective. Therefore, the gene testing performed on 8/11/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "8211b5c9a8c248c1880e1d0f8e16b023", "question": "What is the background context in this case summary?", "title": "8211b5c9a8c248c1880e1d0f8e16b023", "sufficiency_score": 4}
+{"answers": {"text": ["A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that despite its promise, pharmacogenetics is not yet ready for mainstream clinical application. The American Psychiatric Association (APA) does not endorse such testing in its current clinical practice guidelines. In this case, the documentation submitted for review failed to show the patients longitudinal illness burden and extent of impairment at the time of testing, including family history, psychosocial stressors, substance use disorders and medical comorbidities. In addition, there was no mention of prior interventions used to treat panic, depression and excessive worry. Without the review of the specific type, setting and duration of psychotherapies, or, the selection, dosing and length of previous psychotropic medication trials, it cannot be inferred that the patient had exhausted standard treatments available to treat her condition. In sum, considering the relevant peer-reviewed literature and current practice standards, it is not possible to assert with any degree of confidence that the disputed gene test yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity. Thus, the gene testing performed on 8/11/16 was not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "9c37b2ac9e2645bfbbd263af2315ee0c", "question": "What is the background context in this case summary?", "title": "9c37b2ac9e2645bfbbd263af2315ee0c", "sufficiency_score": 1}
+{"answers": {"text": ["The patient is a 20-year-old male with significant daytime frequency every hour and nocturia every four to six hours. The patient reportedly also has insomnia. The patient has tried pelvic floor muscle rehabilitation as well as multiple medications including oxybutynin, Vesicare, and Myrbetriq. The patient experienced side effects and no substantial improvement in his symptoms with these therapies. The patient is currently on desmopressin with some improvement. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. It was suggested that this patient undergo treatment with PTNS therapy for significant urinary frequency. The records document treatment failure with multimodal primary and secondary treatments for his condition. He does not wish to proceed with sacral neuromodulation or Botox injections."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nThe patient is a 20-year-old male with significant daytime frequency every hour and nocturia every four to six hours. The patient reportedly also has insomnia. The patient has tried pelvic floor muscle rehabilitation as well as multiple medications including oxybutynin, Vesicare, and Myrbetriq. The patient experienced side effects and no substantial improvement in his symptoms with these therapies. The patient is currently on desmopressin with some improvement. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. It was suggested that this patient undergo treatment with PTNS therapy for significant urinary frequency. The records document treatment failure with multimodal primary and secondary treatments for his condition. He does not wish to proceed with sacral neuromodulation or Botox injections. As noted in the medical literature, PTNS is performed as a salvage procedure. For these reasons, the PTNS provided on 10/16/17 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "050705479bb0450fa0a02899818614b1", "question": "What is the background context in this case summary?", "title": "050705479bb0450fa0a02899818614b1", "sufficiency_score": 4}
+{"answers": {"text": ["A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. There are two important decision points in the treatment of cutaneous melanoma. The first is\nwhether or not to do sentinel node; the pathology alone here strongly indicates that the procedure should be done. The second issue is that of whether adjuvant therapy should be given. Coupling the initial pathology, along with the results of the sentinel node, would give enough information to make the decision about adjuvant therapy.\nDecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases and found good correlation between DecisionDx-Melanoma testing prediction and prognosis in patients undergoing sentinel node biopsy. However, it is not clear how the DecisionDx-Melanoma testing five-year data compares to the ten-year Balch data. Most importantly, it is not known if it can be used to make therapeutic decisions beyond those that can be made on the pathologic data. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.\n\n\n", "id": "ea172bd79740420d96961a5d346e4fb6", "question": "What is the background context in this case summary?", "title": "ea172bd79740420d96961a5d346e4fb6", "sufficiency_score": 3}
+{"answers": {"text": ["A 60-year-old male enrollee has requested reimbursement for the fecal calprotectin testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees Crohns disease."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 60-year-old male enrollee has requested reimbursement for the fecal calprotectin testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees Crohns disease.   The physician reviewer found calprotectin is a small calcium-binding protein and is a member of the S100 family of zinc-binding proteins found primarily in neutrophils. Any disturbance to the mucosal architecture due to the inflammatory process, results in leakage of neutrophils, and hence, calprotectin, into the lumen and its subsequent excretion in feces. Studies have demonstrated that of patients with Crohns in remission, only a small percentage had a significant within-individual variability for calprotectin concentrations over three samples suggesting that measurements are reliable (Walsham and Sherwood; Schoepfer, et al; Sipponen, et al). Given this support, the fecal calprotectin testing performed on 11/17/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "d710f63736734b4a89bcda3dca60b067", "question": "What is the background context in this case summary?", "title": "d710f63736734b4a89bcda3dca60b067", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nThe parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStep PLUS test provided on 11/23/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "6cbd056cd27d4257b1dd87f0a1333743", "question": "What is the background context in this case summary?", "title": "6cbd056cd27d4257b1dd87f0a1333743", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia.", "the patient is a 38-year old male with unexplained anemia."], "answer_start": [20, 343]}, "context": "Summary Reviewer 3\n\nA 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that based on the records provided, the patient is a 38-year old male with unexplained anemia. Although elevated homocysteine levels have been associated with anemia, an elevated homocysteine level does not point to a specific cause of the anemia (den Elzen, et al). Moreover there is a lack of clinical trials that demonstrate outcome improvement with treatment targeted at reducing homocysteine levels (Lonn; Toole, et al). Likewise, even though results of homocysteine levels may be abnormal and considered independent risk markers for coronary disease, there is a paucity of scientific data demonstrating outcome benefits by treating routinely obtained abnormal results. Thus, the homocysteine testing provided on 9/5/14 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.", "id": "30bcebce02d64dc4a15c993798c85727", "question": "What is the background context in this case summary?", "title": "30bcebce02d64dc4a15c993798c85727", "sufficiency_score": 3}
+{"answers": {"text": ["A 68-year-old female insured has requested reimbursement for a Guardant360 CDx test provided \non 1/19/22. The Health Insurer has denied this request indicating that the services at issue were \nconsidered investigational for evaluation of the insured's metastatic non-small cell lung cancer."], "answer_start": [20]}, "context": "Summary Reviewer 2 \nA 68-year-old female insured has requested reimbursement for a Guardant360 CDx test provided \non 1/19/22. The Health Insurer has denied this request indicating that the services at issue were \nconsidered investigational for evaluation of the insured's metastatic non-small cell lung cancer. \nThe physician reviewer found that the integration of next-generation sequencing (NGS) testing \ninto the routine management of stage IV non-small cell lung cancer demonstrates a marked \nincrease  in  the  detection  of  therapeutically  targetable  mutations  and  improved  delivery  of \nmolecularly guided therapy. The National Comprehensive Cancer Network (NCCN) guidelines \nrecommend liquid or plasma NGS if the patient has insufficient tissue from the tumor, or if \nexpedited results are necessary. A repeat biopsy can delay care and lead to unnecessary procedures. \nIn this case, the provider noted that the patient had insufficient tissue for full NGS testing. \nTherefore, the Guardant360 CDx test provided on 1/19/22 was likely to be more beneficial for the \nevaluation of the patients condition than any available standard therapy. \n \n \n", "id": "056d63a5090040f18e5da0246fa2ef58", "question": "What is the background context in this case summary?", "title": "056d63a5090040f18e5da0246fa2ef58", "sufficiency_score": 3}
+{"answers": {"text": ["A 25-year-old transgender male enrollee has requested authorization and coverage for total hysterectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.", "The Health Insurer noted that the requested services are not medically necessary because he needs to be living as male for two years and on hormones for one year before surgery."], "answer_start": [19, 410]}, "context": "Summary Reviewer \n\nA 25-year-old transgender male enrollee has requested authorization and coverage for total hysterectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The Health Insurer noted that the requested services are not medically necessary because he needs to be living as male for two years and on hormones for one year before surgery. World Professional Association for Transgender Health (WPATH) has no requirements for social transition before hysterectomy. There is a one year requirement before reconstructive genital surgery, such as phalloplasty or metoidioplasty, but not for hysterectomy. Per WPATH, social transition is not required before hysterectomy. WPATH recommends one year of hormones before hysterectomy, unless this is not clinically indicated. The decision that this is clinically indicated before one year lies with the patients treatment team, which recommends the surgery. WPATH lists 12 continuous months of hormone therapy as appropriate to the patients gender goals (unless hormones are not clinically indicated for the individual). This provides flexibility for the treatment team to decide on the appropriate hormone treatment regimen before hysterectomy. WPATH noted that hysterectomy is one of the medically necessary treatments for gender dysphoria. There is sufficient support for the requested services in this clinical setting. Therefore, the requested hysterectomy is medically necessary for the treatment of this patient.", "id": "c660304cf8054685ad6f4b90ddc46503", "question": "What is the background context in this case summary?", "title": "c660304cf8054685ad6f4b90ddc46503", "sufficiency_score": 3}
+{"answers": {"text": ["A 25-year-old female enrollee has requested authorization and coverage for surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.", "This patient has undergone a thorough evaluation, with no distinct etiology found.", "In this case, the patient has failed medical management options, including oral contraceptive pills and a short trial of Mirena intrauterine device, which she was unable to tolerate. She is not a candidate for tranexamic acid, given her prolonged bleeding pattern (greater than five days per month) and is not a candidate for endometrial ablation given her age and high risk of failure. The patient desires definitive management hysterectomy.", "she has completed childbearing status-post bilateral salpingectomy"], "answer_start": [19, 788, 1247, 1701]}, "context": "Summary Reviewer \n\nA 25-year-old female enrollee has requested authorization and coverage for surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that abnormal uterine bleeding is a common gynecologic problem. Prolonged uterine bleeding can result in anemia and interfere with daily activities, as in this case. Abnormal uterine bleeding encompasses a heterogeneous group of conditions with diverse etiologies. Diagnosing the etiology of the abnormal uterine bleeding involves a thorough history, physical examination, imaging, and endometrial sampling. This patient has undergone a thorough evaluation, with no distinct etiology found. Initial management usually consists of progestin-based treatments, including combination oral contraceptive pills, the 52 mg levonorgestrel-releasing intrauterine device, and tranexamic acid. Surgical treatment options include endometrial ablation for patients who desire uterine sparing or definitive treatment with hysterectomy for patient who have completed childbearing.  In this case, the patient has failed medical management options, including oral contraceptive pills and a short trial of Mirena intrauterine device, which she was unable to tolerate. She is not a candidate for tranexamic acid, given her prolonged bleeding pattern (greater than five days per month) and is not a candidate for endometrial ablation given her age and high risk of failure. The patient desires definitive management hysterectomy. Given that she has completed childbearing status-post bilateral salpingectomy, a hysterectomy is appropriate for this patient. Therefore, surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy) is medically necessary for the treatment of this patient.", "id": "40e5ab1eb6334ddcb4efae605214038d", "question": "What is the background context in this case summary?", "title": "40e5ab1eb6334ddcb4efae605214038d", "sufficiency_score": 4}
+{"answers": {"text": ["A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.", "In this patients case", "this test was done as a follow-up of an indeterminate result."], "answer_start": [20, 1062, 1135]}, "context": "Summary Reviewer 2\n\nA 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that molecular testing has emerged as a promising method for clarifying the gray area of indeterminate thyroid fine needle aspirations, with the aim of reducing the overtreatment of benign nodules and increasing the preoperative detection of malignant nodules that should be treated by a single surgery (total thyroidectomy) rather than a two-step procedure. When molecular testing informs patient management, it should be further integrated with clinical findings and ultrasonographic results. As additional information accumulates to further refine these integrated approaches to patient management, the genetic information provided by molecular tests is expected to increasingly individualize the management of patients with thyroid nodules and cancer. In this patients case, a second thyroid biopsy was not necessary because this test was done as a follow-up of an indeterminate result. A benign result by the ThyGenX/ThyraMIR test has a significant negative predictive value. The medical evidence supports the services at issue in this clinical setting. All told, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "23e8c01b1a0e48b1b962f4183ed77c94", "question": "What is the background context in this case summary?", "title": "23e8c01b1a0e48b1b962f4183ed77c94", "sufficiency_score": 1}
+{"answers": {"text": ["The patient is a 42-year-old female who is requesting reimbursement for fetal chromosomal analysis via cell-free DNA. The records document advanced maternal age and history of prior miscarriages."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 42-year-old female who is requesting reimbursement for fetal chromosomal analysis via cell-free DNA. The records document advanced maternal age and history of prior miscarriages. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy, is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. This is the case for both younger women and for women of advanced maternal age. This test is less invasive, with less risk to the pregnancy. Therefore, fetal chromosomal microdeletions genomic sequence analysis (81422) performed on 7/09/19 was medically necessary for the evaluation of this patient.", "id": "911ed59a0c374e9e90cc0e4bbbc48e90", "question": "What is the background context in this case summary?", "title": "911ed59a0c374e9e90cc0e4bbbc48e90", "sufficiency_score": 3}
+{"answers": {"text": ["A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.", "the patient has chronic left sacroiliac dysfunction and pain that interferes with activities of daily living."], "answer_start": [20, 332]}, "context": "Summary Reviewer 1\n\nA 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has chronic left sacroiliac dysfunction and pain that interferes with activities of daily living. The selected procedure of minimally invasive sacroiliac fusion using the triangular titanium implant is a relatively popular procedure, with 88 percent fusion rate and documented excellent results at five-year follow-up. Minimally invasive sacroiliac joint fusion has become an increasingly popular and accepted surgical option for chronic sacroiliac joint dysfunction, a common cause of unremitting chronic low back/buttock pain. Minimally invasive sacroiliac joint surgery has been proven to be a safe and effective procedure, with a high fusion rate, a good safety profile and significant improvements in pain severity and disability reported through 12 months post-procedure. A five-year follow-up showed continued excellent clinical responses in patients with sacroiliac joint pain treated with sacroiliac joint fusion using triangular titanium implants along with a high rate of joint fusion. Therefore, the requested minimally invasive sacroiliac joint fusion is likely to be more beneficial than any available standard therapy. \n\n", "id": "e79fb57846214f7bbfa284064f12e35b", "question": "What is the background context in this case summary?", "title": "e79fb57846214f7bbfa284064f12e35b", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 12-year-old male enrollee has requested authorization and coverage for Humatrope 12 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency.", "The patient has experienced a deceleration in growth velocity from the 40th percentile to fifth percentile between 2-11 years of age. IGF-1 level was low, and provocative GH testing results were poor.", "He had a good response to one year of therapy without adverse effects"], "answer_start": [20, 429, 746]}, "context": "Summary Reviewer \n\n\nThe parent of a 12-year-old male enrollee has requested authorization and coverage for Humatrope 12 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the requested medication is medically necessary for treatment of the patients medical condition. The patient has experienced a deceleration in growth velocity from the 40th percentile to fifth percentile between 2-11 years of age. IGF-1 level was low, and provocative GH testing results were poor. Based on auxological and biochemical criteria, the patient meets generally established guidelines for GH treatment. He had a good response to one year of therapy without adverse effects, and continuation of GH therapy is medically necessary until epiphyseal fusion. Withdrawal of therapy at the age of expected puberty may result in irreversible impairment in height potential. As such, Humatrope 12 mg cartridge has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "193e80d9084a4cb6859e34826474816e", "question": "What is the background context in this case summary?", "title": "193e80d9084a4cb6859e34826474816e", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a seven-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency.", "his adult predicted height, based on the bone age and height assessment in March 2015, is approximately 66.5 inches", "His growth factors are normal", "The patient underwent provocative testing with serial GH levels assayed for a period of three hours after the baseline measurement"], "answer_start": [20, 566, 722, 1007]}, "context": "Summary Reviewer \n\n\nThe parent of a seven-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patients height is not more than 2 SDS below the mean for age and gender, and his adult predicted height, based on the bone age and height assessment in March 2015, is approximately 66.5 inches, appropriate for his genetic potential. His growth factors are normal, he does not have any known morphological abnormalities of his pituitary gland, and there is no documentation of abnormal growth velocity for age. The delayed bone age is most consistent with a diagnosis of constitutional delay rather than GH deficiency. The patient underwent provocative testing with serial GH levels assayed for a period of three hours after the baseline measurement, but it is not clear from the results provided that two separate provocative tests were performed, with serial measurements of GH levels for 2-3 hours after each test independently. Although the U.S. Food and Drug Administration (FDA) has approved GH therapy for children with intrauterine growth retardation/small for gestational age with failure to catch-up in height, this patients height is not below the 3rd percentile on the growth curve, and thus he would not meet criteria for failure to catch- up in height. In addition, his adult height prediction is not short enough to qualify for GH on the basis of the FDA-approved idiopathic short stature indication. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "de75d2c9068849cd9cf88578214392f5", "question": "What is the background context in this case summary?", "title": "de75d2c9068849cd9cf88578214392f5", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.", "This patient is a 62-year-old female who had a bilateral screening mammogram with tomosynthesis on 3/31/16. The patient reported a positive family history of breast cancer in her maternal grandmother, and in her maternal and paternal aunts. The patient presented for a breast screening examination on 3/31/16. The patients breast was noted with scattered fibroglandular densities in the right breast. The ultrasound showed small cysts. The Health Insurer has denied the tomosynthesis portion of the exam."], "answer_start": [21, 328]}, "context": "Summary Reviewer 2\n\n\nA 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found This patient is a 62-year-old female who had a bilateral screening mammogram with tomosynthesis on 3/31/16. The patient reported a positive family history of breast cancer in her maternal grandmother, and in her maternal and paternal aunts. The patient presented for a breast screening examination on 3/31/16. The patients breast was noted with scattered fibroglandular densities in the right breast. The ultrasound showed small cysts. The Health Insurer has denied the tomosynthesis portion of the exam. The patient has appealed the denial and this denial is the subject of this appeal and determination.\nThe medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 3/31/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "03ba31c351c34e32bee9c46558074b7f", "question": "What is the background context in this case summary?", "title": "03ba31c351c34e32bee9c46558074b7f", "sufficiency_score": 4}
+{"answers": {"text": ["A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "aba3e6e34b35430a8d771f25fbf64ab0", "question": "What is the background context in this case summary?", "title": "aba3e6e34b35430a8d771f25fbf64ab0", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition.", "this patient presented with chronic right wrist pain that interfered with his activities of daily living. He had a past medical history that included right distal radius fracture. Clinical examination findings were consistent with imaging evidence of right wrist post-traumatic arthritis of the radioscaphoid joint and STT joint with positive ulnar variance of 7.5 mm. He had failed to achieve sustained improvement with activity modification, medications, bracing and steroid injection. He underwent right wrist anterior and posterior interosseous neurectomies on 6/10/19 as an alternative to motion-limiting surgeries, including wrist fusion, proximal row carpectomy, and radioscapholunate arthrodesis."], "answer_start": [20, 402]}, "context": "Summary Reviewer 1\n\nA 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient presented with chronic right wrist pain that interfered with his activities of daily living. He had a past medical history that included right distal radius fracture. Clinical examination findings were consistent with imaging evidence of right wrist post-traumatic arthritis of the radioscaphoid joint and STT joint with positive ulnar variance of 7.5 mm. He had failed to achieve sustained improvement with activity modification, medications, bracing and steroid injection. He underwent right wrist anterior and posterior interosseous neurectomies on 6/10/19 as an alternative to motion-limiting surgeries, including wrist fusion, proximal row carpectomy, and radioscapholunate arthrodesis. Current evidence-based medical literature supports the use of anterior and/or posterior interosseous neurectomies for the treatment of chronic wrist pain and to delay or avoid wrist fusion/reconstruction surgeries. There is adequate literature support for the use of this procedure as salvage prior to fusion. He had failed reasonable and/or comprehensive conservative treatment, and no additional conservative treatment would have been reasonably expected to improve his medical condition. Therefore, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.\n\n\n", "id": "cf8feb3f05e44483960a4d598de64ec6", "question": "What is the background context in this case summary?", "title": "cf8feb3f05e44483960a4d598de64ec6", "sufficiency_score": 4}
+{"answers": {"text": ["A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.", "The medical records document paroxysmal atrial fibrillation and a prior stroke with no documented significant bleeding complications on anticoagulation."], "answer_start": [21, 464]}, "context": "Summary Reviewer 1\n\n\nA 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this clinical setting.  The medical records document paroxysmal atrial fibrillation and a prior stroke with no documented significant bleeding complications on anticoagulation.  In this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk, discontinuing anticoagulation while accepting an increased thromboembolic risk or percutaneous left atrial appendage exclusion using a Watchman device.  The Watchman device has been demonstrated in one trial to be non-inferior compared with warfarin.  However, device placement has a high rate of significant complications due to pericardial effusion and procedural stroke related to thromboembolism or air embolization.  The Watchman device is not likely to be of greater benefit than other treatment options, especially in patients who are tolerating anticoagulation without significant bleeding side effects.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "e8eaaf7d731345ffa49a415ebbf500ad", "question": "What is the background context in this case summary?", "title": "e8eaaf7d731345ffa49a415ebbf500ad", "sufficiency_score": 3}
+{"answers": {"text": ["A 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested device in this clinical setting. Wong and colleagues concluded that the option of spinal cord stimulation should be considered after conservative therapy has failed. They pointed to large randomized control studies which showed that high frequency forms of stimulation was effective for chronic low back pain. A systematic review and meta-analysis by Taylor and colleagues concluded that spinal cord stimulation is an effective pain relieving treatment for chronic low back and leg pain with or without a prior history of back surgery.  The mean level of pain relief across 74 studies was found to be 58% at an average follow-up of 24 months. All told, the requested spinal cord stimulator is medically necessary for the treatment of this patient.", "id": "6a1cdc6e5e664fe7ac6e3b4d83a35277", "question": "What is the background context in this case summary?", "title": "6a1cdc6e5e664fe7ac6e3b4d83a35277", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Tuberous sclerosis is a rare genetic disease, and there are not enough patients to have double blind, placebo-controlled studies for the treatment of the associated facial angiofibromas. Topical rapamycin or sirolimus is considered standard of care for the treatment of these lesions.  The International Tuberous Sclerosis Complex Consensus Statement also recommends the use of this medication for treatment of facial angiofibromas in tuberous sclerosis. Therefore, sirolimus cream is likely to be more beneficial than other available standard therapy. \n\n", "id": "42efd578b2f74d1aaec23da1446e5b7e", "question": "What is the background context in this case summary?", "title": "42efd578b2f74d1aaec23da1446e5b7e", "sufficiency_score": 3}
+{"answers": {"text": ["A 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.", "this patient has mild facet arthropathy as demonstrated on magnetic resonance imaging (MRI) as well as having discogenic radiculopathy."], "answer_start": [21, 390]}, "context": "Summary Reviewer 2\n\n\nA 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.   The physician reviewer found that the available records document that this patient has mild facet arthropathy as demonstrated on magnetic resonance imaging (MRI) as well as having discogenic radiculopathy. However, the medial branch blocks performed on 8/4/15 are not indicated in the presence of another clear cause of the patients low back and radicular pain. Further, the use of repeated diagnostic blocks absent a plan for radiofrequency neurolysis is not consistent with clinical practice guidelines. Thus, the in-office surgical injections performed on 8/4/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n", "id": "f9182697477e489a9611933ebdadebf0", "question": "What is the background context in this case summary?", "title": "f9182697477e489a9611933ebdadebf0", "sufficiency_score": 2}
+{"answers": {"text": ["A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the concept of following drug levels when using tumor necrosis factor (TNF)-alpha antibodies to provide personalized dosing has been around for many years. Following drug levels can keep a patient at a target level which translates into a higher probability of clinical benefit. This concept is based primarily on retrospective data which has demonstrated that, in general, higher trough levels correlate directly, and the presence of antibody correlates indirectly, with clinical efficacy. Knowledge of the drug and antibody level would therefore assist the provider in the decision to increase a drugs dose or perhaps switch to another class of biologics. However, this approach has not been shown to be superior to making empiric changes. There is a lack of controlled data which have identified the optimal drug level. A recent trial demonstrated this approach had no impact on clinical efficacy compared to empiric dose titration (Steenholdt, et al). Therefore, the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "c57608c9ea85499598e4ff8c5bbd01cf", "question": "What is the background context in this case summary?", "title": "c57608c9ea85499598e4ff8c5bbd01cf", "sufficiency_score": 3}
+{"answers": {"text": ["A 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction.", "This patient has lateral nasal wall collapse from lower lateral cartilage weakness."], "answer_start": [20, 423]}, "context": "Summary Reviewer 2\n\nA 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that there is sufficient support for the requested services in this case. This patient has lateral nasal wall collapse from lower lateral cartilage weakness. The images appear to show significant collapse. The Latera implant is a U.S. Food and Drug Administration (FDA) approved device which has been used successfully for lateral nasal wall collapse. In sum, vestibular stenosis repair is likely to be more effective than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "11707e654e684add8bf21013104482c2", "question": "What is the background context in this case summary?", "title": "11707e654e684add8bf21013104482c2", "sufficiency_score": 3}
+{"answers": {"text": ["A 46-year-old male enrollee has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.", "the patient is a 46-year-old male who was evaluated in the emergency department at 14:31 on 7/2/17 with complaints of chest discomfort that had persisted for a couple of weeks. His pain was intermittent, and radiated to his left arm and jaw. He described his pain as heaviness and pressure that was moderate in intensity. His pain was accompanied by shortness of breath and diaphoresis. He had experienced tingling to the left face. The patient indicated that he initially thought his symptoms were due to discontinuing temazepam, but his symptoms had persisted. The patients medical history is significant for diabetes. His family history includes coronary artery disease. Differential diagnoses considered included unstable angina, pulmonary embolism, and atypical chest pain. The patients heart sounds were regular, normal perfusion was present and lungs were clear with unlabored respirations. An electrocardiogram (EKG) did not reveal any acute ischemia. A chest x-ray was negative for acute disease. Laboratory data was significant for an elevated D-dimer and a normal Troponin. A computed tomography (CT) angiogram of the chest did not show any evidence of pulmonary embolism. The patient was medicated with oral aspirin and sublingual nitroglycerin. He was admitted to observation unit on telemetry. The patient has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis."], "answer_start": [19, 263]}, "context": "Summary Reviewer \n\nA 46-year-old male enrollee has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 46-year-old male who was evaluated in the emergency department at 14:31 on 7/2/17 with complaints of chest discomfort that had persisted for a couple of weeks. His pain was intermittent, and radiated to his left arm and jaw. He described his pain as heaviness and pressure that was moderate in intensity. His pain was accompanied by shortness of breath and diaphoresis. He had experienced tingling to the left face. The patient indicated that he initially thought his symptoms were due to discontinuing temazepam, but his symptoms had persisted. The patients medical history is significant for diabetes. His family history includes coronary artery disease. Differential diagnoses considered included unstable angina, pulmonary embolism, and atypical chest pain. The patients heart sounds were regular, normal perfusion was present and lungs were clear with unlabored respirations. An electrocardiogram (EKG) did not reveal any acute ischemia. A chest x-ray was negative for acute disease. Laboratory data was significant for an elevated D-dimer and a normal Troponin. A computed tomography (CT) angiogram of the chest did not show any evidence of pulmonary embolism. The patient was medicated with oral aspirin and sublingual nitroglycerin. He was admitted to observation unit on telemetry. The patient has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.At issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients symptoms on 7/2/17 did meet the prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. This patient presented to the emergency department after experiencing intermittent chest pain for a few weeks. Symptoms of paresthesia with an elevated D-dimer made pulmonary embolism a consideration. His symptoms were classic for acute coronary syndrome as they were described as intermittent, radiating to his arm and jaw, and associated with shortness of breath and diaphoresis. In addition, the patients significant risk factors for coronary artery disease included diabetes, obesity, and a family history of coronary artery disease. These factors, combined with the patients age, would generate a history, EKG, age, risk factors and initial troponin (HEART) score of 4. Admission is recommended for such patients as a score of 4 is associated with a 12-16% risk of an adverse cardiac event. A patient who experiences intermittent chest pain with significant cardiac risk factors meets prudent layperson criteria for an emergency. Thus, the services provided on 7/2/17 were for treatment of an emergency medical condition. \n\n\n", "id": "6ed747edd6b84438aaf070f3848252ce", "question": "What is the background context in this case summary?", "title": "6ed747edd6b84438aaf070f3848252ce", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 42-year-old female with a history of treatment resistant, recurrent major \ndepressive disorder. The patient has requested reimbursement and prospective authorization \nand coverage for adult mental health transcranial magnetic stimulation provided from 10/15/21 \nforward.", "This  patient  had  also  tried  electroconvulsive  therapy.  She  completed  five \ntreatments but could not tolerate the confusion and headaches.", "she was evaluated \nby a psychiatrist who recommended transcranial magnetic stimulation at this point in her \ntreatment."], "answer_start": [21, 699, 861]}, "context": "Summary Reviewer  \n \nThe patient is a 42-year-old female with a history of treatment resistant, recurrent major \ndepressive disorder. The patient has requested reimbursement and prospective authorization \nand coverage for adult mental health transcranial magnetic stimulation provided from 10/15/21 \nforward. The physician reviewer found that per the medical literature, transcranial magnetic \nstimulation is indicated for severe, recurrent major depressive disorder that has not responded \nto traditional medication and psychotherapy treatment.  This patient qualifies for the diagnosis \nof treatment refractory depression given her two failed antidepressant trials in addition to \npsychotherapy.  This  patient  had  also  tried  electroconvulsive  therapy.  She  completed  five \ntreatments but could not tolerate the confusion and headaches.  Additionally, she was evaluated \nby a psychiatrist who recommended transcranial magnetic stimulation at this point in her \ntreatment. Based on the records, transcranial magnetic stimulation was the appropriate next \nstep  in  treatment  for  this  patient.  Therefore,  adult  mental  health  transcranial  magnetic \nstimulation provided from 10/15/21 forward was and is medically necessary for the treatment of \nthis patient.  \n ", "id": "d79d9c4d4d214bb894591a9bf85ec3d0", "question": "What is the background context in this case summary?", "title": "d79d9c4d4d214bb894591a9bf85ec3d0", "sufficiency_score": 4}
+{"answers": {"text": ["A 65-year-old male enrollee has requested authorization and coverage for Rytary. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Parkinsons disease.", "The patient has not been placed on extended release formulations of carbidopa/levodopa."], "answer_start": [20, 683]}, "context": "Summary Reviewer \n\n\nA 65-year-old male enrollee has requested authorization and coverage for Rytary. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Parkinsons disease. The physician reviewer found that the submitted documentation fails to support the medical necessity for the requested medication. While Rytary is a medication that is commonly used for the treatment of patients with Parkinsons disease, it is prescribed after the patient has tried and failed extended release formulations. The documentation provided do not demonstrate that this has been administered in this patient.  The patient has not been placed on extended release formulations of carbidopa/levodopa. As such, it would be appropriate for the patient to try the extended release formulations prior to being started on Rytary. Accordingly, Rytary is not currently medically necessary for treatment of this patient.  Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n", "id": "0c29fcff509d46c28d30082e819722c1", "question": "What is the background context in this case summary?", "title": "0c29fcff509d46c28d30082e819722c1", "sufficiency_score": 4}
+{"answers": {"text": ["A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue such as this patient. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and overall increase in diagnostic accuracy compared to two-dimensional imaging alone. The medical evidence supports the service at issue in this clinical setting. All told, breast tomosynthesis performed on 3/15/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "67fa7fd2da264492b82549d50d7f985a", "question": "What is the background context in this case summary?", "title": "67fa7fd2da264492b82549d50d7f985a", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patientas parent has requested reimbursement for occupational and speech therapy services provided from 7/24/20 through 8/20/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.", "The patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties."], "answer_start": [19, 516]}, "context": "Summary Reviewer \n\nThe patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patientas parent has requested reimbursement for occupational and speech therapy services provided from 7/24/20 through 8/20/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. Spittle and colleagues compared the effectiveness of early developmental intervention program provided post hospital discharge to prevent motor or cognitive impairment in preterm infants versus standard medical follow-up of preterm infants at infancy, preschool age, school age, and adulthood. The authors noted, aInfants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants.a Spittle and colleagues noted, aEarly intervention programs for preterm infants have a positive influence on cognitive and motor outcomes during infancy, with cognitive benefits persisting into preschool age.a Woodward and colleagues stated that infants born before 34 weeks of gestation have three times the risk of impairments in multiple developmental domains compared with term infants. Bui reported, aPreterm children should be screened regularly for developmental delay, and parents of preterm infants should be counseled about the options of early intervention programs, and their potential positive impact on development.a In an article describing the importance of physical, occupational and speech therapy for infants born prematurely, Orton and colleagues noted, aThe developmental allied health team, consisting of physical therapy, occupational therapy, and speech pathology, is crucial in early evaluation of gross motor, fine motor, feeding, and language development. Surveillance of neurodevelopment in the first year of life is essential to ensure early detection of specific developmental delays and impairments, and to ensure timely referral for early intervention. Early intervention is not only important in optimizing long-term outcomes for the child, but it also plays an important role in enhancing the parent-child relationship and parental well-being.a The medical evidence supports the services at issue in this clinical setting. Therefore, occupational and speech therapy services provided from 7/24/20 through 8/20/20 were medically necessary for the treatment of this patient.", "id": "10e134befb17438cbb9b035be046de42", "question": "What is the background context in this case summary?", "title": "10e134befb17438cbb9b035be046de42", "sufficiency_score": 4}
+{"answers": {"text": ["A 31-year-old male enrollee has requested authorization and coverage for anastrozole 1 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.", "This patient is being treated for testicular hypodysfunction with testosterone and human chorionic gonadotropin.  The laboratory studies from November 2015 and February 2016 show normal or high values of testosterone."], "answer_start": [20, 402]}, "context": "Summary Reviewer \n\n\nA 31-year-old male enrollee has requested authorization and coverage for anastrozole 1 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is being treated for testicular hypodysfunction with testosterone and human chorionic gonadotropin.  The laboratory studies from November 2015 and February 2016 show normal or high values of testosterone.  For men who are hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning serum testosterone concentration on three separate occasions, testosterone replacement therapy is recommended. The approved uses for anastrozole 1 mg include first-line treatment of locally-advanced or metastatic breast cancer (hormone receptor-positive or unknown) in postmenopausal women, adjuvant treatment of early hormone receptor-positive breast cancer in postmenopausal women or treatment of advanced breast cancer in postmenopausal women with disease progression following tamoxifen therapy.  In this case, the patient does not have an approved indication for the use of anastrozole.  Furthermore, this medication is not recommended for the use of testicular hypofunction.  The documentation supports that the patient has had improved symptoms while taking testosterone and human chorionic gonadotropin.  Thus, the requested anastrozole 1 mg is not medically indicated for the treatment of this patient.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n\n", "id": "5cdc3463735a4871900257c1d894aa10", "question": "What is the background context in this case summary?", "title": "5cdc3463735a4871900257c1d894aa10", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time that pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed by Reynolds and colleagues. The authors found that gastroesophageal reflux disease patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Therefore, the LINX Reflux Management System (code 43284) and one inpatient day are likely to be superior over other treatment options.\n\n", "id": "4c17f6be01d546b88ba34be1db5e08e2", "question": "What is the background context in this case summary?", "title": "4c17f6be01d546b88ba34be1db5e08e2", "sufficiency_score": 2}
+{"answers": {"text": ["A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation.", "the patient has a history of persistent AF and has required cardioversions. She is now on antiarrhythmic drug therapy with dronedarone.", "In this patients case, the provider reported that the patient has symptomatic paroxysmal AF despite antiarrhythmic drug therapy. Thus, catheter ablation of atrial fibrillation was offered."], "answer_start": [21, 367, 902]}, "context": "Summary Reviewer 3\n\n\nA 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that the patient has a history of persistent AF and has required cardioversions. She is now on antiarrhythmic drug therapy with dronedarone.  According to the guidelines endorsed by the American College of Cardiology, American Heart Association and the Heart Rhythm Society, catheter ablation of atrial fibrillation in this patient would be recommended, AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least one class I or III antiarrhythmic medication when a rhythm-control strategy is desired. In this patients case, the provider reported that the patient has symptomatic paroxysmal AF despite antiarrhythmic drug therapy. Thus, catheter ablation of atrial fibrillation was offered. In sum, the requested surgery to treat her heart rhythm is likely to be more effective than the standard options available for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "93f0231216b04476814bd26ab0e5cafb", "question": "What is the background context in this case summary?", "title": "93f0231216b04476814bd26ab0e5cafb", "sufficiency_score": 4}
+{"answers": {"text": ["A 63-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy provided from 8/17/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition.", "according to the documentation submitted for review, the patient had post-operative disability after foot surgery and physical therapy was prescribed to improve function. The patient made improvement in physical therapy through 8/19/15.", "the patient did not show further improvement."], "answer_start": [20, 374, 910]}, "context": "Summary Reviewer \n\n\nA 63-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy provided from 8/17/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient had post-operative disability after foot surgery and physical therapy was prescribed to improve function. The patient made improvement in physical therapy through 8/19/15. On that date further physical therapy was reasonable and medically necessary because the patient had continued deficits that are generally amenable to the care of a skilled physical therapist. Based on improvement up to 8/19/15, further improvement could be expected with skilled services. However, the patient did not show further improvement. As such, six additional physical therapy sessions after 8/19/15 were sufficient to show a plateau. After these six sessions, the patient could have been managed with a home exercise program. For the reasons provided, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.\n\n\n\n", "id": "36756def8cee42c98d263b48a0bc6bd3", "question": "What is the background context in this case summary?", "title": "36756def8cee42c98d263b48a0bc6bd3", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old male enrollee has requested authorization and coverage for apremilast (Otezla) 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis.", "the records indicate that this patient has failed two treatments with NSAIDs", "the psoriasis", "covers at least ten percent of his body surface area."], "answer_start": [21, 451, 837, 856]}, "context": "Summary Reviewer \n\n\n\nA 54-year-old male enrollee has requested authorization and coverage for apremilast (Otezla) 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that the documentation provided do not support the medical necessity for the requested medication in this clinical setting. While the records indicate that this patient has failed two treatments with NSAIDs, the records do not demonstrate that he has tried and failed nonpharmacological treatments (ultravioletlight therapy), disease-modifying antirheumatic drugs (DMARD) therapies, or anti-tumor necrosis factor (TNF) agents. There is also no documentation that he has tried the standard topical therapy to address the psoriasis that covers at least ten percent of his body surface area. While apremilast may represent a promising therapy for the treatment of psoriatic arthritis and psoriasis, the medication should be tried after failure of other standard forms of therapy. Per Zerilli, and Ocheretyaner, Additional long-term studies are needed to further elucidate its place in therapy. As such, the requested medication is not medically indicated for the treatment of this patient. Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "a7237430851749b8bba49cf35981deee", "question": "What is the background context in this case summary?", "title": "a7237430851749b8bba49cf35981deee", "sufficiency_score": 4}
+{"answers": {"text": ["A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 11/07/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld. \n\n\n", "id": "615756a56f60433d8a8ad6a21796208c", "question": "What is the background context in this case summary?", "title": "615756a56f60433d8a8ad6a21796208c", "sufficiency_score": 3}
+{"answers": {"text": ["A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.", "In this case, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems."], "answer_start": [21, 899]}, "context": "Summary Reviewer 1\n\n\nA 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.  The physician reviewer found that the PET scan performed on 2/3/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. PET is a standard procedure performed by providers when dementia is atypical, and most specifically to differentiate Alzheimers disease from frontotemporal dementia. This diagnostic procedure allows the patient and his family to better understand prognosis and treatment, and guide the treating provider to provide the best treatment. In this case, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems. In this complex clinical setting, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "7a5c8498870e4b609e891f0c0a734db3", "question": "What is the background context in this case summary?", "title": "7a5c8498870e4b609e891f0c0a734db3", "sufficiency_score": 4}
+{"answers": {"text": ["A 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria"], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria The physician reviewer found the clinical utility of LHR is not well established and there are currently no national Allergy and Immunology or Dermatology guidelines recommending routine use of this test. LHR is a test that consists of basophil histamine release assay.  This assay is used to detect anti-Fc-epsilon-RI-alpha antibodies. Some concerns with LHR is that there is evidence against a pathogenic role of autoantibodies to IgE or Fc-epsilon-RI and they are not specific to CU.  Anti-Fc-epsilon-RI-alpha antibodies have been identified in healthy normal people and those with other autoimmune diseases.  The level of these antibodies do not appear to change with the clinical disease activity. The presence of these antibodies do not appear to predict refractory disease. In this patients case, her symptoms are consistent with chronic idiopathic urticaria. Her evaluation to include LHR have all been negative.  As such, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to have been more effective than current standard therapy for evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "04eb8334c7fd413a90601563bb886dd7", "question": "What is the background context in this case summary?", "title": "04eb8334c7fd413a90601563bb886dd7", "sufficiency_score": 3}
+{"answers": {"text": ["A 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 9/01/16 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "c74ad41671c14cc2b677f7c6b1ba7c7d", "question": "What is the background context in this case summary?", "title": "c74ad41671c14cc2b677f7c6b1ba7c7d", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation \ntherapy (PBT). The Health Insurer has denied this request and reported that the requested service is \ninvestigational for the treatment of the enrollees locally advanced esophagus cancer."], "answer_start": [22]}, "context": "Summary Reviewer 2 \n \nA 58-year-old male enrollee has requested authorization and coverage for proton beam radiation \ntherapy (PBT). The Health Insurer has denied this request and reported that the requested service is \ninvestigational for the treatment of the enrollees locally advanced esophagus cancer. The physician \nreviewer found that PBT is not likely to be more beneficial for treatment of the patients condition than \nany available standard therapy. \n \n", "id": "c354d552150b41bc9de2853e182f1e32", "question": "What is the background context in this case summary?", "title": "c354d552150b41bc9de2853e182f1e32", "sufficiency_score": 3}
+{"answers": {"text": ["A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Based on the medical literature, Anser IFX testing performed on 9/04/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "e589e2d807694415aa2d62039159cce8", "question": "What is the background context in this case summary?", "title": "e589e2d807694415aa2d62039159cce8", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has \nrequested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower \nextremity, without contrast material, on 9/21/22. The Health insurer has denied this request and \nreported that the services at issue were not medically necessary for the evaluation of this patient.", "In this case, the patient had left ankle and right knee pain for \nyears that did not respond to conservative treatment. Notes dated 9/2/22 reported left posterior \ntibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI \nimaging of the ankle did not show structural issues. The patient reported that the MRIs resulted \nin a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a \nneurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee \nmedial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root \ntear of the meniscus requiring arthroscopy."], "answer_start": [21, 537]}, "context": "Summary Reviewer  \n \nThe patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has \nrequested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower \nextremity, without contrast material, on 9/21/22. The Health insurer has denied this request and \nreported that the services at issue were not medically necessary for the evaluation of this patient.  \nThe physician reviewer found that the submitted documentation supports the medical necessity \nof a portion of the services at issue. In this case, the patient had left ankle and right knee pain for \nyears that did not respond to conservative treatment. Notes dated 9/2/22 reported left posterior \ntibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI \nimaging of the ankle did not show structural issues. The patient reported that the MRIs resulted \nin a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a \nneurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee \nmedial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root \ntear of the meniscus requiring arthroscopy. While the American College of Radiology (ACR) notes \nthat MRI is usually not appropriate in the setting of chronic ankle or knee pain without prior x-\nrays, given this patients multi-year history of prolonged and unexplained ankle and knee pain, \nthe services at issue were medically indicated. Therefore, magnetic resonance imaging of the \nright knee and the left ankle were medically necessary for the evaluation of this patient. \n ", "id": "c509012958f34e8fadd522383b98139a", "question": "What is the background context in this case summary?", "title": "c509012958f34e8fadd522383b98139a", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 13-year-old female enrollee has requested reimbursement for needle \nelectromyography (EMG) of anal or urethral sphincter, any technique; needle \nelectromyography, each extremity; and electroencephalogram performed on 6/10/20. The \nHealth Insurer has denied this request and reported that the services at issue were \ninvestigational for the treatment of the enrollees medical condition.", "This \npatient was being treated for adolescent idiopathic scoliosis. She underwent a thoracoscopic \nanterior spinal tethering."], "answer_start": [22, 537]}, "context": "Summary Reviewer 1 \n \nThe parent of a 13-year-old female enrollee has requested reimbursement for needle \nelectromyography (EMG) of anal or urethral sphincter, any technique; needle \nelectromyography, each extremity; and electroencephalogram performed on 6/10/20. The \nHealth Insurer has denied this request and reported that the services at issue were \ninvestigational for the treatment of the enrollees medical condition. The physician reviewer \nfound that the medical evidence supports the services at issue in this clinical setting. This \npatient was being treated for adolescent idiopathic scoliosis. She underwent a thoracoscopic \nanterior spinal tethering. This procedure involved a high risk of significant complications. The \nuse of electromyographical monitoring has been found beneficial to help prevent further injury \nduring this procedure. Therefore, needle electromyography (EMG) of anal or urethral sphincter, \nany technique; needle electromyography, each extremity; and electroencephalogram \nperformed on 6/10/20 was likely to have been more beneficial than any available standard \ntherapy. \n \n", "id": "1e2ad40b7d9b4d5fbc407b6879096442", "question": "What is the background context in this case summary?", "title": "1e2ad40b7d9b4d5fbc407b6879096442", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nThe parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that CMA is increasingly utilized for genetic testing of individuals with unexplained developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  CMA offers a much higher diagnostic yield for genetic testing of patients with unexplained developmental delay/intellectual disability, autism spectrum disorder, or multiple congenital anomalies than the previous standard testing with G-banded karyotype, primarily because of its higher sensitivity for submicroscopic deletions and duplications.  Available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  Given that the standard of care is now CMA, the FirstStepDx Plus chromosomal microarray was likely to have been of greater benefit than other methods of evaluation.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "645a58ff74a4416588b3c7804fc5907f", "question": "What is the background context in this case summary?", "title": "645a58ff74a4416588b3c7804fc5907f", "sufficiency_score": 3}
+{"answers": {"text": ["A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The medical evidence does not support the use of intravenous, intramuscular, or subcutaneous immune globulin as a treatment to prevent recurrent spontaneous abortion in pregnant women. The American College of Obstetricians and Gynecologists does not support the requested services for the treatment of this patient. The use of intravenous immune globulin for pregnancy loss prevention has not been demonstrated by large scale, prospective clinical trials to have superior outcomes compared to existing therapies. Therefore, immune globulin injection (Gamunex-C), 500 mg is not likely to be of greater benefit than other treatment options.\n\n\n", "id": "043b2c6e56a1450c97e6b6bfccb57717", "question": "What is the background context in this case summary?", "title": "043b2c6e56a1450c97e6b6bfccb57717", "sufficiency_score": 2}
+{"answers": {"text": ["A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.", "This patients provider seeks to treat her recurrent pregnancy loss thought to be of autoimmune nature with intravenous immune globulin (IVIG)."], "answer_start": [20, 534]}, "context": "Summary Reviewer 2\n\nA 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is limited high-quality data on the management of recurrent pregnancy loss. Currently, therapeutic recommendations are largely based upon clinical experience and data from observational studies. This patients provider seeks to treat her recurrent pregnancy loss thought to be of autoimmune nature with intravenous immune globulin (IVIG). The studies cited by the provider are observational and pre-date current systematic reviews. Systematic reviews have consistently found no beneficial effect of immunotherapy for treatment of recurrent pregnancy loss. Wong and colleagues performed a systematic review of 20 trials of high-quality. The authors noted that immunotherapy did not result in a statistically significant improvement in live births compared to untreated controls. Treatment with intravenous immune globulin was included in this study. In sum, immune globulin injection (Gamunex-C), 500 mg is not likely to be superior over other available treatment options.\n\n\n", "id": "f42bb979c39349d0ab2dd5cc61ff1c0a", "question": "What is the background context in this case summary?", "title": "f42bb979c39349d0ab2dd5cc61ff1c0a", "sufficiency_score": 3}
+{"answers": {"text": ["A 63-year-old female has requested reimbursement for Anser ADA testing provided on 4/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 63-year-old female has requested reimbursement for Anser ADA testing provided on 4/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management of ulcerative colitis. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, the clinical literature has not established the superior efficacy of Anser ADA testing performed on 4/25/16.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "f87ee5ab363f4e08a8707be421332c5e", "question": "What is the background context in this case summary?", "title": "f87ee5ab363f4e08a8707be421332c5e", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 19-year-old female with short stature, congenital heart disease, multiple minor malformations, and borderline intellectual disability. A specific diagnosis could not be recognized.  Chromosomal microarray was performed to investigate the etiology of the patients medical issues, in order to direct the patients medical care more specifically. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement and reported the services at issue were investigational for the evaluation of the patients medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nThe patient is a 19-year-old female with short stature, congenital heart disease, multiple minor malformations, and borderline intellectual disability. A specific diagnosis could not be recognized.  Chromosomal microarray was performed to investigate the etiology of the patients medical issues, in order to direct the patients medical care more specifically. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement and reported the services at issue were investigational for the evaluation of the patients medical condition.  Array-based comparative genomic hybridization (CGH, or chromosomal microarray) has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies.  Formerly, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; however, currently it is considered a first-line investigation.  The yield of this test is approximately 8 to 17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The cited references indicate that this test has become an important and mainstream tool in the practice of clinical genetics.  As early as 2007, its utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability.  More recently, its clinical utility has been confirmed in a study by Henderson and colleagues where 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management (including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation).  Medical literature has shown that microarray results affect clinical management, at rates, which are similar to other genetic testing. Given the potential to influence management, microarray is an appropriate test to perform in this clinical scenario. Accordingly, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more effective for the evaluation of this patients medical condition than the other available modalities.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "4e377cfbb39d49c78f4729dd78662c34", "question": "What is the background context in this case summary?", "title": "4e377cfbb39d49c78f4729dd78662c34", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 59-year-old female with listed diagnoses of inflammatory polyarthropathy, osteoarthritis and fibromyalgia. She has been treated with multiple medications, including prednisone, sulfasalazine, Humira, ibuprofen and Toradol.", "This patient reports pain in her back, hands and feet, as well as multiple soft tissue areas. She has been treated with multiple medications to date, all of which have either resulted in side effects or a lack of response."], "answer_start": [19, 414]}, "context": "Summary Reviewer \n\nThe patient is a 59-year-old female with listed diagnoses of inflammatory polyarthropathy, osteoarthritis and fibromyalgia. She has been treated with multiple medications, including prednisone, sulfasalazine, Humira, ibuprofen and Toradol. The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested medication in this clinical setting. This patient reports pain in her back, hands and feet, as well as multiple soft tissue areas. She has been treated with multiple medications to date, all of which have either resulted in side effects or a lack of response. The available medical records do not document objective findings to support the presence of an inflammatory arthritis. There is no documentation of synovitis on physical examination, nor is there documentation of radiologic studies with findings consistent with inflammatory disease. On the basis of this lack of documentation, the requested medication is not medically indicated. Additionally, there is a lack of evidence\nsupporting the use of H.P. Acthar Gel in fibromyalgia. Therefore, H.P. Acthar 80 unit/mL Gel is not medically necessary for the treatment of this patient.", "id": "feb744687bdd4c71bc2c12150d783bc1", "question": "What is the background context in this case summary?", "title": "feb744687bdd4c71bc2c12150d783bc1", "sufficiency_score": 4}
+{"answers": {"text": ["An 18-year-old male enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.", "The medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself.", "The patient has had some issues with level of function that were sporadic nature. He showed intact activities of daily living.", "The patient does not have active medical problems or substance use.", "There was no indication of an unsafe home environment.", "The patients parents were involved in treatment on a regular basis.", "the patient has had minimal prior treatment and was cooperative in the residential treatment center program at issue.", "The patient actively participated in therapy on admission.", "The parents worked actively and constructively with clinicians on a regular basis."], "answer_start": [19, 757, 992, 1178, 1341, 1488, 1656, 1847, 1997]}, "context": "Summary Reviewer \n\nAn 18-year-old male enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function that were sporadic nature. He showed intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient does not have active medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient has had minimal prior treatment and was cooperative in the residential treatment center program at issue. In terms of acceptance and engagement, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 16.  This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18 was not medically necessary for the treatment of this patient.", "id": "c790939d268b4aada52ce5d5e585d479", "question": "What is the background context in this case summary?", "title": "c790939d268b4aada52ce5d5e585d479", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 16-month-old female enrollee has requested authorization and coverage for hourly pediatric nursing, 12 hours per day, seven days per week (S9123). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.", "this", "patient has a number of problems as a result of, and in addition to, her cloacal abnormalities, chronic kidney disease, and prematurity.", "With the introduction of skilled nursing services, she has had no further significant urinary tract infections requiring parenteral antibiotics and hospitalization. She has been able to attend preschool to aid in her development and help her to catch up to her peers. The patients mother is the primary caregiver and has significantly modified her schedule in order to provide for the patients custodial needs. She does not have the necessary expertise", "to provide for the patients skilled medical needs, including ostomy care and prevention of urinary tract infections."], "answer_start": [19, 382, 405, 719, 1182]}, "context": "Summary Reviewer \n\nThe parent of a 16-month-old female enrollee has requested authorization and coverage for hourly pediatric nursing, 12 hours per day, seven days per week (S9123). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this medically fragile patient has a number of problems as a result of, and in addition to, her cloacal abnormalities, chronic kidney disease, and prematurity. The most important issue for her at this time, prior to completion of her reconstructive surgeries, is prevention of urinary tract infection and preservation of renal function. With the introduction of skilled nursing services, she has had no further significant urinary tract infections requiring parenteral antibiotics and hospitalization. She has been able to attend preschool to aid in her development and help her to catch up to her peers. The patients mother is the primary caregiver and has significantly modified her schedule in order to provide for the patients custodial needs. She does not have the necessary expertise, however, to provide for the patients skilled medical needs, including ostomy care and prevention of urinary tract infections. The requested skilled nursing services 12 hours daily 7 days per week are essential to this patients current health as well as to the future success of her reconstructive surgeries. Therefore, the requested hourly pediatric nursing, 12 hours per day, seven days per week (S9123), is medically necessary for the treatment of this patient.", "id": "90b5e86ae49146c9adf9189e340a3925", "question": "What is the background context in this case summary?", "title": "90b5e86ae49146c9adf9189e340a3925", "sufficiency_score": 4}
+{"answers": {"text": ["A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found the staging and classification of cutaneous melanoma has classically been described by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma testing is an assay of 31 genes in the cells of an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not known how the five-year DecisionDx-Melanoma testing data compares to the 10-year Balch data. Additionally, it is not clear if the DecisionDx-Melanoma classification can be used to make therapeutic decisions, such as whether to do a sentinel node and/or give adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.\n\n\n", "id": "618a42a45f624e5fb072b60fe80ceb3b", "question": "What is the background context in this case summary?", "title": "618a42a45f624e5fb072b60fe80ceb3b", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 26-year-old female with a history of an intensive care unit admission for alcoholic ketoacidosis. She had a history of depression and anxiety with poor compliance with medication.", "the patient had several episodes of withdrawal and experienced alcoholic ketoacidosis, alcohol hepatocyte injury, macrocytic anemia and physical withdrawal. After discharge from the inpatient hospital, she was stable enough to receive further medical detoxification at the level 3.5 residential treatment level of care.", "the patientas medical problems", "were stable enough to be treated at the 3.5 level of care.", "the patient had a history of anxiety and depression and had difficulty complying with medication on an outpatient basis.", "the patient was ambivalent about residential treatment and thought it was ajust what her family wanteda, showing low insight and poor judgment and supporting the need for further structured treatment to enhance her willingness to change.", "the patient had tried stopping on her own several times and had developed serious medical problems", "the patientas family works in the wine business and she would have been exposed to continuous use had she been discharged to her motheras home. The patient had no support for sobriety at her home in Colorado."], "answer_start": [19, 590, 951, 1006, 1131, 1410, 1719, 1965]}, "context": "Summary Reviewer \n\nThe patient is a 26-year-old female with a history of an intensive care unit admission for alcoholic ketoacidosis. She had a history of depression and anxiety with poor compliance with medication. The physician reviewer found that based on the records, this patient met American Society of Addiction Medicine (ASAM) criteria for sub-acute substance abuse rehabilitation (ASAM 3.5) provided from 6/20/21 through 7/18/21. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. \n\nFor dimension 1, acute intoxication or withdrawal potential, the patient had several episodes of withdrawal and experienced alcoholic ketoacidosis, alcohol hepatocyte injury, macrocytic anemia and physical withdrawal. After discharge from the inpatient hospital, she was stable enough to receive further medical detoxification at the level 3.5 residential treatment level of care.\n\nFor dimension 2, biomedical conditions, the patientas medical problems as cited in dimension 1 were stable enough to be treated at the 3.5 level of care.\n\nFor dimension 3, emotional, behavioral, or cognitive conditions, the patient had a history of anxiety and depression and had difficulty complying with medication on an outpatient basis. Her co-occurring anxiety and depression and need for supervision of medications meets ASAM 3.5 level of care criteria.\n\nFor dimension 4, readiness to change, the patient was ambivalent about residential treatment and thought it was ajust what her family wanteda, showing low insight and poor judgment and supporting the need for further structured treatment to enhance her willingness to change.\n\nFor dimension 5, relapse, continued use, continued problem potential, the patient had tried stopping on her own several times and had developed serious medical problems which could worsen and be potentially fatal outside of a structured 24-hour monitored treatment setting.  \n\nFor dimension 6, recovery environment, the patientas family works in the wine business and she would have been exposed to continuous use had she been discharged to her motheras home. The patient had no support for sobriety at her home in Colorado. She met 3.5 level of care on dimension 6.\n\nAccordingly, sub-acute substance abuse rehabilitation (ASAM 3.5) provided from 6/20/21 through 7/18/21 was medically necessary for the treatment of this patient\n\n", "id": "64d982d946704583b1b1a746354815ee", "question": "What is the background context in this case summary?", "title": "64d982d946704583b1b1a746354815ee", "sufficiency_score": 4}
+{"answers": {"text": ["A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the automated nerve conduction studies in dispute performed during surgery are not supported in the peer-reviewed literature. Intraoperative monitoring utilizing automated nerve conduction testing on peripheral nerves during surgery was not indicated. There is a lack of support in the medical literature supporting nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. As such, the automated intraoperative nerve conduction studies were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n\n\n\n", "id": "9a88ae1734ac418c8aa0fabb8c2f4bb0", "question": "What is the background context in this case summary?", "title": "9a88ae1734ac418c8aa0fabb8c2f4bb0", "sufficiency_score": 2}
+{"answers": {"text": ["A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that the medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/30/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n", "id": "7b0f35d417424441b74784748222fb04", "question": "What is the background context in this case summary?", "title": "7b0f35d417424441b74784748222fb04", "sufficiency_score": 3}
+{"answers": {"text": ["A 54-year-old female enrollee has requested reimbursement for acute hospital stay from 12/30/17 through 2/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition."], "answer_start": [19]}, "context": "Summary Reviewer \n\nA 54-year-old female enrollee has requested reimbursement for acute hospital stay from 12/30/17 through 2/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. At the time of admission, the records did not document that she required frequent treatment with intravenous analgesic medication. The documentation did not indicate an emergent need for surgical intervention. The current medical evidence does not support the services at issue in this clinical setting. Therefore, acute hospital stay provided from 12/30/17 through 2/11/18 was not medically necessary for the treatment of this patient.", "id": "98ad4efbb9994601a8e11e9f39047dbf", "question": "What is the background context in this case summary?", "title": "98ad4efbb9994601a8e11e9f39047dbf", "sufficiency_score": 1}
+{"answers": {"text": ["The patient is a 26-year-old male with a history of suspected multiple sclerosis (MS). In an effort \nto treat the patients flare and as maintenance therapy for suspected MS, the provider has \nrecommended treatment with intravenous immunoglobulin (IVIG) therapy with Gamunex-C. The \nHealth Insurer has denied the requested treatment as not medically necessary for the treatment \nof the patients medical condition.", "the patient experienced an exacerbation of symptoms from suspected MS."], "answer_start": [21, 515]}, "context": "Summary Reviewer  \n \nThe patient is a 26-year-old male with a history of suspected multiple sclerosis (MS). In an effort \nto treat the patients flare and as maintenance therapy for suspected MS, the provider has \nrecommended treatment with intravenous immunoglobulin (IVIG) therapy with Gamunex-C. The \nHealth Insurer has denied the requested treatment as not medically necessary for the treatment \nof the patients medical condition. The physician reviewer found that the records provided for \nreview indicate that the patient experienced an exacerbation of symptoms from suspected MS. \nFor patients who experience an acute MS exacerbation that results in neurologic symptoms and \nincreased disability or impairments in vision, strength, or cerebellar function, a short course of \nhigh-dose glucocorticoid therapy is recommended (Olek, et al.). If the patient has a poor response \nto treatment with high-dose glucocorticoids, treatment with plasma exchange is considered for \nthe next line of therapy. Other options for a second treatment course after a poor response to \ninitial high-dose glucocorticoid therapy include adrenocorticotropic hormone (ACTH), a second \ncycle of high-dose glucocorticoid therapy, or immunoadsorption. There is a paucity of high-\nquality medical studies demonstrating that IVIG therapy is an effective treatment option for \npatients who experience an exacerbation of symptoms from suspected MS. A small number of \nlimited medical studies have demonstrated that IVIG therapy may be used for patients with \nrelapsing-remitting MS who do not tolerate or have contraindications to approved therapies \n(Bayry, et al.). In this case, a diagnosis of relapsing-remitting MS has not been established for the \npatient. The records indicate that the patient experienced an acute exacerbation of symptoms \nfrom suspected MS. Based on the current medical literature, IVIG therapy is not recommended \nas a treatment option for patients with acute exacerbations of symptoms from suspected MS. \nTherefore, the requested Gamunex-C is not medically necessary for the treatment of this patient. \n ", "id": "28d1bc5892e144cd8bd33e9d26d91fc2", "question": "What is the background context in this case summary?", "title": "28d1bc5892e144cd8bd33e9d26d91fc2", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 3\n\nA 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing provided on 5/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.", "id": "a5a952ca46294364b1beed8ee2e39bb9", "question": "What is the background context in this case summary?", "title": "a5a952ca46294364b1beed8ee2e39bb9", "sufficiency_score": 3}
+{"answers": {"text": ["A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing \nperformed on 8/14/19. The Health Insurer has denied this request and reported that the services \nat issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [22]}, "context": "Summary Reviewer 3 \n \nA 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing \nperformed on 8/14/19. The Health Insurer has denied this request and reported that the services \nat issue were investigational for the evaluation of the enrollees medical condition. The physician \nreviewer found that the staging and prognosis of cutaneous melanoma has classically been \ndetermined by applying the system spelled out by Balch. Mitotic index may add a bit to these \nstatistics. DecisionDx-Melanoma testing is an assay of 31 genes in a particular melanoma. It then \nplaces that particular melanoma into either Class 1 or 2, with somewhat different risks of \nmetastasis by five years. It is not clear how the five-year DecisionDx-Melanoma data compares \nto the ten-year Balch data. Most importantly, it has not been shown that one can use the \nDecisionDx-Melanoma data to make important clinical decisions, such as the need for sentinel \nnode biopsy or the use of adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed \non 8/14/19 was not likely to have been more beneficial than any available standard therapy. \n \n ", "id": "0838bbed78f740c6b2d221fd18e21386", "question": "What is the background context in this case summary?", "title": "0838bbed78f740c6b2d221fd18e21386", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 14-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) services for 30 hours per week. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder.", "this patient is reported to be on the autism spectrum."], "answer_start": [20, 374]}, "context": "Summary Reviewer \n\n\nThe parent of a 14-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) services for 30 hours per week. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found that this patient is reported to be on the autism spectrum. However, the records provided for review do not provide details regarding the frequency of challenging behaviors, nor his response to previous ABA therapy. Some of the goals being addressed in the proposed ABA therapy plan provided are more consistent with goals addressed with occupational or vocational therapy than directly addressing the patients autism spectrum disorder. These goals include completing chores and using utensils. In the medical literature, Orinstein and colleagues reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Luiselli and colleagues reached similar conclusions. Thus, the Health Insurers approval for 15 hours per week of direct ABA therapy is appropriate to address this patients current needs as documented in the records reviewed. Accordingly, the requested ABA services for 30 hours per week is not supported as medically necessary. Based on the foregoing discussion, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.", "id": "d622c7fc88f544f8b409ba1eda15c8f7", "question": "What is the background context in this case summary?", "title": "d622c7fc88f544f8b409ba1eda15c8f7", "sufficiency_score": 3}
+{"answers": {"text": ["A 51-year-old female enrollee has requested authorization and coverage for Provigil 200 mg tablets, 60 tablets per 30 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.", "The medical records indicate that the patient has a long history of hypersomnia. She has been evaluated by multiple specialists in order to maximize her medications. This patient has significant functional problems due to her hypersomnia as well as her bipolar disorder", "Based on the records, the requested medication appears to be working well for her"], "answer_start": [19, 432, 826]}, "context": "Summary Reviewer \n\nA 51-year-old female enrollee has requested authorization and coverage for Provigil 200 mg tablets, 60 tablets per 30 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The medical records indicate that the patient has a long history of hypersomnia. She has been evaluated by multiple specialists in order to maximize her medications. This patient has significant functional problems due to her hypersomnia as well as her bipolar disorder, as referenced by her use of the antipsychotic medication Clozaril, which is typically reserved for recalcitrant illnesses. Based on the records, the requested medication appears to be working well for her, and discontinuation of the requested medication could have significant adverse results. Therefore, Provigil 200 mg tablets, 60 tablets per 30 days are medically necessary for the treatment of this patient.", "id": "cb9e4a0a1c6c4401974ce1b80390d3cd", "question": "What is the background context in this case summary?", "title": "cb9e4a0a1c6c4401974ce1b80390d3cd", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 68-year-old male who has requested reimbursement for DecisionDx-Melanoma testing. The patient has requested reimbursement for DecisionDx-Melanoma testing performed on 11/23/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 68-year-old male who has requested reimbursement for DecisionDx-Melanoma testing. The patient has requested reimbursement for DecisionDx-Melanoma testing performed on 11/23/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the use of gene expression profiling (GEP) testing according to specific melanoma stage (either before or after sentinel lymph node biopsy) requires rather prospective investigation in large, contemporary datasets of unselected patients. Prognostic GEP testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. Commercially available GEPs, such as DecisionDx-Melanoma, are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular, to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 11/23/20 was not medically necessary for the evaluation of this patient. ", "id": "367bb0cf6ac448739e41cd085b742dd4", "question": "What is the background context in this case summary?", "title": "367bb0cf6ac448739e41cd085b742dd4", "sufficiency_score": 3}
+{"answers": {"text": ["A 38-year-old female enrollee has requested authorization and coverage for Tysabri.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.", "this patient has been diagnosed with relapsing-remitting multiple sclerosis.", "She has been prescribed Tysabri", "This patient did not tolerate Copaxone."], "answer_start": [20, 295, 415, 712]}, "context": "Summary Reviewer \n\n\nA 38-year-old female enrollee has requested authorization and coverage for Tysabri.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found this patient has been diagnosed with relapsing-remitting multiple sclerosis. Treatment is indicated to reduce attacks.  She has been prescribed Tysabri, and the current medical evidence supports the requested medication in this clinical setting.  Guidelines and clinical experience show reduction of relapse rates and progression, with generally favorable tolerability. Compliance with once monthly regimen is high.  This patient did not tolerate Copaxone.  There is sufficient support for the requested medication in this patients case.  All told, Tysabri is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n\n\n", "id": "52adb135aaea4486ae87c73ba7dac012", "question": "What is the background context in this case summary?", "title": "52adb135aaea4486ae87c73ba7dac012", "sufficiency_score": 4}
+{"answers": {"text": ["A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of objective measurable evidence of functional gain and/or improvement. There are a lack of clinical references to objective functional improvement during the dates in dispute. In sum, the records lacked sufficient evidence supporting treatment with acupuncture was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "609bde3943b74d0e92be9f239811c161", "question": "What is the background context in this case summary?", "title": "609bde3943b74d0e92be9f239811c161", "sufficiency_score": 3}
+{"answers": {"text": ["A 45-year-old female enrollee has requested authorization and coverage for L-methylfolate. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is homozygous for methylene tetrahydrofolate reductase (MTHFR) enzyme deficiency.", "The patient has trialed many standard therapies for major depressive disorder, to no avail.", "The patient has a genetic test that demonstrates a defective MTHFR gene which suggests L-methylfolate deficiency."], "answer_start": [22, 1053, 1231]}, "context": "Summary Reviewer \n\n\n\n\nA 45-year-old female enrollee has requested authorization and coverage for L-methylfolate. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is homozygous for methylene tetrahydrofolate reductase (MTHFR) enzyme deficiency. The physician reviewer found there is sufficient support for the requested medication in this clinical setting.  Folic acid is vitamin B9.  It is converted to L-methylfolate, the active form of the vitamin in the body, by an enzyme, MTHFR.  If individuals lack the ability to convert folic acid, they may be prescribed synthetic L-methylfolate.  It is hypothesized that L-methylfolate may help the body create neurotransmitters such as serotonin, dopamine and norepinephrine, and thus may augment antidepressant medications for those struggling with treatment-resistant depression.  Despite the rather limited data, L-methylfolate is safe and reasonably expected to improve the patients condition in this case.  The patient has trialed many standard therapies for major depressive disorder, to no avail.  Thus, the affective illness can be characterized as treatment-resistant depression.  The patient has a genetic test that demonstrates a defective MTHFR gene which suggests L-methylfolate deficiency.  There are several well-designed studies that demonstrate the benefit of L-methylfolate augmentation.  Further, when considering the favorable safety profile, the potential benefits appear to outweigh the risks of treatment.  Finally, the patient is reportedly in remission on the combination of bupropion and L-methylfolate.  Thus, L-methylfolate is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.  \n", "id": "0d16998ac1364f81a2e35f04d6a917fa", "question": "What is the background context in this case summary?", "title": "0d16998ac1364f81a2e35f04d6a917fa", "sufficiency_score": 4}
+{"answers": {"text": ["The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program services from 5/21/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program services from 5/21/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2 given her reported history of physical abuse and poor social skills. In terms of functional status, the records support a score of 2 based on her history of the suspension from school and conflict in the home environment. In terms of comorbidity, the records support a score of 2 due to poor social skills and emotional expression for her chronological age without current medical illness. With regards to level of stress of the recovery environment, the records support a score of 3 due to the death of her ex-boyfriend prior to the start of treatment and her sisters car accident during treatment, as well as her sisters cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3 due to the parent stating that she was giving up on parenting the patient in a family therapy session on 6/05/19. With regards to resiliency and treatment history, the records support a score of 3 due to having been in a residential treatment center for 17 months and continuing to decline in functioning since returning home. In terms of acceptance and engagement of the patient, the records support a score of 3 since the patient refused to speak in groups after 5/21/19. With regards to acceptance and engagement of the parent, the records support a score of 3 due to the parent stating in family therapy that she was done parenting the patient. Therefore, the patient has a composite score of 21. Mental health intensive outpatient program services were and are appropriate in this clinical setting. Thus, mental health intensive outpatient program services from 5/21/19 forward were and are medically necessary for the treatment of this patient.", "id": "9a205d2ffcce4367a27f2f15e184aece", "question": "What is the background context in this case summary?", "title": "9a205d2ffcce4367a27f2f15e184aece", "sufficiency_score": 2}
+{"answers": {"text": ["The patient is a 32-year-old female who presented to her provider on 8/31/21. The records noted \nthat the patient was 66.5 inches tall and weighed 296.6 pounds, with a body mass index (BMI) of \n47.15 kg/m2. The patient has requested authorization and coverage for (1) Mounjaro 7.5 mg, (2) \nOzempic 2 mg, and (3) Rybelsus 7 mg. The Health Insurer has denied this request and reported \nthat the requested medications are not medically necessary for the treatment of this patient."], "answer_start": [10]}, "context": "Summary  \nThe patient is a 32-year-old female who presented to her provider on 8/31/21. The records noted \nthat the patient was 66.5 inches tall and weighed 296.6 pounds, with a body mass index (BMI) of \n47.15 kg/m2. The patient has requested authorization and coverage for (1) Mounjaro 7.5 mg, (2) \nOzempic 2 mg, and (3) Rybelsus 7 mg. The Health Insurer has denied this request and reported \nthat the requested medications are not medically necessary for the treatment of this patient. This \ndenial is the subject of this appeal and determination. The physician reviewer found that the \nsubmitted documentation does not support the medical necessity of the requested medications. \nPrediabetes is defined as an elevated hemoglobin A1C in the range of 5.7% to 6.4%. Some \nindividuals with prediabetes may progress to developing diabetes mellitus. The American Diabetes \nAssociation (ADA) guidelines on the prevention of type 2 diabetes recommend that individuals \nwith prediabetes undergo counseling on lifestyle changes including weight loss and routine \nexercise. The ADA recommends that the only pharmacologic agent to be considered for use for \nprediabetes is metformin for those at high risk for developing diabetes. Obesity is a disease \nassociated with many health risks, including type 2 diabetes mellitus, hypertension, dyslipidemia, \nand coronary heart disease. Weight loss in  patients with obesity or who are overweight is \nassociated with a reduction in mortality. The American Association of Clinical Endocrinologists \nguidelines for the medical care of patients with obesity notes that patients with obesity or who are \noverweight  and  with  dyslipidemia  should  be  considered  for  treatment  with  a  weight-loss \nmedication combined with lifestyle therapy when necessary to achieve sufficient improvements in \nlipids. The guidelines further note that for patients who struggle with weight loss and who would \nreceive health benefit from weight loss, management of medications that are contributing to weight \ngain and the use of approved medications for chronic weight management along with lifestyle \nchanges are appropriate. Medications for weight loss are generally considered an option for \npatients with a BMI over 27 kg/m2 with comorbidities such as diabetes or sleep apnea, or a BMI \nover 30 kg/m2 without comorbidities. There are multiple medications approved by the U.S. Food \nand  Drug Administration  (FDA)  for  the  treatment  of  obesity  including  orlistat,  naltrexone-\nbupropion, lorcaserin, phentermine, phentermine with topiramate, liraglutide and semaglutide. \nWIlding and colleagues note that semaglutide has demonstrated impressive efficacy in weight \nreduction, along with improvement in blood sugars and cholesterol levels. Semaglutide is available \nunder the brand name Wegovy, Ozempic and Rybelsus. The FDA approves the use of Wegovy to \nassist patients with obesity, or who are overweight with weight-related medical problems, to lose \nweight when added to diet and exercise. The FDA approves the use of Ozempic and Rybelsus to \nlower blood sugar levels in adults with type 2 diabetes, in addition to diet and exercise. The FDA \napproves  the  use  of  tirzepatide  (Mounjaro),  a  unique  dual  glucagon-like  peptide-1  (GLP-\n1)/glucagon receptor (GIP) agonist, for the treatment of type 2 diabetes.  In an open-label, parallel-\ngroup, randomized, active-controlled trial examining the benefits on weight loss of tirzepatide \nversuss semaglutide in over 1,800 patients with type 2 diabetes over 40 weeks, Frias and colleagues \nconcluded that reductions in body weight were greater with tirzepatide than with semaglutide. \nWhile concurrent medications for weight loss may be appropriate for patients with a BMI over 27 \nkg/m2 with comorbidities, in this case, the patients most recent BMI is 25.8 kg/m2 and the patient \nreports that her comorbidities of hypertension and hyperlipidemia have resolved. While published \nstudies support the use of Mounjaro, Ozempic, and Rybelsus as effective for weight loss, given \nthe lack of data available on their benefits over FDA approved medications for weight loss in \npatients without diabetes or obesity, the requested medications are not medically indicated.  Therefore, (1) Mounjaro 7.5 mg, (2) Ozempic 2 mg, and (3) Rybelsus 7 mg are not medically \nnecessary for the treatment of this patient. \n ", "id": "4483250c8fdc4ee28ff82addc64c7fa0", "question": "What is the background context in this case summary?", "title": "4483250c8fdc4ee28ff82addc64c7fa0", "sufficiency_score": 2}
+{"answers": {"text": ["A 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition. The physician reviewer found that the DecisionDx-Melanoma test is a clinically validated prognostic tool for patients with stage 1A disease, who are not recommended for sentinel node biopsy. Traditional clinical pathologic assessment for determination of prognosis based on tumor size, and histopathologic features as described in this patients biopsy report, underreport a significant percentage of stage 1 and 2 patients who subsequently present with recurrent disease and metastases with incurable melanoma. The DecisionDx-Melanoma test has been used as a standard method for prognosis assessment, based on multiple publications detailing the test utility in melanoma patients. The DecisionDx-Melanoma test is an independent predictor of risk. In sum, testing (DecisionDx-Melanoma Gene Assay) performed on 7/31/18 was likely to have been more beneficial than other methods of evaluating this patient.\n\n\n", "id": "35c2e56a2b0648e09d68d25adb59b136", "question": "What is the background context in this case summary?", "title": "35c2e56a2b0648e09d68d25adb59b136", "sufficiency_score": 1}
+{"answers": {"text": ["A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition."], "answer_start": [20]}, "context": "Summary Reviewer 2\n\nA 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that bone turnover marker assays measure collagen breakdown products released from osteoclasts and osteoblasts during the process of bone resorption and formation. Measurement of bone turnover markers is complicated by large random within-patient variability, biologic variability (age, gender, body mass index, circadian, and menstrual variation), and poor standardization of most assays. Uncertainties over its clinical use can be in part resolved by adopting international reference standards, which do not exist at this time. Guideline committees typically recommend against routine use of bone turnover markers, due to the limitations of measuring and interpreting bone turnover markers in individual patients. There is a lack of prospective trials to define the most optimal approach for incorporating bone turnover markers into the management of patients with osteoporosis. In sum, collagen crosslinking test (CPT 82523) performed on 9/07/18 was not likely to have been of greater benefit than other methods of evaluating this patient.\n\n\n", "id": "dcd33bd4b66149e5b69d3967a31ae32c", "question": "What is the background context in this case summary?", "title": "dcd33bd4b66149e5b69d3967a31ae32c", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 15-year-old female enrollee has requested reimbursement for mental health inpatient treatment services provided from 8/25/16 through 8/26/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder.", "In records dated 8/25/16, the patients weight was 141.2 pounds and 117.7% of her ideal body weight and she was compliant with her meal plan."], "answer_start": [20, 605]}, "context": "Summary Reviewer \n\n\nThe parent of a 15-year-old female enrollee has requested reimbursement for mental health inpatient treatment services provided from 8/25/16 through 8/26/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder. The physician reviewer found that applying the guidelines from the American Psychiatric Association (APA), the mental health inpatient treatment services provided from 8/25/16 through 8/26/16 were not medically necessary for treatment of this patients eating disorder. In records dated 8/25/16, the patients weight was 141.2 pounds and 117.7% of her ideal body weight and she was compliant with her meal plan. Thus, the patient did not require 24-hour supervision in a highly restricted setting in a mental health treatment environment to manage her anorexia and depression safely and adequately. All told, the mental health inpatient treatment services provided from 8/25/16 through 8/26/16 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.\n\n", "id": "234b17397be54e109cc5293d61d8b12d", "question": "What is the background context in this case summary?", "title": "234b17397be54e109cc5293d61d8b12d", "sufficiency_score": 4}
+{"answers": {"text": ["A 55-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 55-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, AASLD/IDSA treatment guidelines recommend Harvoni for 12 weeks for treatment-naive patients with HCV genotype 1 infection. Therefore, based on national guidelines Harvoni is medically necessary in this clinical setting.For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. \n\n\n\n", "id": "9a50d52804844340b1c7b864e787de94", "question": "What is the background context in this case summary?", "title": "9a50d52804844340b1c7b864e787de94", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that DecisionDx assay is a study of 15-31 genes in an individuals melanoma cells. It has been used to classify the individuals melanoma as having either a high or low risk of metastasis. It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors. However, there are medical studies that show the effectiveness of this assay in the analysis of prognosis for uveal melanoma (Onken, et al (2010); Onken et al (2012)). This assay is also within the guidelines of the American Joint Cancer Commission. Specifically, a class 1 category carries with it a less than 20% chance for metastasis, whereas class 2 has a greater than 70% risk of metastasis. This assay has become a standard in many ocular cancer centers and is no longer considered investigational. Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy. Overall, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was likely to have been more effective than available standard modality for the evaluation of this patient. Based upon the information set forth above, the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned\n\n\n", "id": "dd80983705544209bebea9bb01349ea3", "question": "What is the background context in this case summary?", "title": "dd80983705544209bebea9bb01349ea3", "sufficiency_score": 3}
+{"answers": {"text": ["A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye.", "This patient has", "ocular melanoma."], "answer_start": [19, 479, 512]}, "context": "Summary Reviewer 3\nA 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that the service at issue was likely to be more effective than other methods of evaluating this patient. This patient has a rare disease, ocular melanoma.  However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography scan. Along these lines, there are clinical studies that support the use of gene expression classifier DecisionDX uveal melanoma. This assay defines two classes of ocular melanoma. Class 1 is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years. Currently, there is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the post-operative surveillance of patients with ocular melanoma. As such, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was likely to be superior over other available methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n", "id": "1e802a8b2c044871bec9f45590fdc68c", "question": "What is the background context in this case summary?", "title": "1e802a8b2c044871bec9f45590fdc68c", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 30-year-old male with a history of gynecomastia. Therefore, the patient has requested authorization and coverage for suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.", "On 5/09/20, the provider noted, aThe bilateral breasts demonstrate Simon Grade IIa gynecomastia. There are tender subareolar masses bilaterally measuring approximately 2 cm x 3 cm x 3 cm.a He also reported that the patient adesires surgical excision of gynecomastia in addition to potential suction lipectomy.", "In this case, photographs demonstrate chest enlargement that significantly exceeds the 2 cm x 3 cm x 3 cm size of the glandular tissue, so that the chest enlargement constitutes mixed gynecomastia, with a mixture of both true glandular gynecomastia and fatty tissue constituting pseudogynecomastia."], "answer_start": [19, 768, 1675]}, "context": "Summary Reviewer \n\nThe patient is a 30-year-old male with a history of gynecomastia. Therefore, the patient has requested authorization and coverage for suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the case was previously reviewed, and additional documentation was submitted for reconsideration. Additional medical information received for review included an email from the provider indicating that a surgical facility charges for liposuction for time and supplies, and there would still be a charge even if he charged no professional fee.  On 5/09/20, the provider noted, aThe bilateral breasts demonstrate Simon Grade IIa gynecomastia. There are tender subareolar masses bilaterally measuring approximately 2 cm x 3 cm x 3 cm.a He also reported that the patient adesires surgical excision of gynecomastia in addition to potential suction lipectomy.a The American Society of Plastic Surgeons reports the following gynecomastia scale adapted from the McKinney and Simon, Hoffman and Kohn scales: grade I a small breast enlargement with localized button of tissue that is concentrated around the areola; grade II - moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest; grade III -moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present; grade IV - marked breast enlargement with skin redundancy and feminization of the breast. In this case, photographs demonstrate chest enlargement that significantly exceeds the 2 cm x 3 cm x 3 cm size of the glandular tissue, so that the chest enlargement constitutes mixed gynecomastia, with a mixture of both true glandular gynecomastia and fatty tissue constituting pseudogynecomastia. There is no change in determination that liposuction is an optional surgical technique that can be used during gynecomastia surgery and is not a separate surgical procedure for the patient for treatment of gynecomastia. Liposuction of the chest area well beyond the limited area of the gynecomastia excision can be performed for improved cosmetic appearance, particularly when the gynecomastia is mixed and there is some degree of pseudogynecomastia present. Liposuction for that purpose would be cosmetic and not medically necessary. Thus, suction assisted lipectomy trunk (CPT 15877) is not medically necessary as a separately billed procedure. CPT 19303 is not medically necessary because it applies to a mastectomy in a woman. In sum, suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303) are not medically necessary for the treatment of this patient. The Health Insurer has approved the appropriate CPT code in this case (CPT code 19300).\n", "id": "a7f4b07d1e2945ea87b3710d0f9d1d68", "question": "What is the background context in this case summary?", "title": "a7f4b07d1e2945ea87b3710d0f9d1d68", "sufficiency_score": 4}
+{"answers": {"text": ["A 64-year-old female enrollee has requested authorization and coverage for Harvoni for 24 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus."], "answer_start": [20]}, "context": "Summary Reviewer \n\n\nA 64-year-old female enrollee has requested authorization and coverage for Harvoni for 24 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. In the ION-2 study, 440 HCV patients underwent randomization and were treated, 20% had cirrhosis and 79% had HCV genotype 1a infection. The rates of sustained virologic response were high in all treatment groups. There was a 99% (95% confidence interval (CI), (95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and 99% (95% CI, 95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and ribavirin (Afdhal, et al). The results of an abstract were presented at the American Association for the Study of Liver Diseases Liver Meeting. In this double-blind study, Bourliere and colleagues randomized 155 patients previously unable to achieve SVR after sequential treatment with a peginterferon and ribavirin regimen followed by a protease-inhibitor (PI), peginterferon  and ribavirin regimen, to undergo treatment with ledipasvir/sofosbuvir and ribavirin placebo for 24 weeks or matching placebo for 12 weeks, followed by ledipasvir/sofosbuvir and ribavirin for 12 weeks. Patients were stratified by HCV subtype and their responses to their most recent therapy. Of the 77 patients treated with ledipasvir/sofosbuvir and ribavirin for 12 weeks, 4% experienced relapse; compared with 3% of the 77 patients treated with ledipasvir/sofosbuvir for 24 weeks, for a 3% total incidence of relapse. Based on the peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.\n\n\n", "id": "0f8fc49b70f344618ebaf17b0def3b24", "question": "What is the background context in this case summary?", "title": "0f8fc49b70f344618ebaf17b0def3b24", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a 20-year-old female who has been diagnosed with posttraumatic stress disorder,\nmajor depressive disorder, generalized anxiety disorder, and alcohol use disorder.The\npatient has requested reimbursement for mental health residential treatment provided from 3/22/20\nthrough 5/22/20. The Health Insurer has denied this request and reported that the services at issue\nwere not medically necessary for the treatment of this patient."], "answer_start": [19]}, "context": "Summary Reviewer \n\nThe patient is a 20-year-old female who has been diagnosed with posttraumatic stress disorder,\nmajor depressive disorder, generalized anxiety disorder, and alcohol use disorder.The\npatient has requested reimbursement for mental health residential treatment provided from 3/22/20\nthrough 5/22/20. The Health Insurer has denied this request and reported that the services at issue\nwere not medically necessary for the treatment of this patient.The physician reviewer found the mental health residential\ntreatment provided from 3/22/20 through 5/22/20 was medically necessary for the treatment of this\npatient.", "id": "b2106e1639d74584ac1bb2c40d18c15f", "question": "What is the background context in this case summary?", "title": "b2106e1639d74584ac1bb2c40d18c15f", "sufficiency_score": 3}
+{"answers": {"text": ["A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.", "the patient has already undergone great saphenous vein removal.  The reflux from the incompetent saphenofemoral junctions is now going down the accessory saphenous veins.  These veins are very large, and have free reflux.  They are essentially acting as refluxing greater saphenous veins."], "answer_start": [20, 370]}, "context": "Summary Reviewer 1\n\nA 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient has already undergone great saphenous vein removal.  The reflux from the incompetent saphenofemoral junctions is now going down the accessory saphenous veins.  These veins are very large, and have free reflux.  They are essentially acting as refluxing greater saphenous veins. In the situation where these veins can be ablated, this treatment is standard of care.  All told, the requested ablation of varicose veins, right and left accessory ablation is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n\n", "id": "076e2b7dc21a49ff9b9fcf5332cee2ea", "question": "What is the background context in this case summary?", "title": "076e2b7dc21a49ff9b9fcf5332cee2ea", "sufficiency_score": 4}
+{"answers": {"text": ["A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition."], "answer_start": [19]}, "context": "Summary Reviewer 2\nA 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Patients with anterior accessory saphenous vein reflux and patients with the great saphenous vein reflux demonstrate similar disease-specific features.  Following great saphenous veins ablation, persistent non-refluxing branches do not appear to have an adverse impact on clinical outcome two years after successful ablation of the great saphenous vein.  Although there is limited clinical data to recommend ablation of the non-axial veins, the published data suggest it is effective in selected patients.  There is evidence to support sclerotherapy in the treatment of accessory recurrent varicose veins following ablation.  Thus, ablation of varicose veins, right and left accessory ablation is likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n\n\n\n", "id": "8cf6855cecb2478c9f478de7b62b19ba", "question": "What is the background context in this case summary?", "title": "8cf6855cecb2478c9f478de7b62b19ba", "sufficiency_score": 3}
+{"answers": {"text": ["A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that while endovenous ablation of the greater saphenous vein has been extensively evaluated in the treatment of varicose veins, little is known about the efficacy in the treatment of accessory saphenous veins.  Furthermore, patterns of recurrence of varicose veins after greater saphenous vein treatment is usually new reflux in the accessory saphenous vein and there is little evidence available to guide optimal therapy, in contrast to greater saphenous vein interventions.  Therefore, given the absence of evidence for the efficacy of endovenous ablation of accessory saphenous veins after surgical therapy of greater saphenous vein incompetence, the superior effectiveness of the requested services has not been established.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.", "id": "107931fa26db42a5b7264a7a48131160", "question": "What is the background context in this case summary?", "title": "107931fa26db42a5b7264a7a48131160", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential services provided from 1/10/18 through 4/20/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.", "On 12/29/17, the documentation noted that the patient had purchased knives and a taser gun.", "these records are from admission.", "The patient has demonstrated episodic failure to achieve expected levels of functioning in relationships with family and peers.", "The patient did not have active medical problems or active substance use issues.", "There is no indication of an unsafe home environment.", "The patients family was actively involved in treatment on a regular basis.", "It appears that the patients major depression symptoms were under good control with minimal signs or symptoms. He continued to have oppositional behaviors.", "The patient was able to establish positive relationships with clinicians despite oppositional behaviors.", "The parents worked actively and constructively with clinicians on a regular basis."], "answer_start": [19, 739, 840, 1151, 1342, 1514, 1664, 1819, 2067, 2260]}, "context": "Summary Reviewer \n\nThe parent of a 15-year-old male enrollee has requested reimbursement for mental health residential services provided from 1/10/18 through 4/20/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. On 12/29/17, the documentation noted that the patient had purchased knives and a taser gun. However, these records are from admission. The records for the disputed timeframe indicated evidence of low risk of harm. Additionally, this note had minimal objective evidence. This record does not document that violent acts or self-harm were committed. In terms of functional status, the records support a score of 2. The patient has demonstrated episodic failure to achieve expected levels of functioning in relationships with family and peers. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or active substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. With regards to level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. It appears that the patients major depression symptoms were under good control with minimal signs or symptoms. He continued to have oppositional behaviors. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient was able to establish positive relationships with clinicians despite oppositional behaviors. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential services provided from 1/10/18 through 4/20/18 were not medically necessary for the treatment of this patient.", "id": "3cf2198f3d6146dfaf80de1ac28e8b31", "question": "What is the background context in this case summary?", "title": "3cf2198f3d6146dfaf80de1ac28e8b31", "sufficiency_score": 4}
+{"answers": {"text": ["A 54-year-old female enrollee has requested reimbursement for emergency services provided on 1/26/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.", "the patient presented for removal of scalp sutures due to a laceration nine days prior to her visit. She admitted to a lingering hangover feeling, but had no specific complaints of headache, vomiting, dizziness, blurry vision, or other symptoms of acute head injury. She denied any symptoms of wound infection.", "the patient was not experiencing the sudden onset of acute symptoms."], "answer_start": [20, 1049, 1370]}, "context": "Summary Reviewer \n\n\nA 54-year-old female enrollee has requested reimbursement for emergency services provided on 1/26/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented for removal of scalp sutures due to a laceration nine days prior to her visit. She admitted to a lingering hangover feeling, but had no specific complaints of headache, vomiting, dizziness, blurry vision, or other symptoms of acute head injury. She denied any symptoms of wound infection. Moreover, the patient was not experiencing the sudden onset of acute symptoms. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/26/16 did not meet prudent layperson criteria for emergency care.\n\n\n", "id": "ff8f18f48a534d46aa7895e8ed1b788c", "question": "What is the background context in this case summary?", "title": "ff8f18f48a534d46aa7895e8ed1b788c", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 57-year-old female with severe osteoporosis. As part of the work-up her endocrinologist ordered a parathyroid scan to rule out a parathyroid adenoma. The patient has requested authorization and coverage for parathyroid planar imaging. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary.", "The laboratory tests performed on 10/26/17 show normal calcium, mid-normal intact PTH level at 36 and normal ionized calcium and phosphorus. The patients 25 vitamin D and 1, 5 vitamin D levels are normal, and urinary calcium is normal. In January 2018, the patient had two normal calcium levels and intact PTH.", "this patient has severe osteoporosis"], "answer_start": [18, 1646, 438]}, "context": "Summary Reviewer\n\nThe patient is a 57-year-old female with severe osteoporosis. As part of the work-up her endocrinologist ordered a parathyroid scan to rule out a parathyroid adenoma. The patient has requested authorization and coverage for parathyroid planar imaging. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary. The records provided for review indicate that this patient has severe osteoporosis and further evaluation for a parathyroid adenoma (primary hyperparathyroidism) is appropriate. However, the medical literature suggests that the diagnosis should be made with biochemical markers showing the combination of hypercalcemia and an elevated or inappropriately normal parathyroid hormone (PTH) level. Measured total serum calcium should be adjusted for albumin. If the corrected serum calcium is normal and PTH is elevated, serum ionized calcium should be measured, as primary hyperparathyroidism can present with an elevated ionized calcium despite a normal albumin-adjusted serum calcium (Khan, et al). The standards of care also indicate that parathyroid scan is appropriate when a decision to remove a parathyroid adenoma has been made (Khan, et al; Bilezikian, et al; Pallan, et al). Overall, parathyroid imaging is not a diagnostic procedure and is not advised unless surgical intervention is planned. The value of imaging rests with accurate identification of abnormal parathyroid tissue in order to assist in planning the appropriate parathyroid surgery (Khan, et al). In this case the diagnosis of primary hyperparathyroidism has not been established. The laboratory tests performed on 10/26/17 show normal calcium, mid-normal intact PTH level at 36 and normal ionized calcium and phosphorus. The patients 25 vitamin D and 1, 5 vitamin D levels are normal, and urinary calcium is normal. In January 2018, the patient had two normal calcium levels and intact PTH. As the patient does not have biochemical evidence of primary hyperparathyroidism, the requested parathyroid planar imaging is not medically necessary for evaluation of this patients medical condition.  Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.\n\n", "id": "f424b2fdcac04cd191ad272fd2c245f1", "question": "What is the background context in this case summary?", "title": "f424b2fdcac04cd191ad272fd2c245f1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a 59-year-old male who presented with hematochezia in August 2021. The patient \nhas requested authorization and coverage for PET imaging with concurrent CT skull base to mid-\nthigh.", "The original disease showed \nsignificant FDG uptake. There were multiple sites of disease making the interpretation of follow-\nup imaging very complex."], "answer_start": [19, 955]}, "context": "Summary Reviewer  \nThe patient is a 59-year-old male who presented with hematochezia in August 2021. The patient \nhas requested authorization and coverage for PET imaging with concurrent CT skull base to mid-\nthigh. The physician reviewer found that there is sufficient support for the requested services in \nthis clinical setting. According to the National Comprehensive Cancer Network (NCCN) guidelines, \nPET/CT has a limited sensitivity but high specificity, and may be considered when there is an \nequivocal finding. When hepatocellular carcinoma is detected by CT or magnetic resonance \nimaging (MRI) and has increased metabolic activity on PET/CT, higher intralesional standardized \nuptake value (SUV) is a marker of biologic aggressiveness and might predict less optimal response \nto  locoregional  therapies.  Sensitivity  is  a  metric  for  the  screening  of  cancer,  but  for \ndiscriminating responses, the specificity may be most relevant.  The original disease showed \nsignificant FDG uptake. There were multiple sites of disease making the interpretation of follow-\nup imaging very complex. The use PET/CT is medically necessary for further care. Therefore, the \nrequested PET imaging with concurrent CT skull base to mid-thigh is medically necessary for the \nevaluation of this patient. \n ", "id": "c35881a384b14abd9fad94c18ed67fd6", "question": "What is the background context in this case summary?", "title": "c35881a384b14abd9fad94c18ed67fd6", "sufficiency_score": 4}
+{"answers": {"text": ["A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes."], "answer_start": [20]}, "context": "Summary Reviewer 1\n\nA 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found there is a lack of support in the medical literature for the services at issue in this clinical setting. The medical literature indicates that Epstein-Barr virus (EBV) is the main etiology of infectious mononucleosis syndrome associated with lymphadenopathy. The main methods of evaluation include PCR testing and testing by ELISA for the viral capsid antigen. Quantitative PCR testing may be indicated for the following EBV evaluations: EBV viral load, to monitor for EBV viral replication in hematopoietic stem cell and solid organ transplant recipients. More frequent testing is worth considering if the EBV load is rising. However, for standard risk individuals, as this patient, testing should be done only when they are suspected to have EBV infection. The submitted documentation does not support that this patient had a medical indication to have warranted the PCR testing. Accordingly, PCR testing provided on 5/30/17 was not likely to have been of greater benefit than the standard therapy available for evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n", "id": "c47dbbf2cdfb4164ba35101f68240355", "question": "What is the background context in this case summary?", "title": "c47dbbf2cdfb4164ba35101f68240355", "sufficiency_score": 3}
+{"answers": {"text": ["A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes.", "the patient has had a history of enlarged lymph nodes of unknown etiology. She has had a biopsy and blood tests, which were all negative. She had a PCR test Epstein-Barr virus and other organisms.", "The test results for this patient were normal but she continued to have large lymph nodes."], "answer_start": [20, 364, 668]}, "context": "Summary Reviewer 2\n\nA 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the patient has had a history of enlarged lymph nodes of unknown etiology. She has had a biopsy and blood tests, which were all negative. She had a PCR test Epstein-Barr virus and other organisms. The common testing performed for lymphadenopathy can generally determine the cause of the lymphadenopathy. The test results for this patient were normal but she continued to have large lymph nodes. A PCR test to detect the cause of the lymphadenopathy is within the standard of care to evaluate uncommon etiologies of large lymph nodes such as in this patients case when all standard first step work up have been negative. As such, PCR testing provided on 5/30/17 was likely to have been more effective than the available standard techniques for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.\n\n\n", "id": "aacccc3964224d5cab8d9b9eac07eaf5", "question": "What is the background context in this case summary?", "title": "aacccc3964224d5cab8d9b9eac07eaf5", "sufficiency_score": 4}
+{"answers": {"text": ["A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes.", "this patient", "presented with lymphadenopathy of unknown origin"], "answer_start": [20, 2058, 2075]}, "context": "Summary Reviewer 3\n\nA 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the Epstein-Barr virus is the main etiology of infectious mononucleosis (IM) syndrome that is characterized by fever, sore throat, and lymph adenopathy. Since this virus could be associated with a number of malignancies, some hematologic disorders, and chronic fatigue syndrome, identification of IM is of importance.  The majority of the human adult population is infected with EBV. Usually the infection is well tolerated without any further symptoms after primary infection. In some patients with infectious mononucleosis, or in some who had an infection in their past, it may be important to diagnose symptomatic disease or differentiate infectious mononucleosis from other conditions. In these cases, serological methods, i.e., immunofluorescence, ELISA, or Western blot, are the methods of choice to come to an unequivocal diagnostic conclusion, while the detection and quantification of viral DNA through PCR plays a minor role. ELISA could be applied as a first and preliminary diagnostic test for IM. In addition, this test could be applied in various phases of the disease with a higher sensitivity comparing to PCR. In individuals where EBV infection is associated or causally linked with autoimmune or malignant disease or in patients who have been bone marrow or solid organ transplanted, or in patients with severe immune-suppression, prolonged EBV primary infection or EBV reactivation from latency may be a serious and life-threatening complication. As such, determining the serostatus correctly is important for these patients. However, in this patients case, there was no documentation that this patient had immunosuppression or that she was a transplant patient. In sum, for this patient who presented with lymphadenopathy of unknown origin, PCR testing provided on 5/30/17, was not likely to have been superior over other standard methods of evaluating her medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "d7f4b4a08b784da4b88a7f8f376548aa", "question": "What is the background context in this case summary?", "title": "d7f4b4a08b784da4b88a7f8f376548aa", "sufficiency_score": 3}
+{"answers": {"text": ["The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.", "In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission."], "answer_start": [22, 1012]}, "context": "Summary Reviewer \n\n\n\n\nThe parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the records for the medical necessity of the services at issue in this clinical setting.  Evidence-based assessments are indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The medical literature states that children should be treated in the setting that is least restrictive and disruptive to their lives. More restrictive facilities, like inpatient or residential treatment, are indicated in emergencies or when patients are not responding to efforts at outpatient treatment. In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible to maintain and foster natural supports. This patient did not appear to have adequate treatment progress, and it would not have been safe to treat the patient in a less restrictive setting. The RTC was likely the least restrictive safe setting for this patient after having failed the PHP. Therefore, the mental health residential treatment center services from 11/17/16 through 12/10/16 were medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.", "id": "e8b8caacc7154798a763d9cf84c956e4", "question": "What is the background context in this case summary?", "title": "e8b8caacc7154798a763d9cf84c956e4", "sufficiency_score": 4}
+{"answers": {"text": ["A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis."], "answer_start": [21]}, "context": "Summary Reviewer 1\n\n\nA 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  There is a lack of prospective controlled data to support random measurement of Remicade/Remicade antibody levels.  The concept of targeted drug level monitoring is supported for several classes of drugs.  However, evidence is lacking for biologic agents in the treatment of this patients condition.  There are multiple variables which drug level monitoring does not consider, thus making this line of testing suboptimal.  For example, the optimal trough level of Remicade remains unknown and likely varies from individual to individual based on unique pharmacokinetics.  Additionally, tissue levels of drug also play an important role.  Therefore, Anser IFX testing performed on 8/17/15 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n", "id": "5e5a561775b84413ad42160554ff04cf", "question": "What is the background context in this case summary?", "title": "5e5a561775b84413ad42160554ff04cf", "sufficiency_score": 3}
+{"answers": {"text": ["A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis."], "answer_start": [21]}, "context": "Summary Reviewer 2\n\n\nA 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told, Anser IFX testing performed on 8/17/15 was not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n", "id": "f4569b99d4f1402c840152d26637c354", "question": "What is the background context in this case summary?", "title": "f4569b99d4f1402c840152d26637c354", "sufficiency_score": 3}
+{"answers": {"text": ["A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis."], "answer_start": [21]}, "context": "Summary Reviewer 3\n\n\nA 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the management of ulcerative colitis using Anser IFX testing has not been standardized, and standardized recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed. The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Per the clinical literature, Anser IFX testing performed on 8/17/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.\n\n\n\n\n", "id": "37e5f0c0eb10454db497e5623c0170b8", "question": "What is the background context in this case summary?", "title": "37e5f0c0eb10454db497e5623c0170b8", "sufficiency_score": 3}
+{"answers": {"text": ["This case involves patient who presented to the Emergency Department with a clogged percutaneous endoscopic gastrostomy (PEG) tube. The patient was admitted for PEG tube malfunction and had an Interventional Radiology (IR) evaluation.  The patient underwent a removal of the blockage in IR.  The patient was then discharged.", "Diagnosis: Clogged feeding tube", "Treatment: Inpatient admission, interventional procedure", "The insurer denied the admission."], "answer_start": [150, 0, 34, 92]}, "context": "Diagnosis: Clogged feeding tube\n \nTreatment: Inpatient admission, interventional procedure\n\nThe insurer denied the admission. The denial was upheld.\n\nThis case involves patient who presented to the Emergency Department with a clogged percutaneous endoscopic gastrostomy (PEG) tube. The patient was admitted for PEG tube malfunction and had an Interventional Radiology (IR) evaluation.  The patient underwent a removal of the blockage in IR.  The patient was then discharged.\n\nThe records failed to support that the patient was unstable or had findings to support the need for inpatient admission. The patient could have undergone the procedure as an outpatient or been placed on observation status.", "id": "ad2ed3b700554db6b23fc41b7c21fd44", "question": "What is the background context in this case summary?", "title": "ad2ed3b700554db6b23fc41b7c21fd44", "sufficiency_score": 4}
+{"answers": {"text": ["This patient is a male who presented with abdominal pain, nausea, and vomiting. He had a blood pressure of 152/103 and a pulse of 109. There was no abdominal rebound or guarding. The white blood count (WBC) was 17.6. The lactate level was 4.4. The patient was reassessed and at that time, the abdominal pain had decreased and the lactate level was normal at 1.2. A CT scan was negative for acute disease. It was felt the patient had cannabis-induced vomiting. The WBC count came down to 12.1. The patient was also found to have poorly controlled diabetes and a hemoglobin A1C of 10. He signed out against medical advice.", "Diagnosis: Lactic acidosis", "Treatment: inpatient hospital admission", "The insurer denied inpatient hospital admission.", "He had hypertension and tachycardia on admission but they improved. The lactic acidosis resolved with intravenous (IV) hydration. He was hemodynamically stable. The diabetes was poorly controlled", "This patient had vomiting and lactic acidosis that was attributed to cannabis-induced vomiting. He responded rapidly to IV hydration and the lactic acidosis resolved. The leukocytosis was much improved."], "answer_start": [143, 0, 29, 70, 1055, 1304]}, "context": "Diagnosis: Lactic acidosis\n \nTreatment: inpatient hospital admission\n\nThe insurer denied inpatient hospital admission. The denial was upheld.\n\nThis patient is a male who presented with abdominal pain, nausea, and vomiting. He had a blood pressure of 152/103 and a pulse of 109. There was no abdominal rebound or guarding. The white blood count (WBC) was 17.6. The lactate level was 4.4. The patient was reassessed and at that time, the abdominal pain had decreased and the lactate level was normal at 1.2. A CT scan was negative for acute disease. It was felt the patient had cannabis-induced vomiting. The WBC count came down to 12.1. The patient was also found to have poorly controlled diabetes and a hemoglobin A1C of 10. He signed out against medical advice.\n\nAccording to Milliman Care Guidelines (MCG), clinical indications for admission for vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, severe electrolyte abnormalities, high fevers and acute renal failure. The patient did not have these conditions. He had hypertension and tachycardia on admission but they improved. The lactic acidosis resolved with intravenous (IV) hydration. He was hemodynamically stable. The diabetes was poorly controlled but the patient did not have diabetic ketoacidosis.\n\nThis patient had vomiting and lactic acidosis that was attributed to cannabis-induced vomiting. He responded rapidly to IV hydration and the lactic acidosis resolved. The leukocytosis was much improved. IV hydration, Reglan, and Pepcid could have been given with observation status. The patient responded well to the ER treatment. If antibiotics were felt to be needed, they could have been continued orally as an outpatient. He did not meet MCG guidelines for admission for vomiting. The healthcare plan acted reasonably and with sound medical judgment. Inpatient hospital services were not medically necessary.\n\nBased on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.\n", "id": "4c2223def6074457aeb07b2538eb2937", "question": "What is the background context in this case summary?", "title": "4c2223def6074457aeb07b2538eb2937", "sufficiency_score": 4}
+{"answers": {"text": ["The patient failed 1% testosterone gel and Fortesta.  He has benefited from the requested formulation.", "Diagnosis:  Testicular hypofunction", "Treatment:  Formulary exception for testosterone gel", "The patient is a male diagnosed with Hypogonadism.  This request is for Testosterone gel.  As reported, he used testosterone 1 % in the past and had treatment failure.  He had Pituitary adenoma s/p (status post) resection in the past.  In past he has blurry vision and headache diagnosed with Tolosa Hunt syndrome.  He completed testosterone XRT.  The formulary alternatives include testosterone transdermal gel 10 mg per actuation 2% and testosterone cypionate and testosterone enanthate.  He also tried Fortesta transdermal gel 10 mg per actuation.  He benefited from the requested formulation testosterone 1% 50mg/5g.", "The patient's testosterone was 141 (264-916, median 590); free testosterone was 6.4 (6.6-18.1, median 12.35).", "Previously the patient's testosterone was 232 (264-916, median 590); Estradiol was 34.6.", "Previous to the above, the patient's testosterone was 444.33 (300-1080, median 690); PSA (prostate specific antigen) was 1.74 (0-4).", "Previous to that the patient's testosterone was 211.74 (300-1080, median 690); SHBG (Sex Hormone Binding Globulin) was 27; LH (luteinizing hormone) was <0.50; IGF1 (insulin-like growth factor 1) was 125; GH (growth hormone) was 0.08; FSH (follicle stimulating hormone) was 0.6; ACTH (adrenocorticotropic hormone) was 113; Free testosterone was 5.1 (4-29 median 16); testosterone Bioavailable was 96 (77-367, median 222) .", "This patient has two documented low testosterone levels, with non-elevated LH levels in the setting of a history of pituitary surgery."], "answer_start": [3335, 0, 36, 165, 787, 898, 989, 1123, 3123]}, "context": "Diagnosis:  Testicular hypofunction\nTreatment:  Formulary exception for testosterone gel\nThe health plan should cover the Formulary exception for Testosterone gel.\n\nThe patient is a male diagnosed with Hypogonadism.  This request is for Testosterone gel.  As reported, he used testosterone 1 % in the past and had treatment failure.  He had Pituitary adenoma s/p (status post) resection in the past.  In past he has blurry vision and headache diagnosed with Tolosa Hunt syndrome.  He completed testosterone XRT.  The formulary alternatives include testosterone transdermal gel 10 mg per actuation 2% and testosterone cypionate and testosterone enanthate.  He also tried Fortesta transdermal gel 10 mg per actuation.  He benefited from the requested formulation testosterone 1% 50mg/5g.\n\nThe patient's testosterone was 141 (264-916, median 590); free testosterone was 6.4 (6.6-18.1, median 12.35).\n\nPreviously the patient's testosterone was 232 (264-916, median 590); Estradiol was 34.6. \n\nPrevious to the above, the patient's testosterone was 444.33 (300-1080, median 690); PSA (prostate specific antigen) was 1.74 (0-4).\n\nPrevious to that the patient's testosterone was 211.74 (300-1080, median 690); SHBG (Sex Hormone Binding Globulin) was 27; LH (luteinizing hormone) was <0.50; IGF1 (insulin-like growth factor 1) was 125; GH (growth hormone) was 0.08; FSH (follicle stimulating hormone) was 0.6; ACTH (adrenocorticotropic hormone) was 113; Free testosterone was 5.1 (4-29 median 16); testosterone Bioavailable was 96 (77-367, median 222) .\n\nThe American association of clinical endocrinologists and the Endocrine society recommendations require documentation of two low morning testosterone or free testosterone levels (1, 2).  The diagnosis of hypogonadotropic or primary hypogonadism is made with a low testosterone, or free testosterone (2, 3).  The causes of acquired hypogonadotropic hypogonadism are the following:  1)  structural (tumors, infiltrative lesions, infarction, head trauma), and 2)  functional (hyperprolactinemia, hypercortisolism, obesity, chronic systemic disease) (4). \nSince the majority of causes involve abnormalities of the pituitary or hypothalamus, an MRI is indicated to rule out structural lesions in these patients (3).  MRI is indicated in this group of patients when they are <50 for all patients with a low testosterone and a normal LH or an elevated prolactin (5-8).  In older men, an MRI is indicated when there is a very low testosterone <150ng/dl and a normal LH or an elevated prolactin or with visual changes or headaches.  Obesity is a known cause of hypogonadotropic hypogonadism (5).  The diagnosis of hypogonadism is made using a low testosterone and an elevated LH and FSH (primary) or low or normal LH (secondary). \n\nThe endocrine society criteria recommend adjusting testosterone dosing to keep the testosterone level in the middle of the normal range. \n\n\"We suggest aiming at achieving serum testosterone levels during treatment in the mid-normal range.\" \n\nThe endocrine society criteria also recommend that testosterone be adjusted with the patient symptoms in mind.\n\nThis patient has two documented low testosterone levels, with non-elevated LH levels in the setting of a history of pituitary surgery.  Based on this, he meets accepted criteria for treatment with testosterone.\n\nThe patient failed 1% testosterone gel and Fortesta.  He has benefited from the requested formulation.  Given the fact that the patient already failed two forms of testosterone gel, and the fact that he benefited from the requested formulation, the health plan should cover the requested treatment.\n\n", "id": "6c737c79e2fd46b89f73efa0db11a02d", "question": "What is the background context in this case summary?", "title": "6c737c79e2fd46b89f73efa0db11a02d", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female patient who was seen as an outpatient in her Cardiologist's office in spring of 2019. Two weeks prior to this, she had symptoms consistent with a transient ischemic attack/cerebrovascular accident (TIA)/CVA).  She was admitted to a hospital for a CVA workup, which was negative. The office notes stated that a carotid duplex showed no evidence of carotid artery stenosis.  A venous duplex revealed no evidence of deep vein thrombosis (DVT) and an EKG revealed no evidence of arrhythmia.   Medication history revealed that she was taking atorvastatin 40 mg daily and discontinued it due to leg cramps; she was subsequently started Livalo 2 milligrams daily. Further review of the patient's medications indicated that she discontinued taking Crestor 5 mg daily and Lipitor 40 mg daily due to leg cramps. The conclusion was that there was no hemodynamically significant stenosis of the bilateral lower extremities.", "Diagnosis: Transient ischemic attack/cerebrovascular accident (TIA)/CVA)", "Treatment: Livalo 2 milligrams OR tablets", "The insurer denied Livalo 2 milligrams OR tablets."], "answer_start": [193, 0, 74, 117]}, "context": "Diagnosis: Transient ischemic attack/cerebrovascular accident (TIA)/CVA)\n\nTreatment: Livalo 2 milligrams OR tablets\n\nThe insurer denied Livalo 2 milligrams OR tablets. The denial was upheld. \n\nThis is a female patient who was seen as an outpatient in her Cardiologist's office in spring of 2019. Two weeks prior to this, she had symptoms consistent with a transient ischemic attack/cerebrovascular accident (TIA)/CVA).  She was admitted to a hospital for a CVA workup, which was negative. The office notes stated that a carotid duplex showed no evidence of carotid artery stenosis.  A venous duplex revealed no evidence of deep vein thrombosis (DVT) and an EKG revealed no evidence of arrhythmia.   Medication history revealed that she was taking atorvastatin 40 mg daily and discontinued it due to leg cramps; she was subsequently started Livalo 2 milligrams daily. Further review of the patient's medications indicated that she discontinued taking Crestor 5 mg daily and Lipitor 40 mg daily due to leg cramps. The conclusion was that there was no hemodynamically significant stenosis of the bilateral lower extremities. \n\nAll FDA-approved statins have been shown to reduce cardiovascular risk; the magnitude of the reduction is related to the magnitude of LDL-C lowering.  Atorvastatin and rosuvastatin at their highest approved doses are the most effective in lowering LDL-C levels and their beneficial effects on clinical outcomes are well-documented.  All of the statins except pitavastatin and pitavastatin magnesium are available generically.  Dosage adjustments are not required with atorvastatin or fluvastatin in patients with severe renal impairment.  Pravastatin, rosuvastatin, and pitavastatin are not metabolized by CYP isozymes and are less likely to interact with other drugs.\n\nOral pitavastatin (Livalo) is a competitive HMG-CoA reductase for the reduction of elevated total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia. Pitavastatin is an effective treatment option in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia, including those at risk of developing type 2 diabetes.\n\nThe carrier's denial of coverage for Livalo 2 milligrams OR tablets is upheld.  The medical necessity is not substantiated.\n", "id": "f8949bb0990b462faeb09840b0f7e5bb", "question": "What is the background context in this case summary?", "title": "f8949bb0990b462faeb09840b0f7e5bb", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.", "The patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.", "The patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra."], "answer_start": [0, 295, 861]}, "context": "The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.\n\nThe patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.\n\nThe patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra.\n\nThe health plan's determination is upheld.\n\nNo, the requested health service/treatment of inpatient substance abuse treatment  is not medically necessary for this patient.\n\nThe proposed treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's alcohol use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.", "id": "954365cfe8b64a86b57391c707f70524", "question": "What is the background context in this case summary?", "title": "954365cfe8b64a86b57391c707f70524", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who was admitted following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient was found in a park and brought to the emergency department; he had eloped and then returned indicating that he had drank all the alcohol he could find with a blood alcohol level of 196. He had laboratory abnormalities that included electrolyte and fluid imbalance and anemia and elevated liver function testing.", "The patient reported drinking one pint or more of vodka daily. He presented with moderately severe alcohol withdrawal at the time of admission  including tremor, fatigue, nausea, sweats, headache, irritability, restlessness and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13 despite having alcohol in his blood. The patient had relapsed after his last detoxification treatment which was one of four previous detoxifications with no past treatment with rehabilitation services and no involvement in recovery groups. He gave no history of withdrawal seizures or past episodes of delirium tremens. He denied use of illicit or prescription drugs, but has a history of cocaine dependence and is tobacco dependent at one-half pack per day."], "answer_start": [0, 500]}, "context": "This is a patient who was admitted following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient was found in a park and brought to the emergency department; he had eloped and then returned indicating that he had drank all the alcohol he could find with a blood alcohol level of 196. He had laboratory abnormalities that included electrolyte and fluid imbalance and anemia and elevated liver function testing.\nThe patient reported drinking one pint or more of vodka daily. He presented with moderately severe alcohol withdrawal at the time of admission  including tremor, fatigue, nausea, sweats, headache, irritability, restlessness and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13 despite having alcohol in his blood. The patient had relapsed after his last detoxification treatment which was one of four previous detoxifications with no past treatment with rehabilitation services and no involvement in recovery groups. He gave no history of withdrawal seizures or past episodes of delirium tremens. He denied use of illicit or prescription drugs, but has a history of cocaine dependence and is tobacco dependent at one-half pack per day.\nThe health plan's determination is overturned.\nThe proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms and general medical conditions associated with laboratory abnormalities and high risk for withdrawal complications such as seizures. Withdraw symptoms were managed with an Ativan protocol requiring monitoring, as well as comfort medications and vitamin replacement therapy, and continuation of medications to manage his general medical illnesses. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.", "id": "bc40ac3a8aa04659ae4130f61592a109", "question": "What is the background context in this case summary?", "title": "bc40ac3a8aa04659ae4130f61592a109", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female to male transgender who is requesting coverage of gender confirming mastectomies with free nipple grafting. He began hormone therapy in 2018. On physical examination there are grade 2 ptotic breasts. Coverage was denied for failure to meet age requirement of the coverage criteria.", "he has lived as a male and been on hormone therapy for over a year"], "answer_start": [0, 1801]}, "context": "The patient is a female to male transgender who is requesting coverage of gender confirming mastectomies with free nipple grafting. He began hormone therapy in 2018. On physical examination there are grade 2 ptotic breasts. Coverage was denied for failure to meet age requirement of the coverage criteria.\n\nThe health plan's determination is overturned.\n\nYes, the bilateral mastectomy and nipple reconstruction are medically necessary for this patient.\n\nThe World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. One of the main functions of WPATH is to promote the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. The SOC are based on the best available science and expert professional consensus. The most recent standards published in 2011 are version 7 and are the current standards of care applied by physicians and surgeons worldwide. Prior to any treatment the criteria requirements are diagnostic and real life experience.\nTheir Criteria for mastectomy and creation of a male chest in female to male (FtM) patients are:\n1) Persistent, well-documented gender dysphoria;\n2) Capacity to make a fully informed decision and to consent for treatment;\n3) Age of majority in a given country, (earlier preferably after ample time of living in the desired gender role and after one year of testosterone treatment).;\n4) If significant medical or mental health concerns are present, they must be reasonably well controlled.\nIn this case their criteria have been met because he has lived as a male and been on hormone therapy for over a year, there are no other significant medical or mental health concerns, and the gender dysphoria is well documented and persistent.", "id": "7c3145262c8f4e1c859cfd50182e72bf", "question": "What is the background context in this case summary?", "title": "7c3145262c8f4e1c859cfd50182e72bf", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with metastatic lung cancer who presented to the Emergency Department with a primary complaint of chest pain, with associated cough and vomiting. She is currently receiving chemotherapy and has a history of mycobacterium avium-intracellulare (MAI) infection as well. Workup in the emergency room (ER) showed abnormal chest imaging as well as new electrocardiogram (EKG) changes. Vital signs and physical examination were non-diagnostic. She was admitted for \"chest pain likely as a consequence of cough secondary to irritation from lung cancer\" with a plan for serial troponin measurement and pain control.", "Following admission, her troponins were negative. Oncology and Interventional Radiology were consulted, and she underwent a therapeutic thoracentesis. On the day after admission, she was discharged home with a plan for follow-up with her oncologist."], "answer_start": [0, 631]}, "context": "The patient is a female with metastatic lung cancer who presented to the Emergency Department with a primary complaint of chest pain, with associated cough and vomiting. She is currently receiving chemotherapy and has a history of mycobacterium avium-intracellulare (MAI) infection as well. Workup in the emergency room (ER) showed abnormal chest imaging as well as new electrocardiogram (EKG) changes. Vital signs and physical examination were non-diagnostic. She was admitted for \"chest pain likely as a consequence of cough secondary to irritation from lung cancer\" with a plan for serial troponin measurement and pain control.\nFollowing admission, her troponins were negative. Oncology and Interventional Radiology were consulted, and she underwent a therapeutic thoracentesis. On the day after admission, she was discharged home with a plan for follow-up with her oncologist.\n\nThe health plan's determination of medical necessity is upheld.\n\nNo, the requested health service of inpatient stay was not medically necessary.\nThis admission does not meet criteria for inpatient acute medical admission based upon the standard Milliman Care Guidelines (MCG) guidelines for chest pain, which was both the chief complaint in the ER and the principal diagnosis by the admitting and discharging doctor. The hospital argued that there was concern the signs and symptoms may develop into a serious medical condition. Unfortunately, that is not backed up in any way by the medical documentation from the doctors involved in her care.\nIn fact, the actual documented assessment and plan of her condition was lacking and does not demonstrate that concern. In fact, it suggests that his belief was that her lung cancer was the cause of her chest pain (but there was no plan to address that). There was no explanation for the EKG abnormalities or how it potentially could represent something serious like acute coronary syndrome, nor does it have a treatment strategy for a serious condition. There were no high risk features of life-threatening acute disease, such as significantly abnormal vital signs or elevated troponin, and pretest probability for a condition requiring cardiac intervention was low (Penumetsa 2012). Her HEART score was only 2, which suggests a very low risk of major cardiac events (Backus 2013). Without supportive documentation, an inpatient stay was not medically necessary, and could have been managed at a lower level of care status, which is appropriate for most chest pain patients even if there is adequate documentation of concerning features.", "id": "6c22fbd464994c7ab402125545a4c373", "question": "What is the background context in this case summary?", "title": "6c22fbd464994c7ab402125545a4c373", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who presented with a request for detoxification services.  The patient reported that he was using alcohol on a continuous daily basis together with the use of crack cocaine and Xanax.  He has a history of bipolar mood disorder and posttraumatic stress disorder with associated symptoms of anxiety.  He was taking Seroquel and Lexapro to address the mood, trauma and anxiety disorders.  He had received multiple past substance use disorder treatments including three recent detoxification treatment episodes.  He had also received multiple other detoxification treatments in the year prior to his presentation without significant follow up for aftercare or use of medication assisted treatment.", "The patient", "had a history of lower back pain and neuropathy.  He was tobacco dependent."], "answer_start": [0, 712, 878]}, "context": "This is a patient who presented with a request for detoxification services.  The patient reported that he was using alcohol on a continuous daily basis together with the use of crack cocaine and Xanax.  He has a history of bipolar mood disorder and posttraumatic stress disorder with associated symptoms of anxiety.  He was taking Seroquel and Lexapro to address the mood, trauma and anxiety disorders.  He had received multiple past substance use disorder treatments including three recent detoxification treatment episodes.  He had also received multiple other detoxification treatments in the year prior to his presentation without significant follow up for aftercare or use of medication assisted treatment.\nThe patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms.  He had no acute general medical problems; he had a history of lower back pain and neuropathy.  He was tobacco dependent.\nThe health plan's determination is upheld.\nThe treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring.  The patient displayed no serious disturbance of mental status, despite having a history of ongoing substance use disorder with alcohol and use of crack cocaine and Xanax.  Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment.  There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently.", "id": "9135b1e20c9f4da0841520b76cd225f2", "question": "What is the background context in this case summary?", "title": "9135b1e20c9f4da0841520b76cd225f2", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented to the emergency department (ED) just before midnight with the complaint of coughing and breathing fast for two days. The patient has a history of asthma and did not improve following albuterol. The patient also also began vomiting. The Vital Signs on ED arrival were a temperature of 99.0F, heart rate (HR) 142, respiratory rate (RR) 48, blood pressure (BP) 114/76, and pulse oximetry 90%. The patient was started on supplemental oxygen and given nebulizer treatments and oral steroid", "Patient was admitted with a diagnosis of status asthmaticus. After admission placed on albuterol every 2 hours, oxygen, and continued on PO steroid. Patient was also suspected to have a left lower lobe pneumonia and was started on intravenous (IV) ampicillin for this. Patient had initially a poor clinical response to treatment and was then given IV magnesium sulfate x1."], "answer_start": [0, 508]}, "context": "The patient presented to the emergency department (ED) just before midnight with the complaint of coughing and breathing fast for two days. The patient has a history of asthma and did not improve following albuterol. The patient also also began vomiting. The Vital Signs on ED arrival were a temperature of 99.0F, heart rate (HR) 142, respiratory rate (RR) 48, blood pressure (BP) 114/76, and pulse oximetry 90%. The patient was started on supplemental oxygen and given nebulizer treatments and oral steroid\nPatient was admitted with a diagnosis of status asthmaticus. After admission placed on albuterol every 2 hours, oxygen, and continued on PO steroid. Patient was also suspected to have a left lower lobe pneumonia and was started on intravenous (IV) ampicillin for this. Patient had initially a poor clinical response to treatment and was then given IV magnesium sulfate x1. The health plan determination is overturned in whole. The inpatient stay was medically necessary. This patient had respiratory distress as indicted by tachypnea and significant retractions and decreased oxygen saturations. Patient had vomiting secondary to increased work of breathing. The severity of his symptoms and poor response to initial treatment warranted inpatient medical care. ", "id": "1cfac6010f9a4f76bd4782e8a29947bc", "question": "What is the background context in this case summary?", "title": "1cfac6010f9a4f76bd4782e8a29947bc", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Ascending lymphangitis", "Treatment: Inpatient admission", "The insurer denied coverage for inpatient admission.", "This patient is a female child with a history of intermittent asthma and allergy to peanut butter who presented to the Emergency Department (ED) with the chief complaint of left arm redness and pruritus. The parent clearly gave the history of this beginning as a small white dot on the dorsum of her finger (2nd metacarpophalangeal joint), which she thought was a bug bite, and reported that by the next morning she woke up with erythema and local itchiness. There was no pain or fever by history.", "In the ED she had no fever and her vital signs were stable. On examination there was a tiny scab on the dorsal aspect of the left hand with surrounding erythema, and erythema and swelling tracking up the left forearm, but this was not tender to palpation. There were additional areas of redness and warmth on ventral aspect of the wrist with streaking up the forearm and another area of warmth and redness proximal to the elbow on the upper arm.", "This was", "ascending lymphangitis. There was no lymphadenopathy.", "She was admitted for IV antibiotics and observation", "these areas of redness representing lymphangitis were extensive, the largest being 16.5 cm measured longitudinally"], "answer_start": [0, 36, 68, 145, 644, 1144, 1179, 1385, 1493]}, "context": "Diagnosis: Ascending lymphangitis\n \nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission. The denial was upheld.\n\nThis patient is a female child with a history of intermittent asthma and allergy to peanut butter who presented to the Emergency Department (ED) with the chief complaint of left arm redness and pruritus. The parent clearly gave the history of this beginning as a small white dot on the dorsum of her finger (2nd metacarpophalangeal joint), which she thought was a bug bite, and reported that by the next morning she woke up with erythema and local itchiness. There was no pain or fever by history.\n\nIn the ED she had no fever and her vital signs were stable. On examination there was a tiny scab on the dorsal aspect of the left hand with surrounding erythema, and erythema and swelling tracking up the left forearm, but this was not tender to palpation. There were additional areas of redness and warmth on ventral aspect of the wrist with streaking up the forearm and another area of warmth and redness proximal to the elbow on the upper arm. There was no sign of fluctuance, abscess or drainage. This was a classic presentation of ascending lymphangitis. There was no lymphadenopathy.\nThe documentation shows that it was unlikely that the cause was infectious, that she had no signs of sepsis, and that she had normal laboratory values. She was admitted for IV antibiotics and observation, but the rationale for that is not documented. Although these areas of redness representing lymphangitis were extensive, the largest being 16.5 cm measured longitudinally, there was no evidence of deeper soft tissue involvement, (no evidence of tenosynovitis, joint involvement, muscle involvement, fasciitis, or compartment syndrome). The patient had no complaints of pain; she had itching and discomfort. Given her age, after receiving 1 dose of IV Clindamycin, the patient could safely have been treated and observed as an outpatient on oral antibiotics to cover both group A Strep and Staphylococcus aureus infection as possible bacterial causes of her cellulitis with lymphangitis secondary to the dorsum of hand lesion as the portal of entry.\n\nBased on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.\n", "id": "6aa18e8d66ee4039a24ca24a82ac2edd", "question": "What is the background context in this case summary?", "title": "6aa18e8d66ee4039a24ca24a82ac2edd", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Testicular cancer\nIssue under review: PET/CT\n", "The AP's note that, \"... given the substantial size of the lymph nodes, a PET scan is warranted to check fluorodeoxyglucose (FDG) activity,\""], "answer_start": [0, 426]}, "context": "Diagnosis: Testicular cancer\nIssue under review: PET/CT\n\nDetermination:\nThe PET/CT is not medically necessary.\n\nFor a residual mass under 3cm for pure seminoma with normal tumor markers, the NCCN does not recognize the role of PET/CT for disease management.  Per the NCCN, a patient such as this should be placed on surveillance, and there would be no role for PET/CT, as the patient's lymph node disease is all under 3cm.  \n\nThe AP's note that, \"... given the substantial size of the lymph nodes, a PET scan is warranted to check fluorodeoxyglucose (FDG) activity,\" is not correct. Per the NCCN, PET/CT should only be performed if a residual mass is over 3cm. Per the NCCN, following completion of chemotherapy CT scans should be performed, and then, if a mass is over 3cm, then PET/CT can be performed. The NCCN does not base the use of PET/CT on the size of the original masses. This patient's residual LN was less than 3cm, and therefore would not support a PET/CT. Therefore, the 78815 - PET CT is not medically necessary.\n", "id": "501c15058384477a9bc3561d041aca40", "question": "What is the background context in this case summary?", "title": "501c15058384477a9bc3561d041aca40", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male who presented to the emergency department requesting detoxification/rehabilitation and was medically screened and admitted to inpatient level services for detoxification of opioids, cocaine, Xanax and alcohol use; he had been using up to 14 bags of heroin with intravenous (IV) administration together with up to one gram of cocaine, as well as use of 4 milligrams (mg) of Xanax and alcohol. His substance use disorder had its onset in adolescence with progression of the disease over a ten year time frame with severe opioid, stimulant sedative-hypnotic-anxiolytic and alcohol class substance use disorders. The patient reported a past history of withdrawal seizures two years prior to admission but had no history of delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors and withdrawal symptoms. He presented with", "complaints of loose stool, headache and chills.", "The patient was admitted and placed on a detoxification regimen with comfort medications, as well as vitamin replacement therapy. He was prescribed quetiapine, sertraline and gabapentin to address his mental health conditions.", "The patient received counseling and education from the staff.", "the patient was discharged with referral for", "aftercare and rehabilitation services.", "The patient in this case was using heroin, alcohol, cocaine and other substances of abuse on a continuous daily basis."], "answer_start": [0, 1191, 1240, 1542, 1670, 1738, 1979]}, "context": "The patient is a male who presented to the emergency department requesting detoxification/rehabilitation and was medically screened and admitted to inpatient level services for detoxification of opioids, cocaine, Xanax and alcohol use; he had been using up to 14 bags of heroin with intravenous (IV) administration together with up to one gram of cocaine, as well as use of 4 milligrams (mg) of Xanax and alcohol. His substance use disorder had its onset in adolescence with progression of the disease over a ten year time frame with severe opioid, stimulant sedative-hypnotic-anxiolytic and alcohol class substance use disorders. The patient reported a past history of withdrawal seizures two years prior to admission but had no history of delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors and withdrawal symptoms. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 2 and Clinical Opiate Withdrawal Scale (COWS) scale score of 6 reflecting minimal withdrawal symptoms and complaints of loose stool, headache and chills.\n\nThe patient was admitted and placed on a detoxification regimen with comfort medications, as well as vitamin replacement therapy. He was prescribed quetiapine, sertraline and gabapentin to address his mental health conditions. The detoxification was uncomplicated with regard to withdrawal management. The patient received counseling and education from the staff. His clinical course was uncomplicated with normal vital signs and the patient was discharged with referral for clinically appropriate aftercare and rehabilitation services.\n\nThe health plan's determination is upheld.\n\nThe requested inpatient substance abuse treatment and withdrawal management could have been safely and effectively provided at a lower level of care status. The patient in this case was using heroin, alcohol, cocaine and other substances of abuse on a continuous daily basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe and the patient had received detoxification treatment 7-8 days prior to his presentation accounting for minimal or light withdrawal symptoms, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of recent complicated withdrawal from drugs or alcohol despite the history of withdrawal seizures two years prior to presentation. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria, scientific literature, referenced below. Additionally, medical necessity for the requested inpatient detoxification and other medical services is not met in keeping with NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.", "id": "8e4d2c4a04374dc68e8a2e34e96d9345", "question": "What is the background context in this case summary?", "title": "8e4d2c4a04374dc68e8a2e34e96d9345", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Right upper quadrant pain, hepatocellular carcinoma\nTreatment: Inpatient admission ", "In the hospital, the patient's pain was controlled with IV morphine. He tolerated the diet well", "He", "remained hemodynamic stable", "He was", "seen by General Surgery and as per their opinion, the patient did not have any evidence of cholecystitis and did not require any surgical intervention."], "answer_start": [0, 105, 243, 251, 363, 375]}, "context": "Diagnosis: Right upper quadrant pain, hepatocellular carcinoma\nTreatment: Inpatient admission \n\nSummary:\nIn the hospital, the patient's pain was controlled with IV morphine. He tolerated the diet well and did not have any episode of vomiting. He also remained hemodynamic stable, and did not have episode of hemodynamic instability, no evidence of any infection. He was also seen by General Surgery and as per their opinion, the patient did not have any evidence of cholecystitis and did not require any surgical intervention. Given this clinical scenario, the patient could have been appropriately managed at the lower level of care, and acute level care was not appropriate and medically necessary.", "id": "21da50fc163c4a9ebbc5369d209b719b", "question": "What is the background context in this case summary?", "title": "21da50fc163c4a9ebbc5369d209b719b", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Alcohol use disorder; psychosis\nTreatment: Inpatient Hospital Admission", "The patient exhibited cognitive impairment (disorder thought processing and executive function) and perceptual disturbance (presence of perceptual disturbance- hallucinations) acting on his paranoid thought content with guarded behavior and medication non-adherence and substance abuse with alcohol, and a decline in functioning with limited insight."], "answer_start": [0, 2172]}, "context": "Diagnosis: Alcohol use disorder; psychosis\nTreatment: Inpatient Hospital Admission\nThe proposed treatment, continued Inpatient hospital admission, was not medically necessary for this patient.\n\nThe continued inpatient level hospital care was not medically necessary for this patient. The patient no longer required the structure of an acute inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance including support of daily activities and safety monitoring together with medication management and other therapeutic interventions. It was not medically necessary for this patient to receive continued acute inpatient level services in view of his improved mood and affect, resolution of overtly psychotic symptoms, and relative lack of impulsive behaviors, as well as improved insight and cooperation with staff with regard to daily functioning and medication adherence. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required continued acute inpatient level services; the patient's alcohol use disorder did not require continued acute inpatient level treatment or 24-hour monitoring. Additionally, the inpatient stay during the time interval under review was not medically necessary in order to monitor the patient for at-risk behaviors, or to address the acute risk of relapse or address the issue in this case with medication non-adherence. The patient had access to continued mental health and substance abuse treatment in the community that could effectively meet the patient's continued mental health needs. Thus, treatment could have continued in a less restrictive setting and medical necessity is not met in this case for the time interval under review. This answer is consistent with the practice guidelines and scientific literature referenced below as well as New York State instruction for medical necessity reviews.\n\nThe patient's presentation and clinical features included an exacerbation of the patient's psychotic and mood disorder in the context of severe symptoms of psychosis, depression, and deterioration in functioning. The patient exhibited cognitive impairment (disorder thought processing and executive function) and perceptual disturbance (presence of perceptual disturbance- hallucinations) acting on his paranoid thought content with guarded behavior and medication non-adherence and substance abuse with alcohol, and a decline in functioning with limited insight. The patient responded to treatment such that by the dates in question, he had no remaining safety issues or persistent symptoms of psychosis that placed him at imminent risk for harm to self or others. There was no evidence of other symptoms or behaviors that would have required continued acute inpatient level of care, as noted above. The patient could have been managed at a lower level of care during the time frame under review. Thus, the health plan's determination is reasonable and reflects sound medical judgment. This answer is consistent with the practice guideline and scientific literature referenced below as well as New York State instruction for medical necessity reviews, and other references pertinent to the patient's co-occurring alcohol use disorder and severe and persistent mental disorder.", "id": "b719a61411e545869f1feae942026ba6", "question": "What is the background context in this case summary?", "title": "b719a61411e545869f1feae942026ba6", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Right-sided flank pain and groin pain", "Treatment: Inpatient hospital services", "The insurer denied the Inpatient hospital services.", "This patient is a female who presented to the emergency department complaining of right-sided flank pain as well as groin pain.  The patient does have a history of prior kidney stones as well has anemia, depression, bipolar disorder, asthma, chronic obstructive pulmonary disease.  The documentation indicated the patient resides in a shelter.  She complained of ongoing pain that was worsening. She also complained of a cough feeling like something was stuck in her throat.  The documentation detailed the patient's prior records did show an 8.5 mm stone on the right ureter.", "The plan was to admit the patient and treat her with intravenous (IV) fluids as well as Toradol and have her undergo additional laboratory and diagnostic studies.  The patient's urinalysis did reveal large blood.  It was recommended that the patient begin Rocephin and undergo surgical intervention to place a stent in the next 24 to 48 hours.  The documentation indicated after admission that the patient was placed on NPO (nothing by mouth) status.  The patient was given morphine for pain control.  The patient did appear to be in mild distress secondary to pain and she continued treatment.  The documentation also detailed that she underwent a gynecology consultation due to decreasing hemoglobin.  She did have 2 fibroids that were discovered on ultrasound and it was recommended the patient continue with Provera and have her undergo a transfusion if needed. The patient underwent ureteroscopy with lithotripsy and stent placement under general anesthesia. Subsequently patient was deemed stable and she was discharged."], "answer_start": [0, 51, 91, 169, 749]}, "context": "Diagnosis: Right-sided flank pain and groin pain\n \nTreatment: Inpatient hospital services\n\nThe insurer denied the Inpatient hospital services. The denial was reversed.\n\nThis patient is a female who presented to the emergency department complaining of right-sided flank pain as well as groin pain.  The patient does have a history of prior kidney stones as well has anemia, depression, bipolar disorder, asthma, chronic obstructive pulmonary disease.  The documentation indicated the patient resides in a shelter.  She complained of ongoing pain that was worsening. She also complained of a cough feeling like something was stuck in her throat.  The documentation detailed the patient's prior records did show an 8.5 mm stone on the right ureter.  \n\nThe plan was to admit the patient and treat her with intravenous (IV) fluids as well as Toradol and have her undergo additional laboratory and diagnostic studies.  The patient's urinalysis did reveal large blood.  It was recommended that the patient begin Rocephin and undergo surgical intervention to place a stent in the next 24 to 48 hours.  The documentation indicated after admission that the patient was placed on NPO (nothing by mouth) status.  The patient was given morphine for pain control.  The patient did appear to be in mild distress secondary to pain and she continued treatment.  The documentation also detailed that she underwent a gynecology consultation due to decreasing hemoglobin.  She did have 2 fibroids that were discovered on ultrasound and it was recommended the patient continue with Provera and have her undergo a transfusion if needed. The patient underwent ureteroscopy with lithotripsy and stent placement under general anesthesia. Subsequently patient was deemed stable and she was discharged.\n\nAccording to referenced literature, an inpatient admission may be needed for a patient when there is evidence of kidney stones as well as severe pain, urinary tract infection, the need for IV hydration, and a stone removal procedure is needed.  Within the documentation it was noted this patient did present complaining of worsening flank pain.  The documentation did detail she had recently been seen and diagnosed with a kidney stone.  She was recommended to have a stent placed however did not do so.  Therefore, the inpatient admission was needed as she did have prior care with ongoing worsening symptoms.  The documentation did detail she required morphine for pain control and had evidence of large blood in her urine.  The patient needed IV hydration as well and a stone removal procedure.  The patient underwent surgical intervention and continued to have rose-colored blood drain into her Foley.  She also complained of nausea and vomiting postoperatively.  Therefore, the continued inpatient services were the most appropriate level of care that could have been provided to this patient.  The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient.\n\nBased on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.\n\n\n", "id": "22ffa20fa7204594bec5a70f32321858", "question": "What is the background context in this case summary?", "title": "22ffa20fa7204594bec5a70f32321858", "sufficiency_score": 4}
+{"answers": {"text": ["This case involves a female who underwent a biopsy of the left calf.  The pathology report detailed the patient had a malignant melanoma with a maximum tumor thickness of 0.4 mm.  There was no ulceration and the pathologic stage was pT1a.  The patient did undergo the requested DecisionDX testing revealing the patient was a class I, which is associated with the lowest risk of recurrence."], "answer_start": [0]}, "context": "This case involves a female who underwent a biopsy of the left calf.  The pathology report detailed the patient had a malignant melanoma with a maximum tumor thickness of 0.4 mm.  There was no ulceration and the pathologic stage was pT1a.  The patient did undergo the requested DecisionDX testing revealing the patient was a class I, which is associated with the lowest risk of recurrence.  \n\nThe DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma.  However, the test is not the standard of care.  The DecisionDx-Melanoma test is not recommended by the panel of expert authors of UpToDate. The following are the guidelines for diagnosis and prognosis of cutaneous melanoma offered by the expert authors in UpToDate: \"SUMMARY - A simple, accurate staging and prognostic system provides important insight into the prognosis of patients with cutaneous melanoma, thus facilitating appropriate treatment.  Staging and prognosis are based upon the tumor (T) node (N) metastasis (M) system, which incorporates information about the primary tumor, regional lymphatics, and potential distant metastatic sites.\"\n\nThe patient would not be considered a good candidate for the requested testing and it was not the best available treatment for the patient at the time of testing.  As such, the requested service is not likely to be more beneficial than any other standard treatment or procedure.  \n\nThe carrier's denial of coverage for DecisionDX-Melanoma testing should be upheld.  ", "id": "108d3dacbcfd4142a22e2a20a4291b07", "question": "What is the background context in this case summary?", "title": "108d3dacbcfd4142a22e2a20a4291b07", "sufficiency_score": 4}
+{"answers": {"text": ["This is an elderly male patient who presented to the emergency department (ED) with complaint of two episodes of hematemesis (bright red blood) with small clots occurring in one day. The patient exhibited normal bowel sounds, abdominal distention, and ascites noted. He has a history of diabetes mellitus, essential hypertension, pleural effusion, gastroesophageal reflux disease (GERD), portal vein thrombosis, shortness of breath, cryptogenic cirrhosis complicated by refractory ascites, requiring Denver hunt status post revision in late 2018, esophageal varices (recent bleeding, repeat hematemesis and esophagogastroduodenoscopy),end stage renal disease (ESRD) on hemodialysis (Monday-Wednesday-Friday), and liver disease.  The patient was admitted overnight and discharged home with plan to follow up with his gastroenterologist.", "Diagnosis: Hematemesis", "Treatment: Inpatient Hospitalization", "The insurer denied the Inpatient Hospitalization."], "answer_start": [137, 0, 24, 62]}, "context": "Diagnosis: Hematemesis\n\nTreatment: Inpatient Hospitalization\n\nThe insurer denied the Inpatient Hospitalization. The denial was upheld. \n\nThis is an elderly male patient who presented to the emergency department (ED) with complaint of two episodes of hematemesis (bright red blood) with small clots occurring in one day. The patient exhibited normal bowel sounds, abdominal distention, and ascites noted. He has a history of diabetes mellitus, essential hypertension, pleural effusion, gastroesophageal reflux disease (GERD), portal vein thrombosis, shortness of breath, cryptogenic cirrhosis complicated by refractory ascites, requiring Denver hunt status post revision in late 2018, esophageal varices (recent bleeding, repeat hematemesis and esophagogastroduodenoscopy),end stage renal disease (ESRD) on hemodialysis (Monday-Wednesday-Friday), and liver disease.  The patient was admitted overnight and discharged home with plan to follow up with his gastroenterologist.\n\nPer MCG, clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy that is moderate to severe and unresponsive to observation treatment, infected ascites, severe hepatitis, severe vomiting, and acute hepatic decompensation. The patient did not have these conditions. Gastrointestinal (GI) bleeding is an indication for admission. However, in this case, there was no evidence of active GI bleeding either by history or based on the endoscopic findings. The patient did not have any high risk endoscopic features and was hemodynamically stable. The patient only reported a minimal amount of blood after he vomited. This patient had cirrhosis. There was no indication of an active GI bleed. \n\nBased on the above, the medical necessity for the inpatient hospitalization is not substantiated.  The insurer's denial is upheld.\n", "id": "a00944e75da74107bd1de06496e9fd8c", "question": "What is the background context in this case summary?", "title": "a00944e75da74107bd1de06496e9fd8c", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male who presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) class substance of abuse. The patient has participated in a medication assisted treatment (MAT) program with Suboxone which he was only taking sporadically; he indicated that he wanted to come off of Suboxone, as well as receiving detoxification treatment for his use of heroin with up to 6 bags used daily with intranasal administration (snorting). He had ten years of sobriety following ten years of incarceration in prison but had relapsed twice in 2018 and again in 2019 despite being on probation and participating in outpatient treatment with Medicated-Assisted Treatment (MAT).", "The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a three day Suboxone taper, and as needed (prn) medications for comfort including medication to address pain and aches, anxiety and insomnia and diarrhea/abdominal cramps. The patient had persistent and mild symptoms of withdrawal scoring an 8 on the COWS scale on hospital days two, three and four, but the patient tolerated the taper of Suboxone. The day following his last dose of Suboxone, the patient was immediately referred to rehabilitation treatment which had followed the use of motivational techniques by the treatment team and case manager. While in detoxification treatment the patient continued to receive counseling and education and attended groups.", "The patient completed the detoxification protocol and was discharged with referral for rehabilitation substance use disorder treatment, and with recommendations for smoking cessation, as well as recommended involvement with recovery groups and follow-up for clinically appropriate treatment of his co-occurring depressive disorder and primary care."], "answer_start": [0, 732, 1501]}, "context": "The patient is a male who presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) class substance of abuse. The patient has participated in a medication assisted treatment (MAT) program with Suboxone which he was only taking sporadically; he indicated that he wanted to come off of Suboxone, as well as receiving detoxification treatment for his use of heroin with up to 6 bags used daily with intranasal administration (snorting). He had ten years of sobriety following ten years of incarceration in prison but had relapsed twice in 2018 and again in 2019 despite being on probation and participating in outpatient treatment with Medicated-Assisted Treatment (MAT).\n\nThe patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a three day Suboxone taper, and as needed (prn) medications for comfort including medication to address pain and aches, anxiety and insomnia and diarrhea/abdominal cramps. The patient had persistent and mild symptoms of withdrawal scoring an 8 on the COWS scale on hospital days two, three and four, but the patient tolerated the taper of Suboxone. The day following his last dose of Suboxone, the patient was immediately referred to rehabilitation treatment which had followed the use of motivational techniques by the treatment team and case manager. While in detoxification treatment the patient continued to receive counseling and education and attended groups.\nThe patient completed the detoxification protocol and was discharged with referral for rehabilitation substance use disorder treatment, and with recommendations for smoking cessation, as well as recommended involvement with recovery groups and follow-up for clinically appropriate treatment of his co-occurring depressive disorder and primary care.\n\nThe health plan's determination is overturned.\n\nThe continued inpatient treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment and risk factors for relapse and lack of a reasonable treatment/recovery environment. Withdrawal symptoms were appropriately managed with tapering dosages of Suboxone requiring monitoring and supportive measures including the availability of comfort medications, as noted in the clinical summary. The patient's history of opioid use and recent relapses while receiving MAT, limited psychosocial supports and psychosocial stressors within several domains including risk for re-incarceration, and risk for relapse in view of his recent relapses did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with addiction to opioids.\n\nThus, the patient did require a safe and effective detoxification treatment with continued inpatient services as it was foreseeable that the patient was unable to abstain from use of heroin, or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, using the of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, the patient did warrant the continued inpatient level care through discharge with the clinically appropriate application of the LOCADTR Guidelines.", "id": "6d304ce9de6b4dd58ac0932872d4e812", "question": "What is the background context in this case summary?", "title": "6d304ce9de6b4dd58ac0932872d4e812", "sufficiency_score": 4}
+{"answers": {"text": ["This is an elderly male patient, who presented to the emergency department with a one-week history of right leg swelling, pain, and tenderness to palpation.  He stated he could not walk on his right leg due to pain.  He had a medical history of hypertension.  It was recommended the patient undergo laboratory studies and an ultrasound.  The patient's laboratory studies revealed an elevated D-dimer of 8.55.  The ultrasound revealed an occlusive deep venous thrombus of the sapheno-femoral junction, proximal, mid, and distal superficial femoral veins and popliteal vein likely sub-acute status.  His chest x-ray was negative for acute pulmonary process.  It was recommended the patient be admitted for further care.  The patient was treated with Lovenox, Amlodipine, and Eliquis.  It was reported that the patient was alert, oriented, and was able to ambulate.  The patient experienced no significant adverse events during his hospital admission.  He was discharged when deemed medically stable with recommendations for follow up.", "Diagnosis:  Deep Vein Thrombosis", "Treatment:  Inpatient Admission", "The insurer denied the Inpatient Admission."], "answer_start": [137, 0, 34, 67]}, "context": "Diagnosis:  Deep Vein Thrombosis\n\nTreatment:  Inpatient Admission\n\nThe insurer denied the Inpatient Admission.  The denial was upheld. \n\nThis is an elderly male patient, who presented to the emergency department with a one-week history of right leg swelling, pain, and tenderness to palpation.  He stated he could not walk on his right leg due to pain.  He had a medical history of hypertension.  It was recommended the patient undergo laboratory studies and an ultrasound.  The patient's laboratory studies revealed an elevated D-dimer of 8.55.  The ultrasound revealed an occlusive deep venous thrombus of the sapheno-femoral junction, proximal, mid, and distal superficial femoral veins and popliteal vein likely sub-acute status.  His chest x-ray was negative for acute pulmonary process.  It was recommended the patient be admitted for further care.  The patient was treated with Lovenox, Amlodipine, and Eliquis.  It was reported that the patient was alert, oriented, and was able to ambulate.  The patient experienced no significant adverse events during his hospital admission.  He was discharged when deemed medically stable with recommendations for follow up. \n\nAccording to current literature a patient may be admitted to inpatient care when there is evidence the patient is considered a high risk for acute complication, such as documentation of a recent surgery, recent Gastrointestinal (GI) bleed, and history of intracranial bleeding, history of active bleeding with anti-coagulation or there is evidence of active substance abuse.  Additionally, if there is a limb threatening infection, then a patient may be admitted.  The submitted documentation did not indicate any of the above conditions.  There is no personal allergic reaction in response to anticoagulation requiring monitoring beyond observation care that would warrant the requested inpatient stay.  There is a lack of submitted documentation detailing why this patient could not have continued care in an observation level.  The patient could have been observed and treated with anticoagulation therapy.  Therefore, the inpatient admission was not medically necessary, and the prior denial remains upheld.  The health plan acted reasonably and with sound medical judgment, in the best interest of the patient.\n\nBased on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.\n", "id": "167e25224e1e4b098f83bc289f1a1788", "question": "What is the background context in this case summary?", "title": "167e25224e1e4b098f83bc289f1a1788", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with a Class I occlusion with minimal overbite and overjet. The orthodontist states he has anterior crossbites on teeth 7 and 10. He has a convex profile. He is treatment planned for 24 months of orthodontics with extraction of 5, 12, 21 and 28 to correct his malocclusion. This was denied by the health plan based on lack of medical necessity."], "answer_start": [0]}, "context": "The patient is a male with a Class I occlusion with minimal overbite and overjet. The orthodontist states he has anterior crossbites on teeth 7 and 10. He has a convex profile. He is treatment planned for 24 months of orthodontics with extraction of 5, 12, 21 and 28 to correct his malocclusion. This was denied by the health plan based on lack of medical necessity. The subject under review is the medical necessity for the requested orthodontic treatment.\n\nThe health plan's determination is upheld. \n\nThe requested treatment is not medically necessary for this patient.\nThe patient has an excellent occlusion and appropriate overbite and overjet. There is some minor spacing, but this alone does not rise to the threshold of medically necessary. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. Although the patient has some minor spacing, his teeth are in a solid Class I occlusal relationship. He has minimal overbite and overjet on 7 and 10, but the photographs do not indicate any incisors in a traumatic relationship. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions.", "id": "4604a016796a4a2686a09ffcb214344c", "question": "What is the background context in this case summary?", "title": "4604a016796a4a2686a09ffcb214344c", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Pain due to Sickle Cell\nTreatment: Inpatient admission", "The patient is a teenage male with medical history significant for sickle cell SS disease on a monthly transfusion program, with multiple PICU admissions, including admissions for pain crises and acute chest syndrome. He was referred to the ED for evaluation of abdominal pain. The pain initially started in his knee and shoulder the day prior. It migrated to his abdomen, was periumbilical in location, rate 6/10, and described as stabbing. It was unrelieved by Percocet and ibuprofen. He had no other symptoms, no fevers, anorexia, vomiting. He did report onset of a nonproductive cough.", "The patient's vital signs included temperature 37.2, heart rate 90, respiratory rate 20 with 97% saturation in room air. Examination was significant for no acute distress, clear lungs, and diffuse abdominal tenderness, worst in the periumbilical area. His port was inaccessible, so an IV was started and he was treated with Dilaudid. Laboratory evaluation revealed hemoglobin 9.8 with 2+ sickle like cells, 5.4% reticulocytes, total bilirubin 4.6, AST (aspartate aminotransferase) 63, and WBC (white blood cells) 14.2K with 52% neutrophils and 7% bands.", "The patient was diagnosed with sickle cell crisis with vasoocclusive abdominal pain, and admitted for further pain management. Admit orders included round-the-clock Toradol, maintenance IV fluids, Tylenol as needed for moderate pain, Dilaudid as needed for severe pain, ranitidine for GI (gastrointestinal) protection, folic acid, albuterol for his dry cough, and Hematology consultation.", "The patient's pain was severe overnight, requiring Dilaudid in the morning. He was transfused as per his transfusion program. By the day of discharge, his pain had improved, and he had no tenderness on exam. He was deemed stable for discharge home, to follow-up with Hematology in one to two weeks and pediatrician in one to two days."], "answer_start": [0, 116, 708, 1264, 1655]}, "context": "Diagnosis: Pain due to Sickle Cell\nTreatment: Inpatient admission\nThe inpatient admission was medically necessary.\n\nThe patient is a teenage male with medical history significant for sickle cell SS disease on a monthly transfusion program, with multiple PICU admissions, including admissions for pain crises and acute chest syndrome. He was referred to the ED for evaluation of abdominal pain. The pain initially started in his knee and shoulder the day prior. It migrated to his abdomen, was periumbilical in location, rate 6/10, and described as stabbing. It was unrelieved by Percocet and ibuprofen. He had no other symptoms, no fevers, anorexia, vomiting. He did report onset of a nonproductive cough. \n\nThe patient's vital signs included temperature 37.2, heart rate 90, respiratory rate 20 with 97% saturation in room air. Examination was significant for no acute distress, clear lungs, and diffuse abdominal tenderness, worst in the periumbilical area. His port was inaccessible, so an IV was started and he was treated with Dilaudid. Laboratory evaluation revealed hemoglobin 9.8 with 2+ sickle like cells, 5.4% reticulocytes, total bilirubin 4.6, AST (aspartate aminotransferase) 63, and WBC (white blood cells) 14.2K with 52% neutrophils and 7% bands. \n\nThe patient was diagnosed with sickle cell crisis with vasoocclusive abdominal pain, and admitted for further pain management. Admit orders included round-the-clock Toradol, maintenance IV fluids, Tylenol as needed for moderate pain, Dilaudid as needed for severe pain, ranitidine for GI (gastrointestinal) protection, folic acid, albuterol for his dry cough, and Hematology consultation. \n\nThe patient's pain was severe overnight, requiring Dilaudid in the morning. He was transfused as per his transfusion program. By the day of discharge, his pain had improved, and he had no tenderness on exam. He was deemed stable for discharge home, to follow-up with Hematology in one to two weeks and pediatrician in one to two days.\n\nThis male teen presented with abdominal pain characteristic of previous vasoocclusive crises, preceded by extremity pain, rated 6/10. He had failed outpatient treatment with Percocet, and required Dilaudid in the ED with marginal improvement. He had a cough but was otherwise stable with no fevers. He was due for his routine transfusion. Based on his presentation and the standard of care at the time, acute inpatient admission for parenteral pain management was medically necessary and appropriate. This intensity of care could not have been safely provided at a lower level.", "id": "80735fc8b30549d99caf0173d28ae7e9", "question": "What is the background context in this case summary?", "title": "80735fc8b30549d99caf0173d28ae7e9", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Fever, vomiting\nIssue under review: Inpatient admission", "This patient presented to the ED with signs and symptoms consistent with viral infection. Because of persistent tachycardia despite fluid resuscitation and antipyretics, additional studies were obtained that were indicative of myocarditis. She was initially admitted to the PICU for cardiorespiratory monitoring. She remained stable overnight, so was able to transfer to the pediatric floor. Once her symptoms resolved (afebrile, able to tolerate a regular diet, decreased fatigue) she was considered at decreased risk for complications and stable to go home.", "Additionally, she was treated with broad-spectrum antibiotics pending culture results."], "answer_start": [0, 1700, 2522]}, "context": "Diagnosis: Fever, vomiting\nIssue under review: Inpatient admission\n\nDetermination:\nThe Inpatient admission was medically necessary.\n\nMyocarditis is an inflammatory disease of heart muscle. There are numerous causes, including infection, autoimmune disease, hypersensitivity reactions, and toxins. In developed countries, the cause is usually viral. Enteroviruses are the classic viral pathogen, but other viral agents may cause myocarditis, including adenovirus, parvovirus, Epstein-Barr virus, and cytomegalovirus. Characteristic symptoms on presentation include tachypnea, abdominal pain, vomiting, chest pain, palpitations, and tachycardia. \n\nMost patients present with resting tachycardia. Electocardiographic findings include ST-T wave abnormalities and premature contractions. Inflammatory markers are typically elevated. Troponin is a particularly useful marker to trend the disease. The most common echocardiographic finding is dilated cardiomyopathy with left ventricular dilation and reduced ejection fraction, but other phenotypes may be present. Cardiac MRI is particularly useful, because it can be used to assess left ventricular ejection, chamber size, wall thickness, and local areas of edema and fibrosis. Specific MRI diagnostic criteria are available for suspected myocarditis. \n\nComplications of myocarditis include arrhythmias, chest pain, myocardial infarction, acute heart failure, and sudden death. Treatment includes limitation of aerobic activities and management of the primary medical manifestations (e.g., treatment of arrhythmias, heart block, decreased left ventricular function). Research has suggested a role for immunosuppressive therapies and antiviral therapies.\n\nThis patient presented to the ED with signs and symptoms consistent with viral infection. Because of persistent tachycardia despite fluid resuscitation and antipyretics, additional studies were obtained that were indicative of myocarditis. She was initially admitted to the PICU for cardiorespiratory monitoring. She remained stable overnight, so was able to transfer to the pediatric floor. Once her symptoms resolved (afebrile, able to tolerate a regular diet, decreased fatigue) she was considered at decreased risk for complications and stable to go home. Myocarditis is a serious disease, with potential for significant morbidity and even mortality. Appropriate medical management in this situation included ICU monitoring, Cardiology and ID (infectious diseases) consultations, and comprehensive diagnostic studies. Additionally, she was treated with broad-spectrum antibiotics pending culture results. Acute inpatient management was medically necessary and appropriate. She could not have been safely managed at a lower level of care.\n", "id": "904bec4342b04b09895d6ca9a4a4b798", "question": "What is the background context in this case summary?", "title": "904bec4342b04b09895d6ca9a4a4b798", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Urinary Tract Infection", "Treatment: Inpatient Admission", "The insurer denied the Inpatient Admission.", "This is a female patient who presented to the Emergency Department with complaints of fever, chills, and dysuria. She has a past medical history of diabetes mellitus, hyperlipidemia, and parotid gland drainage. The patient was empirically started on intravenous antibiotics for treatment of her urinary tract infection (UTI). The chest x-ray was negative. A renal ultrasound was negative for hydronephrosis. The urine culture was positive for E. coli.  The patient remained hemodynamically stable and clinically improved. She was discharged to continue antibiotics as an outpatient management.", "According to the medical records, the patient was treated by her primary physician for a UTI as an outpatient with antibiotics for three days without improvement. She presented with high fevers (39.3 C) and tachycardia (heart rate-132). Urinalysis and cultures confirmed an E. coli UTI. The patient had multiple co-morbid conditions including diabetes that placed her at high-risk for complications."], "answer_start": [0, 37, 69, 142, 737]}, "context": "Diagnosis: Urinary Tract Infection\n \nTreatment: Inpatient Admission\n\nThe insurer denied the Inpatient Admission. The denial was reversed.   \n\nThis is a female patient who presented to the Emergency Department with complaints of fever, chills, and dysuria. She has a past medical history of diabetes mellitus, hyperlipidemia, and parotid gland drainage. The patient was empirically started on intravenous antibiotics for treatment of her urinary tract infection (UTI). The chest x-ray was negative. A renal ultrasound was negative for hydronephrosis. The urine culture was positive for E. coli.  The patient remained hemodynamically stable and clinically improved. She was discharged to continue antibiotics as an outpatient management.\n\nAccording to the medical records, the patient was treated by her primary physician for a UTI as an outpatient with antibiotics for three days without improvement. She presented with high fevers (39.3 C) and tachycardia (heart rate-132). Urinalysis and cultures confirmed an E. coli UTI. The patient had multiple co-morbid conditions including diabetes that placed her at high-risk for complications.\n\nBased on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is substantiated. The insurer's denial is reversed.\n", "id": "2d147d3cb9cc4ba79d0cda94f19a95ea", "question": "What is the background context in this case summary?", "title": "2d147d3cb9cc4ba79d0cda94f19a95ea", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female patient who presented to the hospital for scheduled percutaneous coronary intervention (PCI) of left anterior descending artery. She has a history of hypertension, hyperlipidemia, two vessel coronary artery disease (CAD) (right coronary artery, and left anterior descending artery), status post DES of right coronary artery. Immediately post procedure she experienced nausea and chest pain. She was given nitroglycerin and Zofran. She was treated with antiplatelet therapy and remained clinically and hemodynamically stable throughout her hospital stay. She was discharged home for outpatient follow up.", "Diagnosis: Coronary artery disease (CAD)", "Treatment: Inpatient Admission", "The insurer denied the Inpatient Admission."], "answer_start": [143, 0, 42, 74]}, "context": "Diagnosis: Coronary artery disease (CAD)\n\nTreatment: Inpatient Admission\n\nThe insurer denied the Inpatient Admission. The denial was upheld. \n\nThis is a female patient who presented to the hospital for scheduled percutaneous coronary intervention (PCI) of left anterior descending artery. She has a history of hypertension, hyperlipidemia, two vessel coronary artery disease (CAD) (right coronary artery, and left anterior descending artery), status post DES of right coronary artery. Immediately post procedure she experienced nausea and chest pain. She was given nitroglycerin and Zofran. She was treated with antiplatelet therapy and remained clinically and hemodynamically stable throughout her hospital stay. She was discharged home for outpatient follow up.\n\nPer MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization, angioplasty, and coronary stenting.\n\nBased on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.\n", "id": "2bb592e06c984110872164c35e4ca28d", "question": "What is the background context in this case summary?", "title": "2bb592e06c984110872164c35e4ca28d", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with a history of a ruptured ovarian cyst, syncope and chronic back pain. She presented to the emergency room with abdominal pain, diarrhea, vomiting, and palpitations. Her vital signs were unremarkable, she appeared well and in no acute distress. There was slight epigastric tenderness. Except for a minimally elevated troponin, the labs, chest x-ray, and the electrocardiogram (EKG) were essentially normal.", "due to the complaint of palpitations and the minimally elevated troponin, the patient was admitted.", "Upon admission, she was placed in a telemetry bed. An echocardiogram was normal. The hospital course was clinically uneventful, and the patient was discharged the following day."], "answer_start": [0, 446, 547]}, "context": "The patient is a female with a history of a ruptured ovarian cyst, syncope and chronic back pain. She presented to the emergency room with abdominal pain, diarrhea, vomiting, and palpitations. Her vital signs were unremarkable, she appeared well and in no acute distress. There was slight epigastric tenderness. Except for a minimally elevated troponin, the labs, chest x-ray, and the electrocardiogram (EKG) were essentially normal. Apparently, due to the complaint of palpitations and the minimally elevated troponin, the patient was admitted.\n\nUpon admission, she was placed in a telemetry bed. An echocardiogram was normal. The hospital course was clinically uneventful, and the patient was discharged the following day.\nThe health plan's determination is upheld.\n\nNo, the requested health service/treatment of Inpatient stay was not medically necessary for this patient.\n\nBased on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The services provided could have been safely and efficiently provided at a lesser level. The probability of an acute coronary syndrome was extremely low.", "id": "476f1c47e6c44ce688f5c2be9ad4cf64", "question": "What is the background context in this case summary?", "title": "476f1c47e6c44ce688f5c2be9ad4cf64", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient is a patient with a past medical history significant for alcohol abuse, polysubstance abuse, depression, gastroesophageal reflux disease (GERD), and suicidal ideation who presented to the emergency department with alcohol intoxication and withdrawal symptoms.", "The patient was admitted to the hospital and received treatment for alcohol withdrawal symptoms based on the Clinical Institute Withdrawal Assessment (CIWA) protocol. She also received treatment with intravenous fluids, thiamine, multivitamins, folic acid. It was indicated in the discharge summaries that the patient had signs of severe withdrawal.", "Subsequently, patient's alcohol withdrawal symptoms completely resolved, and she was discharged home with a recommendation to follow up with a primary care physician as well as to attend alcohol anonymous group."], "answer_start": [0, 278, 628]}, "context": "This is a patient is a patient with a past medical history significant for alcohol abuse, polysubstance abuse, depression, gastroesophageal reflux disease (GERD), and suicidal ideation who presented to the emergency department with alcohol intoxication and withdrawal symptoms.\nThe patient was admitted to the hospital and received treatment for alcohol withdrawal symptoms based on the Clinical Institute Withdrawal Assessment (CIWA) protocol. She also received treatment with intravenous fluids, thiamine, multivitamins, folic acid. It was indicated in the discharge summaries that the patient had signs of severe withdrawal.\nSubsequently, patient's alcohol withdrawal symptoms completely resolved, and she was discharged home with a recommendation to follow up with a primary care physician as well as to attend alcohol anonymous group. The health plan's determination is overturned.\nThis patient was admitted to the hospital with alcohol withdrawal symptoms. Even though in some cases a patient with mild alcohol withdrawal symptoms could be managed as an outpatient and at the lower level of care, patients with moderate to severe withdrawal symptoms require admission to the hospital. They need very close monitoring, assessment of the withdrawal symptoms based on the CIWA score, and proper administration of benzodiazepines in accordance with CIWA protocol. In this particular case, the patient had a relatively low CIWA score, with several spikes in the CIWA score up to 26, which was in a category of severe withdrawal. Therefore, this patient had episodes of severe alcohol withdrawal qualifying for inpatient level of care.", "id": "6be90067e57c481f883e9e38c143cec6", "question": "What is the background context in this case summary?", "title": "6be90067e57c481f883e9e38c143cec6", "sufficiency_score": 4}
+{"answers": {"text": ["This male infant was born several weeks premature weighing 2630 grams; delivery was via spontaneous vaginal delivery complicated by Group B Streptococcus (GBS) and premature rupture of membranes (PROM).   The Neonatal Intensive Care Unit (NICU) admission was initially for preterm gestation and presumed sepsis.  As of Day #3, the patient was in room air without distress and with normal vital signs.  Fluids and nutrition were being provided by both enteral and intravenous (IV) routes with oral (p.o.) feeding gradually increased and IV fluid gradually decreased.  IV antibiotics had been started for presumed sepsis; the blood culture showed no growth to date.  Phototherapy was started for hyperbilirubinemia of prematurity, but discontinued 12 hours later.  On Day #4, antibiotics were discontinued. Feeding was advanced and IV fluid was decreased. On Day #7 IV fluid was discontinued. Bilateral casts were placed for club feet.  On Day #8 the infant was on p.o. feeding without any significant co-morbidity requiring treatment. ", "Diagnosis: Prematurity\n \nTreatment: Inpatient admission, medication, monitoring, phototherapy", "The insurer denied the continued NICU level of care."], "answer_start": [174, 0, 95]}, "context": "Diagnosis: Prematurity\n \nTreatment: Inpatient admission, medication, monitoring, phototherapy\n\nThe insurer denied the continued NICU level of care. The denial was reversed.\n\nThis male infant was born several weeks premature weighing 2630 grams; delivery was via spontaneous vaginal delivery complicated by Group B Streptococcus (GBS) and premature rupture of membranes (PROM).   The Neonatal Intensive Care Unit (NICU) admission was initially for preterm gestation and presumed sepsis.  As of Day #3, the patient was in room air without distress and with normal vital signs.  Fluids and nutrition were being provided by both enteral and intravenous (IV) routes with oral (p.o.) feeding gradually increased and IV fluid gradually decreased.  IV antibiotics had been started for presumed sepsis; the blood culture showed no growth to date.  Phototherapy was started for hyperbilirubinemia of prematurity, but discontinued 12 hours later.  On Day #4, antibiotics were discontinued. Feeding was advanced and IV fluid was decreased. On Day #7 IV fluid was discontinued. Bilateral casts were placed for club feet.  On Day #8 the infant was on p.o. feeding without any significant co-morbidity requiring treatment.   \n\nAccording to MCG: Neonatal Care, Intermediate Care, Level 3 (LOC:012): Admission for or continuation (from higher level) of care at Level 3 indicated by: inadequate feedings (e.g., oral and nasogastric) requiring ongoing IV fluids. According to MCG: Neonatal Care, Continuing Care, Level 2 (LOC: 011):  Admission for or continuation (from higher level) of care at Level 2 indicated by presence of: Care for mild instability or condition as indicated by 1 or more of the following: Continued inpatient care during convalescence from condition or conditions treated at higher level of care; Limited or absent oral feedings requiring efforts to advance toward expected oral goal; Suspected sepsis: evaluation and observation of asymptomatic infant; Neonatal jaundice requiring monitoring (e.g., elevated bilirubin levels repeated more frequently than every 12 hours) or treatment with phototherapy; Supportive care needed for other instability or condition. \n \nCare at Neonatal Care, Intermediate Care, Level 3 is approved for Days #3-6, and care at Neonatal Care, Continuing Care, Level 2 is approved for the remainder of stay. The carrier's denial of inpatient hospital services at the Neonatal Intensive Care Unit level of care is reversed. ", "id": "20a55f99e3034538a0ff4941542d8f5f", "question": "What is the background context in this case summary?", "title": "20a55f99e3034538a0ff4941542d8f5f", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient with a history of diabetes, hypertension, hyperlipidemia, asthma, pulmonary embolism and obstructive sleep apnea. She presented to the emergency department complaining of chest tightness, dyspnea, palpitations and cough. Her blood pressure was 150/120 millimeters of mercury (mmHg) with a heart rate of 160 beats/minute. Room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and a rapid, irregular rhythm. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate and nonspecific repolarization changes. Her serum troponin level was normal.", "She presented with a new onset of atrial fibrillation (AF)."], "answer_start": [0, 671]}, "context": "This is a patient with a history of diabetes, hypertension, hyperlipidemia, asthma, pulmonary embolism and obstructive sleep apnea. She presented to the emergency department complaining of chest tightness, dyspnea, palpitations and cough. Her blood pressure was 150/120 millimeters of mercury (mmHg) with a heart rate of 160 beats/minute. Room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and a rapid, irregular rhythm. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate and nonspecific repolarization changes. Her serum troponin level was normal. The health plan's determination of medical necessity is upheld. She presented with a new onset of atrial fibrillation (AF). She was hemodynamically stable and there was no evidence of myocardial ischemia or decompensated heart failure. In patients who present to the emergency department with acute AF, the safety of a lower level care or discharge to home with close follow-up has been well demonstrated. \nPer the Milliman Care Guideline for Atrial Fibrillation (ORG: M-505) , indications for inpatient care include: hemodynamic instability, myocardial infarction or ischemia, altered mental status, syncope, heart failure, implantable cardioverter defibrillator discharges, Wolff Parkinson White syndrome, medication toxicity, severe electrolyte or acid base disturbance or other acute serious medical condition requiring inpatient care, need for initiation of antiarrhythmic drug therapy in a patient at high risk for adverse effects, persistent symptomatic tachycardia despite outpatient or observation level care or need for urgent or elective cardioversion that cannot be performed on an outpatient basis or during observation care. This patient met none of these criteria.", "id": "0e950dba09274d7aaff6b33912314fb3", "question": "What is the background context in this case summary?", "title": "0e950dba09274d7aaff6b33912314fb3", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Abdominal Pain\nTreatment: Inpatient admission", "This patient presented with signs and symptoms of acute cholecystitis with confirmatory diagnostic imaging. There were no signs and symptoms of sepsis and no untoward events during or after surgery. All available laboratory data was trending downward after the infected organ was removed."], "answer_start": [0, 1052]}, "context": "Diagnosis: Abdominal Pain\nTreatment: Inpatient admission\nThe proposed inpatient treatment was not medically necessary.\n\nAfter an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.\n\nMost otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class IV, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.\n\nThis patient presented with signs and symptoms of acute cholecystitis with confirmatory diagnostic imaging. There were no signs and symptoms of sepsis and no untoward events during or after surgery. All available laboratory data was trending downward after the infected organ was removed.  Therefore, the inpatient admission was not medically necessary.\n", "id": "e6373d5181674ce29727550747b11a8d", "question": "What is the background context in this case summary?", "title": "e6373d5181674ce29727550747b11a8d", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient with a history of malignant melanoma in situ on the left neck and right deltoid, and a history of malignant melanoma to the left scapula, Breslow 0.7 millimeter (mm). There is no ulceration and the mitotic index is less than one. This is a review for coverage of the DecisionDX melanoma assay."], "answer_start": [0]}, "context": "This is a patient with a history of malignant melanoma in situ on the left neck and right deltoid, and a history of malignant melanoma to the left scapula, Breslow 0.7 millimeter (mm). There is no ulceration and the mitotic index is less than one. This is a review for coverage of the DecisionDX melanoma assay.\n\nThe health plan's determination is upheld. The DecisionDX melanoma testing is not likely to be more beneficial than any standard treatment for the patient's condition. There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions. There is insufficient clinical evidence in the peer-reviewed medical literature to demonstrate improved long-term health outcomes of this testing.\n", "id": "4a96d83ce7944576ae2b6ccfb0925654", "question": "What is the background context in this case summary?", "title": "4a96d83ce7944576ae2b6ccfb0925654", "sufficiency_score": 3}
+{"answers": {"text": ["of", "The patient has a history of Malignant Melanoma of the left medial scapula that was biopsied on 5/17/2017. The Melanoma was read out as having a Breslow depth of 0.7 millimeter (mm), no ulceration, and with less than one mitotic figure per square millimeter field. Regression was noted, but no perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1a. The DecisionDx-Melanoma Gene Expression Assay is under review.\n"], "answer_start": [159, 0]}, "context": "The patient has a history of Malignant Melanoma of the left medial scapula that was biopsied on 5/17/2017. The Melanoma was read out as having a Breslow depth of 0.7 millimeter (mm), no ulceration, and with less than one mitotic figure per square millimeter field. Regression was noted, but no perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1a. The DecisionDx-Melanoma Gene Expression Assay is under review.\n\nThe health plan's determination is upheld. The DecisionDx-Melanoma test is not likely to be more beneficial than standard treatment in this case. It is not in accordance with generally accepted standards of medical practice in the United States, and is not clinically appropriate for this patient's clinical condition. Standard treatment in this case is observation and followup based on the tumor's histologic features. This patient has a relatively superficial melanoma with no ulceration or significant number of dermal mitoses, so that wide excision and appropriate followup only is indicated for this patient. Therefore, at this time, the DecisionDx-Melanoma is not likely to be more beneficial than standard treatment in this case. The only consensus that exists for this test is that more studies need to occur in modern evidence-based and peer-reviewed literature.\n", "id": "ea18d36ccc50425886aa8ad553c6d415", "question": "What is the background context in this case summary?", "title": "ea18d36ccc50425886aa8ad553c6d415", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a cutaneous melanoma to the back, 0.7 millimeter (mm) in depth with absent ulceration. DecisionDx-melanoma assay designated the tumor class 1 (low risk of recurrence within 5 years). The use of the DecisionDx testing is under review."], "answer_start": [0]}, "context": "The patient has a cutaneous melanoma to the back, 0.7 millimeter (mm) in depth with absent ulceration. DecisionDx-melanoma assay designated the tumor class 1 (low risk of recurrence within 5 years). The use of the DecisionDx testing is under review.\n\nThe health plan's determination is upheld. There is no evidence based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care and there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma. Standard of care in a melanoma greater than 1 mm (one millimeter) is wide local excision with a sentinel lymph node biopsy. Further testing or work-up is performed by symptoms and results of sentinel lymph node testing. For melanomas less than 1 mm, wide local excision with routine skin and physical exams is standard of care.", "id": "07bd1cda93d643a3a7bfcfb262e2e8c1", "question": "What is the background context in this case summary?", "title": "07bd1cda93d643a3a7bfcfb262e2e8c1", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Constipation, tenesmus, bowel leakage\nTreatment: Hospital Emergency Admission", "The patient has human immunodeficiency virus and rectal squamous cell carcinoma status post chemotherapy and radiation.  He presented to the hospital with one week of constipation, tenesmus, and bowel leakage.", "The patient was afebrile with a blood pressure of 135/83.  Labs demonstrated a creatinine of 2.0, potassium of 6.1, bicarbonate of 21, magnesium of 1.4, and white blood cell count of 10,400.  Computed tomography (CT) of the abdomen/pelvis demonstrated perirectal fat stranding in the rectal area suggestive of proctitis.  Intravenous fluids, magnesium supplementation, and as needed analgesics were ordered.  One dose each of prednisone and azithromycin were administered for treatment of gonorrhea and chlamydia.  The potassium normalized, and the creatinine dropped to 1.4.  Hydrocortisone suppositories were provided."], "answer_start": [0, 153, 366]}, "context": "Diagnosis: Constipation, tenesmus, bowel leakage\nTreatment: Hospital Emergency Admission\n\nThe hospital emergency admission was not medically necessary.\n\nThe patient has human immunodeficiency virus and rectal squamous cell carcinoma status post chemotherapy and radiation.  He presented to the hospital with one week of constipation, tenesmus, and bowel leakage.  \n\nThe patient was afebrile with a blood pressure of 135/83.  Labs demonstrated a creatinine of 2.0, potassium of 6.1, bicarbonate of 21, magnesium of 1.4, and white blood cell count of 10,400.  Computed tomography (CT) of the abdomen/pelvis demonstrated perirectal fat stranding in the rectal area suggestive of proctitis.  Intravenous fluids, magnesium supplementation, and as needed analgesics were ordered.  One dose each of prednisone and azithromycin were administered for treatment of gonorrhea and chlamydia.  The potassium normalized, and the creatinine dropped to 1.4.  Hydrocortisone suppositories were provided.\n\nThe patient presented to the hospital with proctitis but did not have inflammatory bowel disease, gastrointestinal bleed, fever, hemodynamic instability, or evidence of bowel obstruction.  No surgical intervention was required.  The patient had only a mild degree of acute kidney injury, and renal function improved promptly with administration of intravenous fluids.  The patient's hyperkalemia was mild and was not associated with muscle weakness, ventricular arrhythmia, or electrocardiographic changes.  The potassium normalized with intravenous fluid administration.  In summary, inpatient admission was not medically necessary.  \n", "id": "3130c8cab27444cabf0a833cb6dc5971", "question": "What is the background context in this case summary?", "title": "3130c8cab27444cabf0a833cb6dc5971", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient who underwent a sleep study in early 2019 with decreased oxygen saturation indicative of severe obstructive sleep apnea.  The patient is symptomatic with nonrestorative sleep and excessive daytime somnolence.  A contributing factor to the obstructive sleep apnea is a significant anatomic abnormality in the patient's upper airway with evidence of prior horizontal nasal fracture and severe nasal septum deviations with multiple perforations.  The physician detailed that the first therapeutic modality would be considered continuous positive airway pressure (CPAP) trial with an attended in lab CPAP titration. The notes also indicate that the patient is being treated by a cardiologist for an aortic bicuspid valve.", "Diagnosis: Severe Obstructive Sleep Apnea", "Treatment:  Laboratory based Sleep Study", "The insurer denied the laboratory based Sleep Study."], "answer_start": [168, 0, 44, 86]}, "context": "Diagnosis: Severe Obstructive Sleep Apnea\n \nTreatment:  Laboratory based Sleep Study\n\nThe insurer denied the laboratory based Sleep Study.  The denial was reversed.  \n\nThis is a male patient who underwent a sleep study in early 2019 with decreased oxygen saturation indicative of severe obstructive sleep apnea.  The patient is symptomatic with nonrestorative sleep and excessive daytime somnolence.  A contributing factor to the obstructive sleep apnea is a significant anatomic abnormality in the patient's upper airway with evidence of prior horizontal nasal fracture and severe nasal septum deviations with multiple perforations.  The physician detailed that the first therapeutic modality would be considered continuous positive airway pressure (CPAP) trial with an attended in lab CPAP titration. The notes also indicate that the patient is being treated by a cardiologist for an aortic bicuspid valve.\n\nHome-based sleep studies with portable monitors are preferred over in-laboratory polysomnography, except in those patients who have contraindications to a home sleep study. The patient has previously undergone a sleep study and he was diagnosed with severe obstructive sleep apnea. He is also being monitored by cardiology for an aortic bicuspid valve. He recently had a major facial injury as well with evidence of a prior horizontal nasal fracture, severe nasal septum deviations and multiple perforations.  Therefore, the patient would need to be monitored in a facility with supervision from a trained professional in order to optimize the CPAP and monitor the titration.  \n\nBased on the above, the medical necessity for a laboratory-based sleep study is substantiated.  The insurer's denial is reversed.", "id": "5dba0dbf970043bab29c348173760445", "question": "What is the background context in this case summary?", "title": "5dba0dbf970043bab29c348173760445", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Migraines\nIssue under review:  Zembrace"], "answer_start": [0]}, "context": "Diagnosis:  Migraines\nIssue under review:  Zembrace\n\nDetermination:\nThe Zembrace is not medically necessary.\n\nThere is no documented reason as to why the patient cannot be treated with the preferred formulary agents.  The patient can be treated with sublingual disintegrating triptans.  There is no evidence from high quality clinical trials or support from standard of care guidelines for the preferential use or superiority of Zembrace relative to the preferred agents.  The patient can be treated with sublingual disintegrating triptans. ", "id": "f5b42bad415e42fcae80886c2a303605", "question": "What is the background context in this case summary?", "title": "f5b42bad415e42fcae80886c2a303605", "sufficiency_score": 3}
+{"answers": {"text": ["the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.", "Diagnosis: Class I malocclusion, and anterior crossbite with gingival attachment loss (canines)", "Treatment: Braces", "The insurer has denied coverage for braces.", "This patient is a child.", "this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, and anterior crossbite with gingival attachment loss (canines). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 8 points on review by internal reviewers.", "it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the HLD Index Report (HLD, New York State Medicaid program) modeled after HLD Index."], "answer_start": [1941, 0, 97, 116, 186, 450, 1249]}, "context": "Diagnosis: Class I malocclusion, and anterior crossbite with gingival attachment loss (canines)\n\nTreatment: Braces\n\nThe insurer has denied coverage for braces. The denial was reversed.\n\nThis patient is a child. Upon review of the submitted documentation, including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, peer reviewed literature, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, and anterior crossbite with gingival attachment loss (canines). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 8 points on review by internal reviewers. \n\nUpon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the HLD Index Report (HLD, New York State Medicaid program) modeled after HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. \n\nIn this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.  Regarding the validity of the HLD Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies including:\n\nBeglin, et al. A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need. Am J Orthod Dentofacial Orthoped 2001; 120: 240-6, \n\nParker. A study of 1000 malocclusions selected by the HLD Index. Am J Orthod Dentofacial Orthoped 1999; 115:343-51, \n\nTheis, et al. Eligibility for publically funded orthodontic treatment determined by the handicapping labiolingual deviation index. Am J Orthod Dentofacial Orthoped 2005; 128:708-15. \n \nEach of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  \n\nReverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. The healthcare plan did not act reasonably or with sound medical judgment or the best interest of the patient.\n\nBased on the above, the medical necessity for braces is substantiated.  The insurer's denial is reversed.\n\n\n", "id": "563a9128c7e44068b1952f65c7d2f00a", "question": "What is the background context in this case summary?", "title": "563a9128c7e44068b1952f65c7d2f00a", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Varicose veins\nTreatment: Stab phlebectomy", "The primary basis for denial is that \"documentation does not show the treatment to be performed concurrently with or after saphenous vein stripping or ablation per required criteria\". The requirement that phlebectomy can only be done concurrently with or after saphenous vein stripping or ablation exists in the health plan policy.", "The provider (AP) has proposed left leg phlebectomy for this patient who has minimal axial saphenous reflux.", "The patient's venous reflux study does not show clinically significant axial reflux. She has only focal reflux in separate segments of the greater saphenous vein.", "The physician has documented that the veins to be treated are ropey. The venous duplex also confirms the presence of varicosities in both legs.", "The record shows that the patient has been using prescription-grade compression stockings regularly with only minimal relief of symptoms. She has undergone an unsuccessful, monitored trial of stockings.", "The office notes show that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function."], "answer_start": [0, 95, 1510, 2335, 2780, 2955, 2529]}, "context": "Diagnosis: Varicose veins\nTreatment: Stab phlebectomy\nThe phlebectomy is medically necessary.\n\nThe primary basis for denial is that \"documentation does not show the treatment to be performed concurrently with or after saphenous vein stripping or ablation per required criteria\". The requirement that phlebectomy can only be done concurrently with or after saphenous vein stripping or ablation exists in the health plan policy. However, this requirement is not consistent with published clinical data or consensus guidelines for phlebectomy. When other criteria are met (see discussion below), phlebectomy is widely accepted as medically necessary in the absence of concurrent or prior saphenous ablation.\n\nIt should be noted that the denial letter incorrectly describes CPT 37785 as a code for sclerotherapy. The correct definition of this code is \"Ligation, division, and/or excision of varicose vein cluster(s), 1 leg\".  Additionally, the letter states that CPT 37799 is not the correct code for stab phlebectomy. This statement is incorrect. CPT 37799 (unlisted code) is the code that is supposed to be used for stab phlebectomy when fewer than ten stab incisions are used.  All of the codes requested by the provider are alternative codes for phlebectomy:\n37766 is for phlebectomy with 20+ stab incisions\n37765 is for phlebectomy with ten to 20 stab incisions\n37799, the unlisted code, is used for phlebectomy with under ten stab incisions\n37785 is used for phlebectomy of a single varicose vein cluster.\n\nThe provider (AP) has proposed left leg phlebectomy for this patient who has minimal axial saphenous reflux. In order to evaluate the medical necessity of the service, widely accepted standards will be applied [1-3]. Under these standards, phlebectomy is appropriate when:\n\na) There is no axial saphenous reflux, or any associated axial reflux has been treated. If axial reflux has been treated, a sufficient waiting period (usually four to six weeks minimum) should elapse to allow for evaluation of the patient's residual leg symptoms.\n\nb) The patient has symptoms of venous insufficiency severe enough to interfere with normal function.\n\nc) The patient's varicose veins are large enough to account for the symptoms.\n\nd) The patient has failed a trial of medical grade compression stockings.\n\nRequirement (a) has been met. The patient's venous reflux study does not show clinically significant axial reflux. She has only focal reflux in separate segments of the greater saphenous vein.\n\nRequirement (b) has been met. The office notes show that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function. The appeal letter corroborates and elaborates upon the history reported in the office notes.\n\nRequirement (c) has been met. The physician has documented that the veins to be treated are ropey. The venous duplex also confirms the presence of varicosities in both legs.\n\nRequirement (d) has been met. The record shows that the patient has been using prescription-grade compression stockings regularly with only minimal relief of symptoms. She has undergone an unsuccessful, monitored trial of stockings.\n\nTherefore, in summary, the patient meets published, well accepted criteria for performance of phlebotomy.\n", "id": "9366d57517ec43dfa4cf32d74af65d6f", "question": "What is the background context in this case summary?", "title": "9366d57517ec43dfa4cf32d74af65d6f", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male child who presented to the Emergency Room (ER) for left lateral neck and cheek swelling after having failed to show improvement of the swelling after being started on clindamycin by his primary care physician.  Physical examination in the ER revealed a large area of tenderness and swelling over the submandibular and parotid area.", "A CT confirmed a left intraparotid 2.2 by 1.4 cm fluid collection consistent with abscess.", "the left parotid gland was enlarged and inflamed, consistent with parotitis, indicating that the abscess was a complication of the parotitis. It was also a concern that the left internal jugular vein was compressed", "It was ultimately evident that the parotid infection was caused by Strep pyogenes", "the sonogram of the neck done soon after ER arrival had been even more concerning for a finding of a more than 3 by 2 by 2 cm mass with heterogeneous density fluid components which could have raised suspicion of a deep neck abscess.", "a chest x-ray noted rightward tracheal deviation with concern for left-sided mass, which could possibly be mediastinal, if indeed there was a left-sided deep neck abscess.", "There was leukocytosis at a level of 19,500 and an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) indicating a severe infection. ", "Diagnosis: Parotid abscess", "Treatment: Inpatient admission", "The insurer has denied inpatient admission."], "answer_start": [130, 693, 794, 2029, 1225, 1468, 1870, 0, 28, 60]}, "context": "Diagnosis: Parotid abscess\n\nTreatment: Inpatient admission\n\nThe insurer has denied inpatient admission. The denial was reversed.\n\nThe patient is a male child who presented to the Emergency Room (ER) for left lateral neck and cheek swelling after having failed to show improvement of the swelling after being started on clindamycin by his primary care physician.  Physical examination in the ER revealed a large area of tenderness and swelling over the submandibular and parotid area. The patient clearly needed intravenous antibiotic therapy and close monitoring as an inpatient for possible spread of infection or possible airway compromise. The following facts support this determination:\n \nA CT confirmed a left intraparotid 2.2 by 1.4 cm fluid collection consistent with abscess. Moreover, the left parotid gland was enlarged and inflamed, consistent with parotitis, indicating that the abscess was a complication of the parotitis. It was also a concern that the left internal jugular vein was compressed, which this reviewer assumes was from the parotid mass. Incidentally found were middle ear effusions with possible otomastoiditis, which is another bacterial infection that would require antibiotic therapy. In fact, the sonogram of the neck done soon after ER arrival had been even more concerning for a finding of a more than 3 by 2 by 2 cm mass with heterogeneous density fluid components which could have raised suspicion of a deep neck abscess. Moreover, a chest x-ray noted rightward tracheal deviation with concern for left-sided mass, which could possibly be mediastinal, if indeed there was a left-sided deep neck abscess. The history of Methicillin-resistant Staphylococcus aureus (MRSA) infection in the neonatal period was also significant; therefore, it was reasonable to include MRSA in the list of possible organisms causing the parotid abscess.  There was leukocytosis at a level of 19,500 and an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) indicating a severe infection. \n\nIt was ultimately evident that the parotid infection was caused by Strep pyogenes, which can be a rapidly progressing soft tissue infection and entails the risk of bacteremia in a young infant of this patient's age. The intravenous antibiotic regimen Vancomycin and Unasyn was standard of care.\n\nIn summary, the patient had significant co-morbidities with his bacterial parotid gland infection, and as supported by the review by Stong et al, \"the presence of a significant co-morbidity, fever, or leukocytosis may require inpatient therapy and imaging if patients fail to improve with medical therapy.\" \n\nThe health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The inpatient hospital service is considered medically necessary for this patient. \n\nBased on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated. The insurer's denial is reversed.\n", "id": "27925f2fae554bb3b9de39614696db06", "question": "What is the background context in this case summary?", "title": "27925f2fae554bb3b9de39614696db06", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Lewy body dementia\nIssue under review: Increase in PCW services", "This is a patient with a history of advanced Lewy body dementia and associated psychosis.", "the report from the patient's attending physician that the patient has sustained further cognitive and functional decline", "a recent Uniform Assessment System of New York revealed that the patient had not experienced significant changes in her cognitive, functional status and overall self-sufficiency as compared to her last assessment date."], "answer_start": [0, 149, 248, 371]}, "context": "Diagnosis: Lewy body dementia\nIssue under review: Increase in PCW services\n\nDetermination:\nThe Increase in PCW services is not medically necessary.\n\nThis is a patient with a history of advanced Lewy body dementia and associated psychosis.  Despite the report from the patient's attending physician that the patient has sustained further cognitive and functional decline, a recent Uniform Assessment System of New York revealed that the patient had not experienced significant changes in her cognitive, functional status and overall self-sufficiency as compared to her last assessment date.  Furthermore, her currently approved PCW service is sufficient to meet her ADLs and other needs.  For these reasons, the proposed treatment of an increase in PCW services is not deemed medically necessary.", "id": "b0e5504cfb38476eb970aad8d7ff79f5", "question": "What is the background context in this case summary?", "title": "b0e5504cfb38476eb970aad8d7ff79f5", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Migraines", "Treatment: Medication- Emgality", "The insurer denied coverage for Emgality.", "This child patient has a past medical history notable for anxiety, asthma and obesity with chronic headaches most consistent with migraines.  She has frequent headaches and they are severe, long-lasting and debilitating.  She was referred to a neurologist; she has never taken prophylactic headache medication.  Neurologist recommended Emgality."], "answer_start": [0, 23, 57, 123]}, "context": "Diagnosis: Migraines\n \nTreatment: Medication- Emgality \n\nThe insurer denied coverage for Emgality. The denial was upheld.\n\nThis child patient has a past medical history notable for anxiety, asthma and obesity with chronic headaches most consistent with migraines.  She has frequent headaches and they are severe, long-lasting and debilitating.  She was referred to a neurologist; she has never taken prophylactic headache medication.  Neurologist recommended Emgality.  \n\nEmgality will only be approved for adult patients. Furthermore, the patient must have had serious side-effects or drug failure to a 3-month trial of at least two medications- examples include Propranolol, Topiramate, Valproic Acid, Amitriptyline, Venlafaxine and Botox. There is no documentation that the patient has failed 2 preventative medications for migraines. \n\nThe patient's asthma is a contraindication to propranolol and other beta blockers.  Neurologist states that the patient cannot take amyitryptiline or nortryptiline because she is already taking two other antidepressants, though this is not an absolute contraindication. The patient has no contraindication to Topirimate, Valproate or Botox.\n", "id": "480d5f7a84f6462fb56de9d246463f0b", "question": "What is the background context in this case summary?", "title": "480d5f7a84f6462fb56de9d246463f0b", "sufficiency_score": 4}
+{"answers": {"text": ["The patient in this case was using opioid/heroin together with large quantity of alcohol on a daily continuous basis; and intermittent use of cocaine", "Diagnosis: Substance abuse", "Treatment: Continued inpatient admission", "the patient presented with moderately severe withdrawal symptoms that persisted", "and the patient's social environment was not conducive to detoxification.", "the patient struggled with withdrawal symptoms", "in the context of limited insight, impaired judgment and poor control of impulses."], "answer_start": [304, 0, 28, 812, 925, 1006, 1091]}, "context": "Diagnosis: Substance abuse\n\nTreatment: Continued inpatient admission\n\nThe continued inpatient admission was medically necessary for this patient.\nThe requested benefit of the continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using opioid/heroin together with large quantity of alcohol on a daily continuous basis; and intermittent use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode, could not have safely or effectively proceeded at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient presented with moderately severe withdrawal symptoms that persisted requiring withdrawal management, and the patient's social environment was not conducive to detoxification. Again, the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses. Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring. \n\nThe patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment, and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the LOCADTR Tool that requires the patient in this scenario default to the higher level of care.\n\nThe requested benefit of continued inpatient admission is medically necessary in this case scenario, and therefore should be covered in this case scenario. The health plan contends that the patient could have been treated at inpatient rehabilitation level of care. However, the patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria, referenced below. \n", "id": "f79a02959041411a8cfbf10481a78bf3", "question": "What is the background context in this case summary?", "title": "f79a02959041411a8cfbf10481a78bf3", "sufficiency_score": 4}
+{"answers": {"text": ["This is a middle aged male who presented to the visit in mid-2019 for alopecia areata and vitiligo. The patient reported that it had been present for years. He also had loss of his eyebrows and eyelashes, and had 30% hair loss to the scalp. Additionally, he had severe eye irritation, scattered patches on the scalp and body. His face and neck had demonstrated vitiligo depigmented patches as well. The recommendation was to start Xeljanz 5 mg oral tablet, one tablet twice per day.", "The patient's condition has had a severe negative impact on his personal life. It has caused embarrassment, isolation, and depression, in addition to having a negative impact on his livelihood and overall well-being. The patient has tried and failed conservative therapies.", "Diagnosis: Alopecia Areata and Vitiligo", "Treatment: Xeljanz", "The insurer denied the Xeljanz.", "The patient has alopecia areata and vitiligo."], "answer_start": [122, 867, 0, 42, 62, 605]}, "context": "Diagnosis: Alopecia Areata and Vitiligo \n\nTreatment: Xeljanz\n\nThe insurer denied the Xeljanz. The denial was reversed. \n\n\nThis is a middle aged male who presented to the visit in mid-2019 for alopecia areata and vitiligo. The patient reported that it had been present for years. He also had loss of his eyebrows and eyelashes, and had 30% hair loss to the scalp. Additionally, he had severe eye irritation, scattered patches on the scalp and body. His face and neck had demonstrated vitiligo depigmented patches as well. The recommendation was to start Xeljanz 5 mg oral tablet, one tablet twice per day.\nThe patient has alopecia areata and vitiligo.  There is no Food and Drug Administration (FDA) approved or plan approved therapies for alopecia areata or vitiligo. Xeljanz has been found to be effective and safe for the treatment of alopecia areata and vitiligo. The patient's condition has had a severe negative impact on his personal life. It has caused embarrassment, isolation, and depression, in addition to having a negative impact on his livelihood and overall well-being. The patient has tried and failed conservative therapies.\n\n\"Agents which are commonly used to treat rheumatologic diseases and psoriasis are also being studied in the treatment of autoimmune diseases including vitiligo. Janus kinase (JAK) inhibitors have been evaluated in several case reports, with potential therapeutic promise thought to be related to their interference with interferon (IFN)- signaling 48, 49, 74, 75. Research has shown that IFN-induced expression of CXCL10 is critical for the progression and maintenance of depigmentation in vitiligo 76. In a recent case report, a patient with vitiligo was treated with tofacitinib, an oral JAK 1/3 inhibitor, for 5 months, and had significant repigmentation with no significant adverse effects 74.\" (Manga, P., Elbuluk, N., & Orlow, S. J., 2016).\n\nBased on the above, the medical necessity for Xeljanz is substantiated.  The insurer's denial is reversed.\n", "id": "6e9adea9ecba4f89bddb9ff23a9b88ca", "question": "What is the background context in this case summary?", "title": "6e9adea9ecba4f89bddb9ff23a9b88ca", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male who presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid, cocaine, and cannabis class substances of abuse. He had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis with up to two pints of liquor and 12 beers. He had multiple prior substance use disorder treatments including an interval of sobriety for two years while in a healthy relationship with family and while participating in treatment. However, he reported up to 100 previous detoxification treatments and 5 previous rehabilitation substance use disorder treatment episodes with more recent treatments.", "The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and prn medications prescribed for pain, anxiety, and insomnia. The patient's hospital course progressed without incident. Vital signs remained normal, and the patient reported mild tremor, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished over the first four days of admission. He was socially withdrawn but participating in counseling and educational sessions. From the next day forward, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.", "Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment which was achieved at the time of discharge.", "the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare."], "answer_start": [0, 762, 1663, 1817]}, "context": "The patient is a male who presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid, cocaine, and cannabis class substances of abuse. He had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis with up to two pints of liquor and 12 beers. He had multiple prior substance use disorder treatments including an interval of sobriety for two years while in a healthy relationship with family and while participating in treatment. However, he reported up to 100 previous detoxification treatments and 5 previous rehabilitation substance use disorder treatment episodes with more recent treatments.\n\nThe patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and prn medications prescribed for pain, anxiety, and insomnia. The patient's hospital course progressed without incident. Vital signs remained normal, and the patient reported mild tremor, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished over the first four days of admission. He was socially withdrawn but participating in counseling and educational sessions. From the next day forward, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.\n\nArrangements were being made for a direct referral to rehabilitation substance use disorder treatment which was achieved at the time of discharge. Again, the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.\n\nThe health plan denied the last day of the admission as not medically necessary. The health plan's determination is overturned. \n\nThe requested benefit of continued inpatient detoxification treatment and withdrawal management and monitoring and other medical services for the last day of service could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with multiple other substances of abuse that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. The continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services. And it was in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of American Society of Addiction Medicine (ASAM) Criteria and application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.", "id": "da1ab2636cae4dfe9e7df498ed5bc95c", "question": "What is the background context in this case summary?", "title": "da1ab2636cae4dfe9e7df498ed5bc95c", "sufficiency_score": 4}
+{"answers": {"text": ["This case involves male who was seen in early 2019 for a consultation.  The patient was being seen for a bilateral provoked pulmonary emboli, as well as community-acquired pneumonia. He had a history of a fractured his fibula and tibia back in early 2019 and underwent an internal fixation. He experienced increasing pain to the left lower extremity after surgery and was found to be negative for a deep venous thrombosis. He began to complain of back and chest pain; a CT scan of the chest was performed showing filling defects in both lower lobe pulmonary arteries compatible with pulmonary emboli.  The patient began utilizing Xarelto and continues on the medication.  The patient stated he had a family history of thrombosis. It was recommended he undergo a hypercoagulable work-up due to his recent diagnosis and family history. The patient completed a three months regimen of anticoagulation; and additional laboratory studies were recommended.", "Diagnosis: Bilateral Lower Lobe Pulmonary Emboli and Pneumonia.", "Treatment: Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)", "The insurer denied the Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)."], "answer_start": [353, 0, 66, 190]}, "context": "Diagnosis: Bilateral Lower Lobe Pulmonary Emboli and Pneumonia.\n \nTreatment: Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)\n\nThe insurer denied the Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant). The denial was upheld.   \n\nThis case involves male who was seen in early 2019 for a consultation.  The patient was being seen for a bilateral provoked pulmonary emboli, as well as community-acquired pneumonia. He had a history of a fractured his fibula and tibia back in early 2019 and underwent an internal fixation. He experienced increasing pain to the left lower extremity after surgery and was found to be negative for a deep venous thrombosis. He began to complain of back and chest pain; a CT scan of the chest was performed showing filling defects in both lower lobe pulmonary arteries compatible with pulmonary emboli.  The patient began utilizing Xarelto and continues on the medication.  The patient stated he had a family history of thrombosis. It was recommended he undergo a hypercoagulable work-up due to his recent diagnosis and family history. The patient completed a three months regimen of anticoagulation; and additional laboratory studies were recommended.\nThe F2 gene is known as the coagulation factor which is associated with impaired clotting ability. The F5 gene is also known as coagulation factor V, and is associated with coagulation factors essential for proper blood clot formation. According to current peer-reviewed literature, the testing for hypercoagulable disorders in a patient with a diagnosis of venous thromboembolism is not warranted. This is because the identification of an inheritable defect does not alter therapeutic or prophylactic anticoagulation management, and consequently it has not been associated with improved outcomes. \n\nBased on the above, the medical necessity for genetic testing for CPT code 81241 (F5 coagulation Factor V gene analysis, Leiden variant) and 81240 (F2 gene analysis 20210G>A variant) is not substantiated.  The insurer's denial is upheld.\n\t\n", "id": "ab19e77b7dee4b878d05ea1ef5c8acee", "question": "What is the background context in this case summary?", "title": "ab19e77b7dee4b878d05ea1ef5c8acee", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented to the emergency department with suicidal ideation. The patient reported being noncompliant with the psychiatry medications for approximately 3 weeks. In the emergency department, the patient verbalized wishes to harm himself. The patient was found to have uncontrolled diabetes with a glucose in the 400s. The initial work up showed a chest x-ray that was unremarkable. On examination, the patient had reduced ability to focus attention, thought content paranoid, poor judgment, depressed mood, poor insight with auditory hallucinations. The patient was evaluated by psychiatry for suicidal ideation and medication management. A one-to-one sitter for patient safety was recommended. The patient was started on citalopram, quetiapine and hydroxyzine. The patient was admitted to medicine unit for treatment of uncontrolled diabetes and was started on basal insulin with Lantus, regular insulin before meals and a sliding scale."], "answer_start": [0]}, "context": "The patient presented to the emergency department with suicidal ideation. The patient reported being noncompliant with the psychiatry medications for approximately 3 weeks. In the emergency department, the patient verbalized wishes to harm himself. The patient was found to have uncontrolled diabetes with a glucose in the 400s. The initial work up showed a chest x-ray that was unremarkable. On examination, the patient had reduced ability to focus attention, thought content paranoid, poor judgment, depressed mood, poor insight with auditory hallucinations. The patient was evaluated by psychiatry for suicidal ideation and medication management. A one-to-one sitter for patient safety was recommended. The patient was started on citalopram, quetiapine and hydroxyzine. The patient was admitted to medicine unit for treatment of uncontrolled diabetes and was started on basal insulin with Lantus, regular insulin before meals and a sliding scale.\n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was evaluated by psychiatry and one-to-one sitter for safety was ordered; he was restarted on his psychiatric medications. He was also followed by endocrinology and insulin regimen was adjusted for better diabetes management. He remained clinically stable during his hospitalization, pending possible transfer to inpatient psych facility, however, after further evaluation by psychiatry, he was considered stable from psychiatry standpoint to be discharged home. Based on the available clinical information, and patient's presentation and plan of care, the patient required hospitalization for further monitoring and evaluation of his clinical condition, however, the services could have been provided at a lower level of care. ", "id": "da1a00a8381f410fa58019934ec8d0c7", "question": "What is the background context in this case summary?", "title": "da1a00a8381f410fa58019934ec8d0c7", "sufficiency_score": 4}
+{"answers": {"text": ["This is a middle aged male who presented to the Emergency Department (ED) in early 2019 with complaints of an allergic reaction after taking Aleve. His presenting complaints were an acute onset of flushing, hives, facial swelling; difficulty speaking that started 15 minutes after taking Aleve. He was given Benadryl in the ambulance and symptoms improved. On examination in the ED it was noted that there was tongue swelling with mallimpati 3. He has a history of hypertension, hyperlipidemia, anxiety and obstructive sleep apnea.\nThe documentation indicates that the patient was seen due to an allergic reaction after taking Aleve. He got hives and had tongue swelling.  Airway was non-obstructive. The patient was given medications with improvement in the emergency department.", "Diagnosis: Angioedema", "Treatment: Inpatient Admission", "The insurer denied Inpatient Admission."], "answer_start": [120, 0, 24, 56]}, "context": "Diagnosis: Angioedema \n\nTreatment: Inpatient Admission\n\nThe insurer denied Inpatient Admission. The denial was upheld.\n\nThis is a middle aged male who presented to the Emergency Department (ED) in early 2019 with complaints of an allergic reaction after taking Aleve. His presenting complaints were an acute onset of flushing, hives, facial swelling; difficulty speaking that started 15 minutes after taking Aleve. He was given Benadryl in the ambulance and symptoms improved. On examination in the ED it was noted that there was tongue swelling with mallimpati 3. He has a history of hypertension, hyperlipidemia, anxiety and obstructive sleep apnea.\nThe documentation indicates that the patient was seen due to an allergic reaction after taking Aleve. He got hives and had tongue swelling.  Airway was non-obstructive. The patient was given medications with improvement in the emergency department. There was no indication that the patient had an allergic reaction with severe symptoms not responsive to emergency or observational care treatment such as airway edema, stridor, respiratory distress, bronchospasm or hemodynamic instability.\n\nBased on the above, the medical necessity for inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.\n", "id": "e03ae00272104041813bfb166422219b", "question": "What is the background context in this case summary?", "title": "e03ae00272104041813bfb166422219b", "sufficiency_score": 4}
+{"answers": {"text": ["The patient with a past medical history significant for a generalized anxiety disorder who presented to the emergency department with sudden onset of progressive right arm and hand weakness and tingling.The patient, complained of paresthesia, which was described as a \"pins and needles\", sensation in the right medial aspect of the arm. During the hospital stay the patient's symptoms, which included weakness and tingling in the right arm, improved but did not resolve completely. The patient was discharged from the hospital"], "answer_start": [0]}, "context": "The patient with a past medical history significant for a generalized anxiety disorder who presented to the emergency department with sudden onset of progressive right arm and hand weakness and tingling.The patient, complained of paresthesia, which was described as a \"pins and needles\", sensation in the right medial aspect of the arm. During the hospital stay the patient's symptoms, which included weakness and tingling in the right arm, improved but did not resolve completely. The patient was discharged from the hospital the health plans determination is upheld in whole. The admission for a lower level of care and with a workup was appropriate, since the admitting diagnosis in the emergency department was transient ischemic attack (TIA). The workup of the TIA does not usually require admission at the acute inpatient level of care, since the patient was hemodynamically stable, had no progression of the neurological deficits during the hospital stay, did not require administration of parenteral anticoagulants or antiplatelet agents, and had no additional medical conditions that would justify medical necessity for the admission at acute inpatient level of care.", "id": "fc3083f404664237a06e82fc9faa152d", "question": "What is the background context in this case summary?", "title": "fc3083f404664237a06e82fc9faa152d", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented to the emergency department (ED) with complaints of dyspnea. According to the documentation provided, the patient was admitted as an observation but developed hypoxemia on the planned day of discharge and was converted to an inpatient level of care. The patient presented with dyspnea that had started the night prior to admission. It was not improved with nebulized albuterol and was associated with increase in the sputum production as well as a change in the character of the produced sputum. The patient was started on intravenous (IV) steroids and given multiple nebulized treatments but continued to have wheezing and dyspnea. The patient was admitted at that time. \n"], "answer_start": [0]}, "context": "The patient presented to the emergency department (ED) with complaints of dyspnea. According to the documentation provided, the patient was admitted as an observation but developed hypoxemia on the planned day of discharge and was converted to an inpatient level of care. The patient presented with dyspnea that had started the night prior to admission. It was not improved with nebulized albuterol and was associated with increase in the sputum production as well as a change in the character of the produced sputum. The patient was started on intravenous (IV) steroids and given multiple nebulized treatments but continued to have wheezing and dyspnea. The patient was admitted at that time. \n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. The patient appeared to be improving and the listed reason for requiring an inpatient level of care was episodic hypoxemia. However, this documented hypoxemia into the 80's was short lasting and appears to have been precipitated from a decrease in her oxygen to 2 lpm (liters per minute) from her baseline requirement of 3 lpm. This appears to have resolved by later the same day on the documents that were provided. This patient could have been cared for at a lower level of care.", "id": "3e0c5e3d9bea401a97b2605a8d851593", "question": "What is the background context in this case summary?", "title": "3e0c5e3d9bea401a97b2605a8d851593", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with multiple medical problems most notably dementia of Alzheimer's type. The patient requested 7 days per week split shift for a total 168 hours per week of level 2 personal-care services. The health plan denied the services as not medically necessary.", "The patient has multiple medical problems most notably dementia of Alzheimer's type. He has a past medical history significant for diabetes mellitus type 2, chronic kidney disease, hypertension, coronary artery disease, hypothyroidism and chronic anemia. He has been maintained on multiple medications for hypertension and diabetes. He has had chronic dementia that was rapidly progressing over the last few months. He had several evaluations noted. A Uniform Assessment System (UAS) state of New York assessment was completed at at he beginning of the year. He had a repeat evaluation, UAS state of New York completed five months later. He was approved for 10 hours a day 7 days per week.", "The patient needs help with his daytime activities of daily living. He is able to walk indoors with a walker without supervision and use a bathroom. He is noted to wander at night meaning that he can walk on his own without falls.", "It is noted on 2 separate UAS that the patient requires help with the services"], "answer_start": [0, 321, 1013, 1413]}, "context": "The patient is a male with multiple medical problems most notably dementia of Alzheimer's type. The patient requested 7 days per week split shift for a total 168 hours per week of level 2 personal-care services. The health plan denied the services as not medically necessary. The health plan's determination is upheld. \n\nThe patient has multiple medical problems most notably dementia of Alzheimer's type. He has a past medical history significant for diabetes mellitus type 2, chronic kidney disease, hypertension, coronary artery disease, hypothyroidism and chronic anemia. He has been maintained on multiple medications for hypertension and diabetes. He has had chronic dementia that was rapidly progressing over the last few months. He had several evaluations noted. A Uniform Assessment System (UAS) state of New York assessment was completed at at he beginning of the year. He had a repeat evaluation, UAS state of New York completed five months later. He was approved for 10 hours a day 7 days per week. \n\nThe patient needs help with his daytime activities of daily living. He is able to walk indoors with a walker without supervision and use a bathroom. He is noted to wander at night meaning that he can walk on his own without falls. Typically, aide services are medically necessary for help with the performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). It is noted on 2 separate UAS that the patient requires help with the services however the services that would be considered medically necessary can be performed during the approved time period. There are no additional services that are noted that would require additional personal-care aide hours. Personal-care aide hours without performance of ADLs or IADLs are typically not considered medically necessary. For example monitoring for supervision or to prevent wandering is not necessarily considered an ADL or IADL. In order for an aide to be present during additional time additional level 1 or level 2 services need to be performed, however this is not the case.", "id": "1bb618ffbe4441f4be0471ef3e5ece4c", "question": "What is the background context in this case summary?", "title": "1bb618ffbe4441f4be0471ef3e5ece4c", "sufficiency_score": 4}
+{"answers": {"text": ["Hyperbilirubinemia\nInpatient stay", "The patient at the time of service was an infant  who was referred from the primary care office with hyperbilirubinemia.\nPatient was born after prolonged rupture of membranes (greater than 18 hours), and mother was positive for group B streptococcus. Patient had some bruising on the head and back after delivery. Bilirubin at 2 days of life was 11 mg/dl. Following discharge to home, patient was well until 2 days prior to presentation when  noted to be more jaundiced and lethargic at home. Patient was sent back to the emergency department (ED) due to significant hyperbilirubinemia. The bilirubin level at that time was 23.2 mg/dl, with a direct bilirubin of 0.7. Patient was given a bolus of fluids at that time and was started on triple phototherapy. Bilirubin was followed every 6 hours and the patient was given intravenous fluids due to decreased intake. During the hospitalization the bilirubin trended down from 23 to 17, 15.3, and 13.6 mg/dl."], "answer_start": [0, 35]}, "context": "Hyperbilirubinemia\nInpatient stay\n\nThe patient at the time of service was an infant  who was referred from the primary care office with hyperbilirubinemia.\nPatient was born after prolonged rupture of membranes (greater than 18 hours), and mother was positive for group B streptococcus. Patient had some bruising on the head and back after delivery. Bilirubin at 2 days of life was 11 mg/dl. Following discharge to home, patient was well until 2 days prior to presentation when  noted to be more jaundiced and lethargic at home. Patient was sent back to the emergency department (ED) due to significant hyperbilirubinemia. The bilirubin level at that time was 23.2 mg/dl, with a direct bilirubin of 0.7. Patient was given a bolus of fluids at that time and was started on triple phototherapy. Bilirubin was followed every 6 hours and the patient was given intravenous fluids due to decreased intake. During the hospitalization the bilirubin trended down from 23 to 17, 15.3, and 13.6 mg/dl. The health plan's determination of medical necessity is overturned in whole. This is a young infant who presented with significantly elevated indirect bilirubin levels. This was likely related to breast-feeding jaundice and inadequate intake, as well as bruising from birth which increases the amount of bilirubin present. The patient required prompt initiation of phototherapy with ongoing monitoring and intravenous fluids to ensure that the levels came down quickly. This is necessary to protect the central nervous system from bilirubin crossing the blood-brain barrier.\nFor well infants greater than 38 weeks gestational age, phototherapy needs to be started when values are greater than 18 mg/dL for infants greater than 72 hours of age. In fact, exchange transfusion is required for infants at that age who have bilirubin levels greater than 24 mg/dL. This is due to the risk of neurotoxicity when bilirubin values exceed the infant's capability of albumin binding to bilirubin to prevent crossing through the blood-brain barrier. This infant exceeded the risk value of total serum bilirubin and required immediate initiation of phototherapy and treatment to mitigate the risk of neurologic injury.", "id": "f7e66eca30ab4b75b9f7d876754ad0e7", "question": "What is the background context in this case summary?", "title": "f7e66eca30ab4b75b9f7d876754ad0e7", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Overbite\nTreatment: Braces", "The patient has a severe overbite that causes her lower front teeth to impinge on her palatal tissues.", "The patient also has very prominent upper anterior teeth."], "answer_start": [0, 75, 259]}, "context": "Diagnosis: Overbite\nTreatment: Braces\nThe braces are medically necessary.\n\nThe patient has a severe overbite that causes her lower front teeth to impinge on her palatal tissues. This is an \"automatic qualifying\" condition according to the handicapping index. The patient also has very prominent upper anterior teeth. Due to their forward position, they will be more prone to trauma over time. Orthodontic treatment is needed to correctly move her teeth into a more protective position. Both of these conditions are a reason for there to have medical necessity for orthodontic benefits.\n\n", "id": "b1a3bc6b06364d89a89a1c623ebc44ec", "question": "What is the background context in this case summary?", "title": "b1a3bc6b06364d89a89a1c623ebc44ec", "sufficiency_score": 4}
+{"answers": {"text": ["The insurer denied the PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week.", "This is an elderly female patient with multiple medical conditions and substantial functional impairment. Her medical history includes: atherosclerotic heart disease, hypertension, hypothyroidism, dementia, hydrocephalus, osteoarthritis, gait and mobility abnormality, history of falls, dizziness, deformities of toes, urinary incontinence, fecal urgency. She currently lives with her daughter, son-law-law and grandson in a home with multiple levels, requiring use of stairs to enter and to move throughout the home.  The previous UAS from late 2018 indicates that the patient lived with her husband at that time and it was noted that the patient was receiving PCA services as a mutual case with her husband.  At the time of the previous UAS, the patient's cognitive status was less impaired as per the description in the UAS.  The patient required limited to extensive assistance for ADLs.", "In early 2019 the patient reportedly fell at home, was hospitalized and transferred to a facility for sub-acute rehab.  As per the UAS from mid-2019, the patient's current functional status had declined from the time of the previous UAS. It was documented that the patient was alert and oriented to person and place only, and required constant supervision. Total dependence was needed for meal preparation, ordinary housework, managing finances, managing medications; extensive assistance was needed for toilet transfer.  ADL status and overall self-sufficiency were noted as declined and deteriorated. The patient is dependent on substantial caregiver support for all IADLs and ADLs. IADL support is mostly maximal assistance or total dependence, and ADL support is extensive or maximal assistance. She needed maximal assistance for transfers (transfer toilet), walking and stairs which involves significant weight bearing support by a caregiver.", "The insurer approved PCA services for 8 hours per day, 7 days per week."], "answer_start": [122, 263, 1156, 2106]}, "context": "Diagnosis: Dementia\nTreatment: PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week\n\nThe insurer denied the PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week. The denial was reversed. \n\nThis is an elderly female patient with multiple medical conditions and substantial functional impairment. Her medical history includes: atherosclerotic heart disease, hypertension, hypothyroidism, dementia, hydrocephalus, osteoarthritis, gait and mobility abnormality, history of falls, dizziness, deformities of toes, urinary incontinence, fecal urgency. She currently lives with her daughter, son-law-law and grandson in a home with multiple levels, requiring use of stairs to enter and to move throughout the home.  The previous UAS from late 2018 indicates that the patient lived with her husband at that time and it was noted that the patient was receiving PCA services as a mutual case with her husband.  At the time of the previous UAS, the patient's cognitive status was less impaired as per the description in the UAS.  The patient required limited to extensive assistance for ADLs.\n\nIn early 2019 the patient reportedly fell at home, was hospitalized and transferred to a facility for sub-acute rehab.  As per the UAS from mid-2019, the patient's current functional status had declined from the time of the previous UAS. It was documented that the patient was alert and oriented to person and place only, and required constant supervision. Total dependence was needed for meal preparation, ordinary housework, managing finances, managing medications; extensive assistance was needed for toilet transfer.  ADL status and overall self-sufficiency were noted as declined and deteriorated. The patient is dependent on substantial caregiver support for all IADLs and ADLs. IADL support is mostly maximal assistance or total dependence, and ADL support is extensive or maximal assistance. She needed maximal assistance for transfers (transfer toilet), walking and stairs which involves significant weight bearing support by a caregiver. \n\nThe insurer approved PCA services for 8 hours per day, 7 days per week.  It is apparent that the patient needs caregiver assistance beyond 8 hours per day.  It is unrealistic to consider that the patient only needs to use the toilet or has incontinence episodes during 8 hours per day.  If the aide leaves after 8 hours, then either the patient is already in bed for the night, which means she is in bed for 16 hours per day; or she is still out of bed and the family needs to assist with change of clothes, toileting needs, placement in bed, and possibly dinner if the aide leaves before dinner time.\n\nBased on the above, the medical necessity for an increase in Personal Care Aide (PCA) Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week is substantiated. The insurer's denial is reversed.\n", "id": "1b0e6c95aa8748379a14fa9e1e8151d3", "question": "What is the background context in this case summary?", "title": "1b0e6c95aa8748379a14fa9e1e8151d3", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a class I molar and class II cuspid malocclusion. Congenitally missing maxillary laterals and retained primary maxillary left cuspid. Mild anterior open bite and overjet. Severe mandibular crowding. The proposed treatment is braces for 24 months."], "answer_start": [0]}, "context": "The patient has a class I molar and class II cuspid malocclusion. Congenitally missing maxillary laterals and retained primary maxillary left cuspid. Mild anterior open bite and overjet. Severe mandibular crowding. The proposed treatment is braces for 24 months. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the patient's malocclusion would score a 14. The patient does not have any auto qualifiers present which include deep impinging overbite, anterior crossbite, overjet 9mm or greater, negative overjet of 3.5mm or greater, or impacted incisors or canines. The HP determination is upheld in whole.", "id": "fe090e2d1f8c471aadd31b7652eca638", "question": "What is the background context in this case summary?", "title": "fe090e2d1f8c471aadd31b7652eca638", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis:  Overbite\nTreatment:  Braces", "The patient has a deep impinging overbite with trauma to the palatal tissues."], "answer_start": [0, 77]}, "context": "Diagnosis:  Overbite\nTreatment:  Braces\nThe braces are medically necessary.\n\nThe patient has a deep impinging overbite with trauma to the palatal tissues.  This is an \"automatic qualifying\" condition for orthodontic benefits.\n", "id": "1d8a4d4df62f4b0ab9392dbcad737fb8", "question": "What is the background context in this case summary?", "title": "1d8a4d4df62f4b0ab9392dbcad737fb8", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a male with a class II molar and cuspid malocclusion. Moderate overjet and overbite. The patient has severe maxillary and mandibular spacing. The proposed treatment is braces for 18 months."], "answer_start": [0]}, "context": "The patient is a male with a class II molar and cuspid malocclusion. Moderate overjet and overbite. The patient has severe maxillary and mandibular spacing. The proposed treatment is braces for 18 months.\nThe subject to be determined is the medical necessity for braces.\n\nThe health plan's determination is upheld.\n\nUsing the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 10 with no auto qualifier present. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5 mm or greater. Since the HLD score is less than 26 without an auto qualifier, braces are not medically necessary for this patient. ", "id": "da529e1c6fe1454d9cd67a153d0b511f", "question": "What is the background context in this case summary?", "title": "da529e1c6fe1454d9cd67a153d0b511f", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Open bite\nIssue under review: Braces"], "answer_start": [0]}, "context": "Diagnosis: Open bite\nIssue under review: Braces\n\nDetermination:\nThe Braces are not medically necessary.\n\nBased upon the records presented, there is no evidence of an anterior open bite. The handicapping index was below 25, therefore the criteria for benefits has not been established. There is no medical necessity in this case.", "id": "b72764845b6f443f9dd18f35cc0f8f38", "question": "What is the background context in this case summary?", "title": "b72764845b6f443f9dd18f35cc0f8f38", "sufficiency_score": 3}
+{"answers": {"text": ["This is a young female patient who presented to her orthodontist for a consult for orthodontic treatment.", "The orthodontist has completed the HLD index attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 22 points on the HLD index.", "Diagnosis: Skeletal Class I Malocclusion, Anterior Crowding Bimaxillary Protrusion, Overjet and Lip Incompetence \"CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip Entrapment, Convex, Lip Incompetence, and Mentalis Strain.\"   \nTreatment: Orthodontic Treatment", "The insurer denied the Orthodontic Treatment."], "answer_start": [368, 854, 0, 293]}, "context": "Diagnosis: Skeletal Class I Malocclusion, Anterior Crowding Bimaxillary Protrusion, Overjet and Lip Incompetence \"CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip Entrapment, Convex, Lip Incompetence, and Mentalis Strain.\"   \nTreatment: Orthodontic Treatment\n\nThe insurer denied the Orthodontic Treatment. The denial was reversed.   \n\nThis is a young female patient who presented to her orthodontist for a consult for orthodontic treatment.  Per Orthodontic the patient had skeletal Class I malocclusion, anterior crowding bimaxillary protrusion, overjet and lip incompetence \"CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip entrapment, Convex, Lip incompetence, and Mentalis strain.\"  A total score of 31 was indicated on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  \n\nThe orthodontist has completed the HLD index attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 22 points on the HLD index. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.\n\nRegarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  \n\nThe carrier's denial of coverage for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is reversed.  The medical necessity is substantiated.\n", "id": "a510a3fa48764541bd8f6359659ba9f4", "question": "What is the background context in this case summary?", "title": "a510a3fa48764541bd8f6359659ba9f4", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Abdominal Pain\nTreatment: Inpatient admission ", "The patient is a female who presented to the ER for further evaluation/management of left upper quadrant abdominal pain. \nThe patient's intake vitals were afebrile, hemodynamically stable.", "Examination was non focal with no critical abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG (electrocardiogram) testing was also without critical abnormalities noted, including no evidence of acute end organ damage. Abdominal CT revealed evidence of splanchnic portal vein thrombosis.", "The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN (as needed) analgesics and continued cardiac monitoring. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition.", "The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN analgesics and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition."], "answer_start": [0, 68, 258, 649, 1029]}, "context": "Diagnosis: Abdominal Pain\nTreatment: Inpatient admission \n\nSummary:\nThe patient is a female who presented to the ER for further evaluation/management of left upper quadrant abdominal pain. \nThe patient's intake vitals were afebrile, hemodynamically stable.\n\nExamination was non focal with no critical abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG (electrocardiogram) testing was also without critical abnormalities noted, including no evidence of acute end organ damage. Abdominal CT revealed evidence of splanchnic portal vein thrombosis. \n\nThe medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN (as needed) analgesics and continued cardiac monitoring. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition. \n\nThe medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN analgesics and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. \n\nThere is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.", "id": "bd472b4005024397a2e79ff4a08aee5d", "question": "What is the background context in this case summary?", "title": "bd472b4005024397a2e79ff4a08aee5d", "sufficiency_score": 4}
+{"answers": {"text": ["According to the records, the patient who initially began physical therapy for impairments and functional deficits related muscle weakness. There is a letter of appeal from the patient stating that she disagrees that physical therapy is not medically necessary, stating that it is necessary for her ability to walk without falling which involves continued work with balance and strengthening of her lower body. She reports having had two recent falls which led her and her physical therapist to believe that she needed continued work with balance and strengthening, particularly of the left leg on which she has had two surgeries, hip replacement surgery, and a knee replacement surgery. It was noted that 17 visits were authorized over six weeks. The patient is requesting coverage for continued skilled physical therapy visits, which was denied by the insurance carrier", "Diagnosis is noted to be M62.81 muscle weakness, generalized, that reportedly began a year prior. It is noted that the patient was previously authorized for 17 visits of physical therapy over six weeks."], "answer_start": [0, 1075]}, "context": "According to the records, the patient who initially began physical therapy for impairments and functional deficits related muscle weakness. There is a letter of appeal from the patient stating that she disagrees that physical therapy is not medically necessary, stating that it is necessary for her ability to walk without falling which involves continued work with balance and strengthening of her lower body. She reports having had two recent falls which led her and her physical therapist to believe that she needed continued work with balance and strengthening, particularly of the left leg on which she has had two surgeries, hip replacement surgery, and a knee replacement surgery. It was noted that 17 visits were authorized over six weeks. The patient is requesting coverage for continued skilled physical therapy visits, which was denied by the insurance carrier and is the subject of this review. The health plan's determination of medical necessity is upheld. The requested health service/treatment of physical therapy is not medically necessary for this patient. Diagnosis is noted to be M62.81 muscle weakness, generalized, that reportedly began a year prior. It is noted that the patient was previously authorized for 17 visits of physical therapy over six weeks. The records provided failed to document any significant ongoing functional progress or objective gains to suggest the patient would require additional physical therapy. It appears the patient had plateaued in treatment. Although the patient reports on appeal that she needed to continue working with balance and strengthening of her lower body, this can be accomplished outside of an office setting, for further progress independently and does not require ongoing skilled therapy sessions. Medical necessity was not established.", "id": "31653b164c574f108594a30e37e0e165", "question": "What is the background context in this case summary?", "title": "31653b164c574f108594a30e37e0e165", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with a history of hypertension and hyperlipidemia. In 2019 he was evaluated by a cardiologist for a complaint dyspnea with bending over. Coronary computed tomography (CT) angiography performed showed significant two vessel disease. He presented to the hospital for scheduled cardiac catheterization. His cardiovascular exam was unremarkable. There were no acute electrocardiographic changes. Catheterization was performed and an obstruction in the proximal left anterior descending coronary artery was treated with atherectomy and two stents. There was residual disease in the distal right coronary artery. The procedure was uncomplicated. He was discharged home the following day."], "answer_start": [0]}, "context": "The patient is a male with a history of hypertension and hyperlipidemia. In 2019 he was evaluated by a cardiologist for a complaint dyspnea with bending over. Coronary computed tomography (CT) angiography performed showed significant two vessel disease. He presented to the hospital for scheduled cardiac catheterization. His cardiovascular exam was unremarkable. There were no acute electrocardiographic changes. Catheterization was performed and an obstruction in the proximal left anterior descending coronary artery was treated with atherectomy and two stents. There was residual disease in the distal right coronary artery. The procedure was uncomplicated. He was discharged home the following day.\n\nThe health plan's determination is upheld. \n\nWhile some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Given that atherectomy was performed and two stents were placed in the same vessel, the patient could have been appropriately managed at a lower level of care status.", "id": "66776bb823fd45869d5a9292240e844c", "question": "What is the background context in this case summary?", "title": "66776bb823fd45869d5a9292240e844c", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has recurrent syncope. An ambulatory monitor documented a 21 second pause. The patient", "needed a permanent pacemaker in view of the recurrent syncope related to sinus pauses. The provider is requesting a leadless pacemaker"], "answer_start": [0, 107]}, "context": "The patient has recurrent syncope. An ambulatory monitor documented a 21 second pause. The patient clearly needed a permanent pacemaker in view of the recurrent syncope related to sinus pauses. The provider is requesting a leadless pacemaker as it has shown a reduction in morbidity relative to a pacemaker with intracardiac leads. This is the subject of this review. \n\nThe health plan's determination is overturned. The leadless pacemaker is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.\nThe patient is young and one can anticipate multiple generator changes and potential lead changes in view of the possibility of the long expected usage based on her young age. The leadless pacemaker has been approved by FDA. In this young patient with expected usage of at least 30-40 years, a leadless pacemaker is likely to be more beneficial than standard treatment. The medical literature supports its use in cases such as the present one.", "id": "709b1ca628474896b3319c10001f0a5e", "question": "What is the background context in this case summary?", "title": "709b1ca628474896b3319c10001f0a5e", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has history of (h/o) a prolonged symptomatic sinus pause for which a pacemaker was required. Under review is the Transcatheter Insertion or Replacement of Permanent Leadless Pacemaker, Right Ventricular, Including Imaging Guidance and Device Evaluation."], "answer_start": [0]}, "context": "The patient has history of (h/o) a prolonged symptomatic sinus pause for which a pacemaker was required. Under review is the Transcatheter Insertion or Replacement of Permanent Leadless Pacemaker, Right Ventricular, Including Imaging Guidance and Device Evaluation.\n\nThe health plan's determination is upheld. A leadless pacemaker has been developed to potentially decrease pocket and lead complications and malfunctions known to occur with current implanted pacemakers. However, they do not have demonstrated long term effectiveness or demonstrated improved outcomes compared to implantable pacemakers. Therefore, they have not been established as standard of care, compared to an implanted pacemaker, towards improved cardiac outcomes. As such it is not indicated in this case.", "id": "b1e5a32ce98646949424c15b43cfecc2", "question": "What is the background context in this case summary?", "title": "b1e5a32ce98646949424c15b43cfecc2", "sufficiency_score": 3}
+{"answers": {"text": ["The patient presented for evaluation of syncope. The patient had a history of bipolar disorder and vasovagal syncope, with episodes occurring over about 10 years and reported episodes of syncope increasing in frequency, to about once or twice a month. An electroencephalogram (EEG) was normal. An event monitor recorded a 21 second pause, with syncope correlating with this finding. An echocardiogram (ECHO) showed normal left ventricular function. Placement of a leadless pacemaker was recommended."], "answer_start": [0]}, "context": "The patient presented for evaluation of syncope. The patient had a history of bipolar disorder and vasovagal syncope, with episodes occurring over about 10 years and reported episodes of syncope increasing in frequency, to about once or twice a month. An electroencephalogram (EEG) was normal. An event monitor recorded a 21 second pause, with syncope correlating with this finding. An echocardiogram (ECHO) showed normal left ventricular function. Placement of a leadless pacemaker was recommended. This is the subject of this review.\n\nThe health plan's determination is overturned. The leadless pacemaker is likely to be more beneficial than standard treatment for this patient. The patient has vasovagal syncope, with prolonged sinus pauses on event monitoring. She requires pacing, but does not need atrial pacing for effective therapy. The leadless pacemaker is an Food and Drug Administration (FDA) approved therapy. Per guidelines, it is acceptable to use for patients who have sinus node dysfunction, including sinus pauses, for whom atrial pacing is not considered necessary. In this patient, an additional advantage would be avoidance of long-term lead complications (fractures, infection, etc).\n", "id": "64502832f00641d7921bef4171dba54a", "question": "What is the background context in this case summary?", "title": "64502832f00641d7921bef4171dba54a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with a history of diabetes, chronic obstructive pulmonary disease (COPD), depression, and anxiety who presented to the hospital with hematuria. She stated that she was had recently started seeing blood in her urine or vagina that morning. She also reported suprapubic pain. She denied fevers, chills, and increased urinary frequency. She did report multiple prior urinary tract infections. Review of systems was negative for fevers, chills, chest pain and shortness of breath. Vital signs showed temperature 36.5 Celsius, heart rate 71, blood pressure 137/81, and respiratory rate 15. On physical examination, she was alert, heart was regular, breath sounds were normal, abdomen was soft and nontender. Labs showed white blood cell (WBC) count of 17.5, hemoglobin 13.6, platelets 266, sodium 143, potassium 4.8, creatinine 1.47, and glucose 112. The patient was admitted with hematuria and suspected urinary tract infection. The plan of care included urine culture, intravenous (IV) antibiotics, kidney ultrasound, monitor kidney function, IV fluids, and continue other home medications. The patient was later diagnosed with Clostridium (C.) difficile (diff) after developing diarrhea. She requested to be discharged against medical advice."], "answer_start": [0]}, "context": "The patient is a female with a history of diabetes, chronic obstructive pulmonary disease (COPD), depression, and anxiety who presented to the hospital with hematuria. She stated that she was had recently started seeing blood in her urine or vagina that morning. She also reported suprapubic pain. She denied fevers, chills, and increased urinary frequency. She did report multiple prior urinary tract infections. Review of systems was negative for fevers, chills, chest pain and shortness of breath. Vital signs showed temperature 36.5 Celsius, heart rate 71, blood pressure 137/81, and respiratory rate 15. On physical examination, she was alert, heart was regular, breath sounds were normal, abdomen was soft and nontender. Labs showed white blood cell (WBC) count of 17.5, hemoglobin 13.6, platelets 266, sodium 143, potassium 4.8, creatinine 1.47, and glucose 112. The patient was admitted with hematuria and suspected urinary tract infection. The plan of care included urine culture, intravenous (IV) antibiotics, kidney ultrasound, monitor kidney function, IV fluids, and continue other home medications. The patient was later diagnosed with Clostridium (C.) difficile (diff) after developing diarrhea. She requested to be discharged against medical advice.\n\nThe health plan's determination is upheld. \n\nNo, the inpatient hospital stay was not medically necessary, based on the available documentation. The patient primarily was admitted for urinary tract infection in the setting of multiple urinary tract infections in the past. The patient was hemodynamically stable. She had an elevated white blood cell count, but no evidence of sepsis or pyelonephritis, she was not encephalopathic, and was only incidentally found to have C. diff infection after developing diarrhea, but this can be treated as an outpatient, especially when symptoms are mild. The patient had no other acute complications. She needed further care, but it could have been safely and effectively provided at a lower level.\n", "id": "223a46ae4e894fbd8726f91c1a2156d9", "question": "What is the background context in this case summary?", "title": "223a46ae4e894fbd8726f91c1a2156d9", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Idiopathic focal segmental glomerulosclerosis post kidney transplant \nTreatment: Velcade", "This child has undergone the standard therapy for antibody mediated rejection and has had no evidence of improvement.", "This child has a very high possibility of losing her graft with the levels of antibodies and specially after failing to respond to standard therapy.  Bortezomib is the last option to attempt to preserve renal function, by eliminating plasma cells that are the producers of antibodies.  This kidney graft does not have significant chronic injury."], "answer_start": [0, 937, 1322]}, "context": "Diagnosis: Idiopathic focal segmental glomerulosclerosis post kidney transplant \nTreatment: Velcade\nThe treatment with Velcade is medically necessary.\n\nIn treating children with this complex rejection presentation, commitment to prolong and rescue this first kidney allograft using the therapies available to control the process and resolve if it is possible must be made.  Most of the immunosuppressive medications do not have absolute FDA indication for immunosuppression in organ transplantation.  The use of these medications is based on clinical retrospective trials, small series, and most importantly, the need to solve complex immunological phenomena by learning from other disciplines such as Pediatric Oncology and others. \n\nPrevious review labeled the use of Bortezomib as unproven, with no RCT (randomized controlled trials) for the evaluation of the efficacy of Bortezomib for the treatment of antibody mediated rejection.  This child has undergone the standard therapy for antibody mediated rejection and has had no evidence of improvement.  The use of Bortezomib for the treatment of antibody mediated rejection in children has been done and published in small series demonstrating that Bortezomib stabilizes the immunological process and may preserve renal function in the majority of children treated.  \n\nThis child has a very high possibility of losing her graft with the levels of antibodies and specially after failing to respond to standard therapy.  Bortezomib is the last option to attempt to preserve renal function, by eliminating plasma cells that are the producers of antibodies.  This kidney graft does not have significant chronic injury.  \n\nIn this reviewer's opinion, and supported by literature in pediatric kidney transplant patients, Bortezomib is justified for the treatment of non-responding acute antibody mediated rejection on this child's care. This child needs adequate renal function in the next years to accomplish adequate growth and development.  Graft failure and dialysis will be a devastating complication. This is a very difficult disorder in pediatric organ transplantation, lacking good agents to treat patients with high levels of antibodies injuring the graft effectively.  In patients like this, it takes a full combination of all agents available to attempt to provide control and possible resolution of this disorder.\n\n", "id": "da12a4a1e4f2493185e1c5a244e6e899", "question": "What is the background context in this case summary?", "title": "da12a4a1e4f2493185e1c5a244e6e899", "sufficiency_score": 4}
+{"answers": {"text": ["The patient  has multiple medical problems but most notably dementia of Alzheimer's type. The patient requests 24 hour a day split shift personal care aide. The patient previously has been approved for a live-in aide"], "answer_start": [0]}, "context": "The patient  has multiple medical problems but most notably dementia of Alzheimer's type. The patient requests 24 hour a day split shift personal care aide. The patient previously has been approved for a live-in aide.The health plans determination of medical necessity is upheld in whole. The requested health service/treatment of 24 Hour/7 Days Split Shift per Week Personal Care Aide is not medically necessary for this patient. There was not a significant change in the medical necessity for additional services from the first assessment to the second assessment.\nThese services can be performed within the 84 hours allotted for the week.", "id": "bac872f06f2940c5993ecc1a821106d1", "question": "What is the background context in this case summary?", "title": "bac872f06f2940c5993ecc1a821106d1", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Pneumonia vs. Bronchitis.", "Treatment: inpatient admission", "The insurer denied coverage inpatient admission.", "This patient is a female with past medical history (PMH) of: hypertension (HTN), chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea (OSA) - non compliant with bilevel positive airway pressure (BIPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) over the past several days. The patient's nebulizer machine at home was broken. The patient has history of multiple intubations in the past for COPD exacerbations. The patient still smokes 3-5 cigarettes/day. The patient had been also suffering from some upper respiratory tract infection (URTI) symptoms. The patient also complained of some palpitations.", "The vital signs at presentation in ER were: blood pressure (BP) 156/89, respiratory rate (RR) 22, heart rate (HR) 102 and oxygen saturations were 86 %. The vital signs per Emergency Department Medical Doctor (MD) were temperature 98.7, respiratory rate (RR) 20, blood pressure (BP) 120/72 mm Hg and oxygen saturation at 100%. The patient was in no acute distress (NAD).  Lungs had mild respiratory distress and bilateral basal rales. The cardiovascular system (CVS) S1 S2 was normal (N). There was no jugular venous distention (JVD).  The abdomen was soft and nontender (NT).", "As per the History & Physical the patient was afebrile and vital signs (VSS) stable. The patient was saturating 100% on nasal cannula. There was no use of accessory muscles. There was mild wheeze. The cardiovascular system (CVS) S1 S2 was normal. The admitting diagnosis was COPD exacerbation likely from Acute Bronchitis. The patient's peak expiratory flow (PEF) was 170 (Baseline 200). The chest x-ray was unremarkable. The computer tomogram (CT) indicates - chest right lower lobe (RLL) infiltrates or Pneumonia. The arterial blood gas (ABG on 2L) was 7.37/68/52/38/ 86 %. This is close to her baseline. The plan was to continue on steroids, bronchodilator, Azithromycin and BIPAP at night with 10/5 setting."], "answer_start": [0, 38, 70, 143, 835, 1412]}, "context": "Diagnosis: Pneumonia vs. Bronchitis.\n\nTreatment: inpatient admission\n\nThe insurer denied coverage inpatient admission. The denial was upheld.\n\nThis patient is a female with past medical history (PMH) of: hypertension (HTN), chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea (OSA) - non compliant with bilevel positive airway pressure (BIPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) over the past several days. The patient's nebulizer machine at home was broken. The patient has history of multiple intubations in the past for COPD exacerbations. The patient still smokes 3-5 cigarettes/day. The patient had been also suffering from some upper respiratory tract infection (URTI) symptoms. The patient also complained of some palpitations.\n\nThe vital signs at presentation in ER were: blood pressure (BP) 156/89, respiratory rate (RR) 22, heart rate (HR) 102 and oxygen saturations were 86 %. The vital signs per Emergency Department Medical Doctor (MD) were temperature 98.7, respiratory rate (RR) 20, blood pressure (BP) 120/72 mm Hg and oxygen saturation at 100%. The patient was in no acute distress (NAD).  Lungs had mild respiratory distress and bilateral basal rales. The cardiovascular system (CVS) S1 S2 was normal (N). There was no jugular venous distention (JVD).  The abdomen was soft and nontender (NT).\n\nAs per the History & Physical the patient was afebrile and vital signs (VSS) stable. The patient was saturating 100% on nasal cannula. There was no use of accessory muscles. There was mild wheeze. The cardiovascular system (CVS) S1 S2 was normal. The admitting diagnosis was COPD exacerbation likely from Acute Bronchitis. The patient's peak expiratory flow (PEF) was 170 (Baseline 200). The chest x-ray was unremarkable. The computer tomogram (CT) indicates - chest right lower lobe (RLL) infiltrates or Pneumonia. The arterial blood gas (ABG on 2L) was 7.37/68/52/38/ 86 %. This is close to her baseline. The plan was to continue on steroids, bronchodilator, Azithromycin and BIPAP at night with 10/5 setting.\n\nThis patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment initiated. The patient was close to her baseline after initial treatment. Pneumonia if present was mild. The white blood cell count (WBC) was normal. There was no fever. The partial oxygen (PaO2) was close to baseline. The CURB 65 score 0. The patient could have been switched to oral steroids and bronchodilators and oral antibiotics after a period in Observation and then subsequently discharged home with close follow-up in an outpatient setting. The prior denial was appropriate.\n\nThe health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.\n", "id": "2725610eb74041f597edf6a24cc15041", "question": "What is the background context in this case summary?", "title": "2725610eb74041f597edf6a24cc15041", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a past medical history significant for hypertension, bronchitis, gastroesophageal reflux disease (GERD), tobacco abuse, and cocaine abuse who presented to the emergency department with complaints of abdominal pain, nausea, vomiting, and anorexia for 4 days. At the time of admission, the patient  was unable to tolerate any liquids or solid food. The patient reported an intermittent lower abdominal cramping pain, which he described as 2-3/10 in intensity. The pain resolved spontaneously, and each bout lasted for 10-15 minutes. At the time of initial evaluation, the patient denied diarrhea and stated that the last bowel movement was 2 days before the day of admission.", "At the time of admission the patient denied any fever, chills, dysphagia, odynophagia, dyspepsia, bloating, hematemesis, melena, or fresh blood in the stool. The patient was afebrile, blood pressure was 129/78, pulse rate 72 beats per minute (bpm), respiratory rate 18, oxygen saturation 98% on room air. The patient had mild tenderness around the umbilicus without rebound tenderness. He also had an itchy scaly rash on the hands. The rest of the physical exam was unremarkable. Abdominal x-ray showed nonspecific bowel gas pattern. Subsequent computed tomography (CT) scan of the abdomen and pelvis did not reveal any significant abnormalities in the abdomen. The patient was admitted to the hospital with a diagnosis of abdominal pain and vomiting, which was attributed to acute gastroenteritis. It was indicated that the patient's electrolytes were within normal limits.", "This patient's hospital stay was very short. The patient responded to the supportive care provided and was discharged from the hospital. In the records submitted the Milliman Care Guidelines criteria for gastroenteritis is referenced."], "answer_start": [0, 690, 1986]}, "context": "The patient has a past medical history significant for hypertension, bronchitis, gastroesophageal reflux disease (GERD), tobacco abuse, and cocaine abuse who presented to the emergency department with complaints of abdominal pain, nausea, vomiting, and anorexia for 4 days. At the time of admission, the patient  was unable to tolerate any liquids or solid food. The patient reported an intermittent lower abdominal cramping pain, which he described as 2-3/10 in intensity. The pain resolved spontaneously, and each bout lasted for 10-15 minutes. At the time of initial evaluation, the patient denied diarrhea and stated that the last bowel movement was 2 days before the day of admission.\nAt the time of admission the patient denied any fever, chills, dysphagia, odynophagia, dyspepsia, bloating, hematemesis, melena, or fresh blood in the stool. The patient was afebrile, blood pressure was 129/78, pulse rate 72 beats per minute (bpm), respiratory rate 18, oxygen saturation 98% on room air. The patient had mild tenderness around the umbilicus without rebound tenderness. He also had an itchy scaly rash on the hands. The rest of the physical exam was unremarkable. Abdominal x-ray showed nonspecific bowel gas pattern. Subsequent computed tomography (CT) scan of the abdomen and pelvis did not reveal any significant abnormalities in the abdomen. The patient was admitted to the hospital with a diagnosis of abdominal pain and vomiting, which was attributed to acute gastroenteritis. It was indicated that the patient's electrolytes were within normal limits. The requested health service/treatment of inpatient stay was not medically necessary for this patient, since neither the severity of the patient's condition nor the complexity of services provided justified acute inpatient level of care. Most likely, according to the records submitted for review, the patient had acute gastroenteritis, which is usually a self-limited condition and mostly requires supportive care only. This patient's hospital stay was very short. The patient responded to the supportive care provided and was discharged from the hospital. In the records submitted the Milliman Care Guidelines criteria for gastroenteritis is referenced.  The patient had none of the circumstances listed above qualifying for an inpatient hospital stay. There was no need for any invasive procedures or diagnostic studies necessitating admission at the acute inpatient level of care. The patient could have received treatment at a lower level of care.\nThe health plan's determination of medical necessity is upheld in whole.", "id": "ecffcba068ab41ba9d77b3c8c0b26203", "question": "What is the background context in this case summary?", "title": "ecffcba068ab41ba9d77b3c8c0b26203", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented with vomiting and abdominal pain. She was afebrile and vital signs were stable. The patient had abdominal guarding but no peritoneal signs. There was no leukocytosis. The pancreatic enzymes were mildly elevated. A sonogram did not show evidence of acute pancreatitis. The abdominal pain improved and the patient was able to tolerate a diet. Proton Pump Inhibitor (PPI) therapy was given for alcoholic gastritis. The patient was discharged and advised to avoid alcohol.", "Diagnosis: Pancreatitis versus gastritis", "Treatment: Inpatient admission, medication, monitoring", "The insurer denied the inpatient admission."], "answer_start": [167, 0, 43, 99]}, "context": "Diagnosis: Pancreatitis versus gastritis\n \nTreatment: Inpatient admission, medication, monitoring\n\nThe insurer denied the inpatient admission. The denial was upheld.\n\nThe patient presented with vomiting and abdominal pain. She was afebrile and vital signs were stable. The patient had abdominal guarding but no peritoneal signs. There was no leukocytosis. The pancreatic enzymes were mildly elevated. A sonogram did not show evidence of acute pancreatitis. The abdominal pain improved and the patient was able to tolerate a diet. Proton Pump Inhibitor (PPI) therapy was given for alcoholic gastritis. The patient was discharged and advised to avoid alcohol.\n\nClinical Indications for admission for pancreatitis (M-250) include having acute pancreatitis as manifested by 2 factors including abdominal pain, pancreatic enzymes greater than 3 times the upper limit of normal or characteristic imaging. This patient did not have pancreatic enzymes greater than 3 times the upper limit of normal or characteristic imaging. She also did not have hemodynamic instability, hypoxemia, acute renal failure, or a severe electrolyte abnormality.\n\nClinical indications for admission for gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, and vomiting that is persistent. The patient did not have these conditions. The vomiting resolved after treatment in the emergency room. \n\nThis patient had alcoholic gastritis and mildly elevated pancreatic enzymes. Intravenous (IV) hydration, PPI therapy, and antiemetics could have been given in the ER. She did not meet MCG criteria for admission for either pancreatitis or gastritis. She could have been managed with observation status. \n\nBased on the above, the patient did not meet medical necessity for the inpatient hospital admission. The insurer's denial is upheld.\n", "id": "87c82f56bc3746eba9b8fc30eee2b93e", "question": "What is the background context in this case summary?", "title": "87c82f56bc3746eba9b8fc30eee2b93e", "sufficiency_score": 3}
+{"answers": {"text": ["This is a patient with a past medical history significant for uterine fibroids, goiter, and hemorrhoids who was referred to the emergency department by her primary care physician because of anemia. At the time of the initial evaluation, the patient denied any injury, overt bleeding, or blood in the stool or urine. She denied any excessive bleeding or bleeding between the menstrual cycles. The review of systems was positive for generalized weakness, otherwise negative.", "At the time of the initial evaluation patient's temperature was 99.1 degrees Fahrenheit (F), pulse rate 105, respiratory rate 19, blood pressure 125/56, and oxygen saturation was 100% on room air. The rest of the physical exam was unremarkable. An EKG demonstrated normal sinus rhythm, no evidence of ischemia."], "answer_start": [0, 473]}, "context": "This is a patient with a past medical history significant for uterine fibroids, goiter, and hemorrhoids who was referred to the emergency department by her primary care physician because of anemia. At the time of the initial evaluation, the patient denied any injury, overt bleeding, or blood in the stool or urine. She denied any excessive bleeding or bleeding between the menstrual cycles. The review of systems was positive for generalized weakness, otherwise negative.\nAt the time of the initial evaluation patient's temperature was 99.1 degrees Fahrenheit (F), pulse rate 105, respiratory rate 19, blood pressure 125/56, and oxygen saturation was 100% on room air. The rest of the physical exam was unremarkable. An EKG demonstrated normal sinus rhythm, no evidence of ischemia.\nThe health plan's determination is upheld. The inpatient admission was not medically necessary. A fecal occult blood test was negative. Anemia workup was initiated. The patient was ordered infusion of two units of packed red blood cells. During the hospital stay, the patient remained afebrile and hemodynamically stable. It was noted in the discharge summary that the patient's anemia was most likely due to iron deficiency. It was also noted that the etiology was still unknown at the time of discharge. The patient had no active massive hemorrhage, active hemolysis or rapidly progressive anemia, hemodynamic instability, cardiovascular symptoms such as dyspnea, chest pain. There was no evidence of heart failure, neurologic symptoms, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, or any other conditions necessitating admission at the inpatient level of care. There was no need for any procedures or diagnostic tests necessitating inpatient level of care. ", "id": "297e5377697f413bb10a32aad1c503b1", "question": "What is the background context in this case summary?", "title": "297e5377697f413bb10a32aad1c503b1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair."], "answer_start": [0]}, "context": "The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair.  Power Wheelchair is not medically necessary for this patient. Provider notes that the patient is able to use a walker in the home. The use of an electric scooter/wheelchair outside of the home is not appropriate. If the patient is able to use a walker in the home patient should be capable of using a manual wheelchair outside of the home. Therefore, a customized manual wheelchair is more appropriate and within the generally accepted standards of medical care. The HP determination is upheld.", "id": "79e5260d9c3f4ca38d2d066b5db69237", "question": "What is the background context in this case summary?", "title": "79e5260d9c3f4ca38d2d066b5db69237", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has a history of chronic low back and neck pain. Due to these conditions, she has difficulty ambulating with associated gait ataxia, frequent falls and difficulty completing her activities of daily living (ADLs). Furthermore, her chronic musculoskeletal pain and decreased range of motion have rendered her chronically homebound, as she is unable to sit/stand/walk for prolonged periods of time longer than 20 to 30 minutes. In addition, she is restricted from bending/pushing/crouching/squatting/stooping and lifting/carrying greater than 10 lbs, per functional assessment statement.", "Diagnosis: Back and neck pain", "Issue under review: Increase in consumer directed personal care assistance services"], "answer_start": [223, 0, 30]}, "context": "Diagnosis: Back and neck pain\nIssue under review: Increase in consumer directed personal care assistance services\n\nDetermination:\nThe Increase in consumer directed personal care assistance services is medically necessary.\n\nThe patient has a history of chronic low back and neck pain. Due to these conditions, she has difficulty ambulating with associated gait ataxia, frequent falls and difficulty completing her activities of daily living (ADLs). Furthermore, her chronic musculoskeletal pain and decreased range of motion have rendered her chronically homebound, as she is unable to sit/stand/walk for prolonged periods of time longer than 20 to 30 minutes. In addition, she is restricted from bending/pushing/crouching/squatting/stooping and lifting/carrying greater than 10 lbs, per functional assessment statement. For these reasons, the proposed treatment of an increase in consumer directed personal care assistance services from 30 to 40 hours per week is deemed medically necessary. ", "id": "b25439e489b94b54b721270da7830109", "question": "What is the background context in this case summary?", "title": "b25439e489b94b54b721270da7830109", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Liver Disease/Fatty Liver", "Treatment: Magnetic Resonance Imaging, Abdomen", "The patient has mild elevation of ALT due to underlying fatty liver disease. She had an MRI of the abdomen in December 2016, which revealed fatty liver disease and a small 3mm cyst in the right lobe of the liver."], "answer_start": [0, 37, 243]}, "context": "Diagnosis: Liver Disease/Fatty Liver\nTreatment: Magnetic Resonance Imaging, Abdomen\n\nSummary:\nNo, the proposed MRI abdomen/MRCP is not appropriate and medically necessary for the evaluation and management of fatty liver and simple liver cyst. The patient has mild elevation of ALT due to underlying fatty liver disease. She had an MRI of the abdomen in December 2016, which revealed fatty liver disease and a small 3mm cyst in the right lobe of the liver. There was no evidence of biliary disease/obstruction/ or primary sclerosing cholangitis (PSC). Since there is no evidence of biliary obstruction or biochemical evidence of cholestasis (intra- or extra-hepatic cholestasis) based upon the liver function tests, no further evaluation is required.\n", "id": "c7c9c8462cf6476d9bf49c68a5c6e975", "question": "What is the background context in this case summary?", "title": "c7c9c8462cf6476d9bf49c68a5c6e975", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient with a history of Melanoma. According to his surgical pathology report, he had a melanoma 2.3 millimeter thickness and a basal cell carcinoma on the left side of his forehead. As recommended, the patient underwent further testing for his diagnosis. The test revealed that the patient was a low risk for a reoccurrence.", "Diagnosis: Melanoma", "Treatment: The DecisionDX-Melanoma Assay test", "The insurer denied the  DecisionDX-Melanoma Assay test."], "answer_start": [149, 0, 22, 69]}, "context": "Diagnosis: Melanoma\n \nTreatment: The DecisionDX-Melanoma Assay test\n\nThe insurer denied the  DecisionDX-Melanoma Assay test. The denial was upheld.\n\nThis is a male patient with a history of Melanoma. According to his surgical pathology report, he had a melanoma 2.3 millimeter thickness and a basal cell carcinoma on the left side of his forehead. As recommended, the patient underwent further testing for his diagnosis. The test revealed that the patient was a low risk for a reoccurrence.\n \nThe DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma. However, the test is still investigational and is not the standard of care. According to the National Comprehensive Cancer Network (NCCN), routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study.  Given that the current recommendations at this time do not include the use of DecisionDX gene expression testing and the current peer-reviewed literature shows studies are needed to identify the clinical utility of such testing, the DecisionDX UM testing is not medically necessary.\n\nBased on the above, the medical necessity for the Decision DX-Melanoma Assay test is not substantiated.  The insurer's denial is upheld.", "id": "44df1557ed2348a4b232eb66e5d1a5c1", "question": "What is the background context in this case summary?", "title": "44df1557ed2348a4b232eb66e5d1a5c1", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Severe bronchopulmonary dysplasia\nTreatment: Continued inpatient stay ", "This is the case of a boy that was born premature at 23 weeks gestation that is medically fragile due to multiple medical problems.  He is ventilator dependent full time due to severe bronchopulmonary dysplasia with chronic respiratory failure.  He has microcephaly and a history of grade 3 intraventricular hemorrhage at birth.  He had a history of a right hemothorax, seizures, retinopathy of prematurity with vision defects, congenital hearing loss, kidney stones, hydronephrosis, pulmonary hypertension, acute drug withdrawal, and dysautonomia. He has profound developmental delays. His most recent admission to the Hospital was following an acute hospital admission for treatment of a perianal abscess.  He reportedly had four prior admissions to the Hospital due to his medically fragile state.  The discharge plan was for this child to be sent to a skilled nursing facility when medically stable.  Reportedly, the child's family was unwilling and felt that they were unable to care for him.  The clinical notes from the Hospital document that over the time in question, no skilled nursing facility bed became available for this child and he remained in need of 24-hour ventilation, skilled nursing care, gastrostomy feeding, multiple medications, and habilitative services.", "He is diagnosed with bronchopulmonary dysplasia, microcephaly, and pulmonary hypertension."], "answer_start": [0, 1154, 2513]}, "context": "Diagnosis: Severe bronchopulmonary dysplasia\nTreatment: Continued inpatient stay \n\nThe proposed treatment is medically necessary based on the patient's complicated medical condition, his medically fragile state, and the New York State Guidelines (Attachment G: Office of Health Insurance Programs Principles for Medically Fragile Children).  The guidelines state the following: A \"medically fragile child\" is defined as an individual under 21 years of age who has a chronic debilitating condition or conditions who may or may not be hospitalized who meets the following criteria:\n1) Is technologically dependent for life or health sustaining functions;\n2) Requires a complex medication regimen or medical interventions to maintain or to improve their health status;\n3) Is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health or development at risk.\n\n\"Chronic debilitating conditions include, but are not limited to, bronchopulmonary dysplasia, cerebral palsy, congenital heart disease, microcephaly, pulmonary hypertension, and muscular dystrophy.\"\n\nThis is the case of a boy that was born premature at 23 weeks gestation that is medically fragile due to multiple medical problems.  He is ventilator dependent full time due to severe bronchopulmonary dysplasia with chronic respiratory failure.  He has microcephaly and a history of grade 3 intraventricular hemorrhage at birth.  He had a history of a right hemothorax, seizures, retinopathy of prematurity with vision defects, congenital hearing loss, kidney stones, hydronephrosis, pulmonary hypertension, acute drug withdrawal, and dysautonomia. He has profound developmental delays. His most recent admission to the Hospital was following an acute hospital admission for treatment of a perianal abscess.  He reportedly had four prior admissions to the Hospital due to his medically fragile state.  The discharge plan was for this child to be sent to a skilled nursing facility when medically stable.  Reportedly, the child's family was unwilling and felt that they were unable to care for him.  The clinical notes from the Hospital document that over the time in question, no skilled nursing facility bed became available for this child and he remained in need of 24-hour ventilation, skilled nursing care, gastrostomy feeding, multiple medications, and habilitative services.\n\nThe patient in this case meets the definition of a medically fragile child.  He is diagnosed with bronchopulmonary dysplasia, microcephaly, and pulmonary hypertension.  He likely has an additional diagnosis of cerebral palsy based on his medical history and description of his neuromuscular examination.  He could not be safely discharged to a home setting with his complex medical needs.  A skilled nursing facility level of care was necessary for him but the discharge remains prolonged due to the lack of an available bed for him.  In the interim, the child is undergoing ongoing medical treatment to reduce the number of his sedating medications, wean him from the ventilator, and provide habilitative services to optimize his functional development.\n\nThe patient in this case requires 24-hour nursing care due to his ventilator dependence and complicated medicine regimen.  His fragile condition requires frequent medical decision making to treat signs and symptoms of dysautonomia that can result in further brain damage if not properly treated.  The patient could not be safely discharged to a lower level of care without the necessary skilled nursing, medical equipment, and safe space for the child to be treated.  The treating hospital clearly documented that the patient was awaiting a bed in an appropriate skilled nursing facility and that no bed had become available.", "id": "e0a941e0f7f74596849909cc20ca4a48", "question": "What is the background context in this case summary?", "title": "e0a941e0f7f74596849909cc20ca4a48", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female with a past medical history of cervical pain, migraines, fibromyalgia, syncope and anxiety.  She had mild migraines until several years ago; not recently an issue.  The patient had previous fainting spells which she felt were due to dehydration. She reported 3 episodes of feeling like she was going to pass out, followed by headache, right-sided numbness/paresthesia, and loss of consciousness.  There was no seizure activity, urinary incontinence or tongue biting.  A magnetic resonance imaging (MRI) of the brain was normal. Given the patient's clinical history and MRI of the brain, further imaging including a MR angiography (MRA) of the head and neck was felt to be medically necessary.", "Diagnosis: Syncope versus seizure", "Treatment: Brain magnetic resonance angiography\n", "The insurer denied the brain magnetic resonance angiography.", "The physician had concern for syncope versus seizure.  An electroencephalogram (EEG) was ordered.  MRI of the brain did not reveal evidence of infarct, mass lesion or hydrocephalus. The patient was to undergo an MRA of the head/neck to exclude the presence of an underlying vascular lesion or dissection."], "answer_start": [170, 0, 36, 85, 1324]}, "context": "Diagnosis: Syncope versus seizure\n \nTreatment: Brain magnetic resonance angiography\n\nThe insurer denied the brain magnetic resonance angiography. The denial was upheld.\n\nThis is a female with a past medical history of cervical pain, migraines, fibromyalgia, syncope and anxiety.  She had mild migraines until several years ago; not recently an issue.  The patient had previous fainting spells which she felt were due to dehydration. She reported 3 episodes of feeling like she was going to pass out, followed by headache, right-sided numbness/paresthesia, and loss of consciousness.  There was no seizure activity, urinary incontinence or tongue biting.  A magnetic resonance imaging (MRI) of the brain was normal. Given the patient's clinical history and MRI of the brain, further imaging including a MR angiography (MRA) of the head and neck was felt to be medically necessary.\n\nMedical literature indicates head MRA may be indicated if aneurysm or arteriovenous malformation is known or suspected, as indicated by follow-up monitoring for a patient with a history of subarachnoid hemorrhage, aneurysm or arteriovenous malformation, initial evaluation of suspected aneurysm or arteriovenous malformation, or re-evaluation after surgical or endovascular therapy for cerebral artery aneurysm or arteriovenous malformation.  The physician had concern for syncope versus seizure.  An electroencephalogram (EEG) was ordered.  MRI of the brain did not reveal evidence of infarct, mass lesion or hydrocephalus. The patient was to undergo an MRA of the head/neck to exclude the presence of an underlying vascular lesion or dissection.  The patient did not require follow-up monitoring for a history of subarachnoid hemorrhage, a known aneurysm or arteriovenous malformation, and did not require a head MR angiography for initial evaluation of a suspected aneurysm or arteriovenous malformation, such as an acute severe headache.  There was no other indication as to why an MRA of the brain would be appropriate.  \n\nThe carrier's denial of coverage for the brain magnetic resonance angiography (MRA) is upheld.  The medical necessity is not substantiated.\n", "id": "84e76bd55e99443b8487e503f19087ef", "question": "What is the background context in this case summary?", "title": "84e76bd55e99443b8487e503f19087ef", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has cocaine, alcohol, opiate and cannabis dependence and was admitted to an inpatient detox service. Patient endorsed typically using alcohol, heroin and cocaine daily. The reported  last use of cocaine and heroin was the day prior, but had drunk two 24 ounce beers earlier that day. Blood alcohol level was zero and urine was positive for cocaine, opiates and tetrahydrocannabinol (THC). Complained to nursing of hot/cold sweats, tremors, diarrhea, headache, abdominal pain, and joint pain. Initial vital signs included a mildly tachycardic pulse of 105 and a normal blood pressure of 128/72. To the nurse practitioner patient complained of the same symptoms; in addition,  nausea, anxiety, irritability, diarrhea, and teary eyes. The physical exam did document tremors and a flushed appearance. The initial Clinical Institute Withdrawal Assessment (CIWA) score was 16 and Clinical Opiate Withdrawal Scale (COWS) was 15.", "The patient reported a psychiatric history of anxiety, depression, and post-traumatic stress disorder (PTSD). Denied current suicidal thoughts and denied current outpatient treatment. Has a history of suicide attempt while intoxicated on alcohol. Patient reported over 100 past treatment episodes and has serious legal and personal consequences from use. Patient was admitted to the detox unit and placed on methadone and Ativan withdrawal protocols. The service of inpatient detoxification treatment was medically necessary The patient has a documented history of chemical dependence on multiple substances (opiates, alcohol, cocaine, and cannabis). Patient has a shelter bed but does not have a sober support network."], "answer_start": [0, 934]}, "context": "The patient has cocaine, alcohol, opiate and cannabis dependence and was admitted to an inpatient detox service. Patient endorsed typically using alcohol, heroin and cocaine daily. The reported  last use of cocaine and heroin was the day prior, but had drunk two 24 ounce beers earlier that day. Blood alcohol level was zero and urine was positive for cocaine, opiates and tetrahydrocannabinol (THC). Complained to nursing of hot/cold sweats, tremors, diarrhea, headache, abdominal pain, and joint pain. Initial vital signs included a mildly tachycardic pulse of 105 and a normal blood pressure of 128/72. To the nurse practitioner patient complained of the same symptoms; in addition,  nausea, anxiety, irritability, diarrhea, and teary eyes. The physical exam did document tremors and a flushed appearance. The initial Clinical Institute Withdrawal Assessment (CIWA) score was 16 and Clinical Opiate Withdrawal Scale (COWS) was 15.\nThe patient reported a psychiatric history of anxiety, depression, and post-traumatic stress disorder (PTSD). Denied current suicidal thoughts and denied current outpatient treatment. Has a history of suicide attempt while intoxicated on alcohol. Patient reported over 100 past treatment episodes and has serious legal and personal consequences from use. Patient was admitted to the detox unit and placed on methadone and Ativan withdrawal protocols. The service of inpatient detoxification treatment was medically necessary The patient has a documented history of chemical dependence on multiple substances (opiates, alcohol, cocaine, and cannabis). Patient has a shelter bed but does not have a sober support network. The CIWA, COWS and physical exam on admission all are consistent with clinically significant withdrawal. Of the substances used, the potential for alcohol withdrawal is the most clinically serious given that alcohol withdrawal can be fatal. Patient does not have a known history of serious withdrawal, but serious withdrawal can manifest at any time in the illness course. The chronicity and amount of  use also places patient at increased risk for withdrawal. The combination of alcohol withdrawal with opiate withdrawal does increase risk of medical complication. An admission LOCADTR  resulted in a recommendation for inpatient services. The HP determination is overturned in whole.", "id": "eb858b1e57a24707a5f0dbcabefa954b", "question": "What is the background context in this case summary?", "title": "eb858b1e57a24707a5f0dbcabefa954b", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient a past medical history significant for hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of high blood pressure. Apparently, the patient did not take her blood pressure medications on the day of the presentation to the ED. While in the emergency department, the patient started to have left-sided chest pain that radiated to the left arm. She described the pain as throbbing, non-exertional. The patient also complained of epigastric abdominal pain and nausea. It was associated with sweating and palpitations.", "The patient was seen by the cardiology service and was found to have atypical chest pain. No intervention was needed."], "answer_start": [0, 938]}, "context": "This is a patient a past medical history significant for hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of high blood pressure. Apparently, the patient did not take her blood pressure medications on the day of the presentation to the ED. While in the emergency department, the patient started to have left-sided chest pain that radiated to the left arm. She described the pain as throbbing, non-exertional. The patient also complained of epigastric abdominal pain and nausea. It was associated with sweating and palpitations.\nDuring the hospital stay, the patient was ruled out for acute coronary The health plan's determination of medical necessity is upheld. The patient presented with atypical chest pain. Considering her risk factors, which included hypertension and hyperlipidemia, it was appropriate to rule out acute coronary syndrome and this was ruled out. The patient was seen by the cardiology service and was found to have atypical chest pain. No intervention was needed.\nEven though the patient came to the hospital with elevated blood pressure, there was no evidence that she had a hypertensive emergency or any other complications that would require management of the blood pressure in inpatient settings. ", "id": "3574f1650f184c34b91891c506fefbe0", "question": "What is the background context in this case summary?", "title": "3574f1650f184c34b91891c506fefbe0", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented to the hospital in early 2019. The patient had a history of chronic lymphedema, recurrent lower extremity cellulitis, and scrotal cellulitis. The patient presented complaining of lower extremity edema, warmth, and scrotal pain. The patient's symptoms were worse on the left side. He also reported fever, sore throat, and nausea. The patient denied chest pain, shortness of breath and diarrhea. The plan of care included intravenous (IV) antibiotics, IV fluids, blood cultures, lower extremity ultrasound, ultrasound of the scrotum, and consider iron supplementation.", "The patient presented with sepsis and cellulitis and had some evidence of hemodynamic instability with tachycardia. He required IV antibiotics and there was concern for toxic shock initially as a possible complication of the patient's presentation.", "the white blood cell count was markedly elevated and he had a relatively high fever."], "answer_start": [0, 681, 943]}, "context": "The patient presented to the hospital in early 2019. The patient had a history of chronic lymphedema, recurrent lower extremity cellulitis, and scrotal cellulitis. The patient presented complaining of lower extremity edema, warmth, and scrotal pain. The patient's symptoms were worse on the left side. He also reported fever, sore throat, and nausea. The patient denied chest pain, shortness of breath and diarrhea. The plan of care included intravenous (IV) antibiotics, IV fluids, blood cultures, lower extremity ultrasound, ultrasound of the scrotum, and consider iron supplementation. \n\nThe health plan's determination is overturned. The inpatient stay is medically necessary. The patient presented with sepsis and cellulitis and had some evidence of hemodynamic instability with tachycardia. He required IV antibiotics and there was concern for toxic shock initially as a possible complication of the patient's presentation. In addition, the white blood cell count was markedly elevated and he had a relatively high fever. The patient was it increased risk of having an adverse outcome because of these factors and it would not have been appropriate to manage at a lower level of care.", "id": "2e5ad5b83e814f57b1344c5f8e6cc210", "question": "What is the background context in this case summary?", "title": "2e5ad5b83e814f57b1344c5f8e6cc210", "sufficiency_score": 4}
+{"answers": {"text": ["The patient was referred from the High Risk OB clinic for admission for glycemic control. The obstetrical history was significant for 1 cesarean section. The patient had history of 2 prior admissions for glycemic control. On presentation, the patient's blood glucose was 61. There were no obstetrical complaints. Fetal heart rate tracing was reassuring. The inpatient admission is under review."], "answer_start": [0]}, "context": "The patient was referred from the High Risk OB clinic for admission for glycemic control. The obstetrical history was significant for 1 cesarean section. The patient had history of 2 prior admissions for glycemic control. On presentation, the patient's blood glucose was 61. There were no obstetrical complaints. Fetal heart rate tracing was reassuring. The inpatient admission is under review.\n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. Based on provided clinical information, the records did not indicate any evidence of hyper/hypoglycemia; fetal heart rate tracing and ultrasound examination were normal; the patient was hemodynamically stable. there was no evidence of ketoacidosis; there was no abnormal bleeding, PPROM (Preterm premature rupture of the membranes) or preterm labor. Insulin regimen (each dose) was increased only by 2 units; the initial and subsequent FS assessments were all normal.\n", "id": "d2e024f29fa24d0a98b93b9c0789bde7", "question": "What is the background context in this case summary?", "title": "d2e024f29fa24d0a98b93b9c0789bde7", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a previously healthy female, whose family has limited English proficiency, who presented to the emergency department (ED) with fevers, vomiting and diarrhea. Symptoms began approximately 1 month prior with waxing and waning course. There were no associated respiratory symptoms or recent travel. Of note, ED records indicate that this child was still nearly exclusively breast fed.", "Labs showed white blood cell (WBC) count of 12 with 44 segs and 43 lymphs, hematocrit (Hct) 32, and platelets (Plt) 562. Sodium (Na) 136, potassium (K) 4.0, chloride (Cl) 105, carbon dioxide (CO2) 15, blood urea nitrogen (BUN) 10, creatinine (Cr) 0.45, and glucose (66). Liver function tests (LFTs) and bilirubin were normal. Initial urinalysis (UA) showed specific gravity (SG) 1.020 and small ketones. The patient received intravenous fluids (IVF) bolus x 2 and intravenous (IV) Zofran. She was admitted to the pediatric ward where she continued to receive IVF and advance diet as tolerated. Her diarrhea and other symptoms improved, and she was able to be discharged home two days later.", "This patient was hemodynamically stable with mild dehydration secondary to acute gastroenteritis. She received 2 IVF boluses in the ED, but reportedly failed an oral challenge so was admitted to the hospital. Hospital notes indicate continued diarrhea"], "answer_start": [0, 398, 1209]}, "context": "The patient is a previously healthy female, whose family has limited English proficiency, who presented to the emergency department (ED) with fevers, vomiting and diarrhea. Symptoms began approximately 1 month prior with waxing and waning course. There were no associated respiratory symptoms or recent travel. Of note, ED records indicate that this child was still nearly exclusively breast fed.\n\nLabs showed white blood cell (WBC) count of 12 with 44 segs and 43 lymphs, hematocrit (Hct) 32, and platelets (Plt) 562. Sodium (Na) 136, potassium (K) 4.0, chloride (Cl) 105, carbon dioxide (CO2) 15, blood urea nitrogen (BUN) 10, creatinine (Cr) 0.45, and glucose (66). Liver function tests (LFTs) and bilirubin were normal. Initial urinalysis (UA) showed specific gravity (SG) 1.020 and small ketones. The patient received intravenous fluids (IVF) bolus x 2 and intravenous (IV) Zofran. She was admitted to the pediatric ward where she continued to receive IVF and advance diet as tolerated. Her diarrhea and other symptoms improved, and she was able to be discharged home two days later.\n\nThe health plan's determination is upheld.\n\nThe requested inpatient stay was not medically necessary for this patient.\nThis patient was hemodynamically stable with mild dehydration secondary to acute gastroenteritis. She received 2 IVF boluses in the ED, but reportedly failed an oral challenge so was admitted to the hospital. Hospital notes indicate continued diarrhea, but do not indicate continued vomiting or other complications. Therefore, based on patient condition her care could have been managed at a lower level of care status.", "id": "0c58c5af3b384bf6acf99c4405386dd0", "question": "What is the background context in this case summary?", "title": "0c58c5af3b384bf6acf99c4405386dd0", "sufficiency_score": 4}
+{"answers": {"text": ["This is a middle aged male who was admitted for inpatient substance detoxification treatment in late 2018 for heroin and crack/cocaine detoxification. He reportedly was using IV heroin and crack/cocaine use since a young age. He had withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches. He had a history of inpatient substance detoxification and rehabilitation treatments. During hospital admission he was placed on a Methadone taper and was then discharged home.", "Diagnosis: Substance Abuse", "Treatment: Inpatient Substance Detoxification", "The insurer denied the Inpatient Substance Detoxification.", "In this case this patient had been using large amounts daily of heroin and crack/cocaine."], "answer_start": [162, 0, 28, 76, 1141]}, "context": "Diagnosis: Substance Abuse\n\nTreatment: Inpatient Substance Detoxification \n\nThe insurer denied the Inpatient Substance Detoxification. The denial was reversed. \n\nThis is a middle aged male who was admitted for inpatient substance detoxification treatment in late 2018 for heroin and crack/cocaine detoxification. He reportedly was using IV heroin and crack/cocaine use since a young age. He had withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches. He had a history of inpatient substance detoxification and rehabilitation treatments. During hospital admission he was placed on a Methadone taper and was then discharged home.\n\nThe American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. \n\nIn this case this patient had been using large amounts daily of heroin and crack/cocaine. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use multiple serious substances of abuse daily with a long history despite reports that he had multiple past inpatient substance detoxification and rehabilitation treatments. The patient also required and needed detoxification medication to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms including severe withdrawal and also was at high risk for overdose so he required this 24 hour inpatient detoxification setting then. Also, he likely would have relapsed again as evidenced by relapsing after past treatments so it was not likely that he could safely and effectively be treated for detoxification in an outpatient setting. It was unlikely that he would remain abstinent while having withdrawal symptoms which he reportedly had as he had reports of withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches.\n\nBased on the above, the medical necessity for the inpatient hospital services at the inpatient detoxification level of care is substantiated. The insurer's denial is reversed.\n", "id": "ef4f3f2091b140f2ab2ccecfce6068ad", "question": "What is the background context in this case summary?", "title": "ef4f3f2091b140f2ab2ccecfce6068ad", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Dental Problems-edentulous spaces", "Treatment: Dental implants placement", "The insurer has denied coverage of dental implants placement.", "This is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous spaces in the anterior maxilla incisor area with missing teeth #7 and #10.  It appears that the patient completed orthodontic therapy and was wearing a removable prosthesis to replace the missing teeth. The orthodontist discussed treatment plans, which included no additional treatment, fixed or bonded bridges or endosteal implants (with grafts) and implant retained crowns. The patient chose endosteal implants to be placed at the sites after discussion of treatment plans.", "The insurer has denied the aforementioned services, stating that in their estimation, endosteal implants are not the only procedure or appropriate treatment. They further state that these services are exclusions from the patients' medical plan coverage, and the insurer will only cover certain dental services under the medical coverage with very specific criteria to be met. Therefore, the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient is appealing the decision.", "the patient exhibits edentulous spaces in the areas of #7, 10."], "answer_start": [0, 46, 84, 170, 788, 1455]}, "context": "Diagnosis: Dental Problems-edentulous spaces\n\nTreatment: Dental implants placement\n\nThe insurer has denied coverage of dental implants placement. The denial was upheld.\n\nThis is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous spaces in the anterior maxilla incisor area with missing teeth #7 and #10.  It appears that the patient completed orthodontic therapy and was wearing a removable prosthesis to replace the missing teeth. The orthodontist discussed treatment plans, which included no additional treatment, fixed or bonded bridges or endosteal implants (with grafts) and implant retained crowns. The patient chose endosteal implants to be placed at the sites after discussion of treatment plans.  \n\nThe insurer has denied the aforementioned services, stating that in their estimation, endosteal implants are not the only procedure or appropriate treatment. They further state that these services are exclusions from the patients' medical plan coverage, and the insurer will only cover certain dental services under the medical coverage with very specific criteria to be met. Therefore, the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient is appealing the decision.\n\nUpon review of the objective documentation, which primarily consists of the panoramic radiograph, it is evident that the patient exhibits edentulous spaces in the areas of #7, 10. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry includes a fixed bridge of some type. Further, a functional impairment is not documented objectively and none appears to be present; therefore, no actual treatment is required and an option is to do nothing.  \n\nUphold denial of coverage of dental implant placement (21248) and bone graft (21210) as not medically necessary since there is no functional deficit documented. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.\n\nBased on the above, the medical necessity for Dental Implant Placement (21248) and Bone Graft (21210) is not substantiated. The insurer's denial is upheld.\n", "id": "2499522ab32741f5a03c1592a695b290", "question": "What is the background context in this case summary?", "title": "2499522ab32741f5a03c1592a695b290", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Infectious colitis\nTreatment:  Inpatient stay ", "The patient was a female, who presented via ambulance to the ED with the complaints of nausea, vomiting and abdominal pain.", "The patient was admitted to start treatment for infectious colitis.  The patient was maintained NPO (nothing by mouth) on intravenous (IV) fluids, IV antibiotics, Zofran and a proton pump inhibitor for acute management of acute infectious colitis.  The patient's tachycardia resolved when her pain was controlled and after getting fluids.  The patient had a repeat set of labs, which showed resolution of the leukocytosis, which lowered the suspicion for a systemic infection cause in this patient.  The patient was taken off antibiotics, and her cultures later returned confirming no bacteremia.  She symptomatically improved, and her vomiting stopped.", "The patient had infectious colitis"], "answer_start": [0, 128, 253, 1033]}, "context": "Diagnosis:  Infectious colitis\nTreatment:  Inpatient stay \nThe acute inpatient admission was not medically necessary.\n\nSummary:\nThe patient was a female, who presented via ambulance to the ED with the complaints of nausea, vomiting and abdominal pain.\n\nThe patient was admitted to start treatment for infectious colitis.  The patient was maintained NPO (nothing by mouth) on intravenous (IV) fluids, IV antibiotics, Zofran and a proton pump inhibitor for acute management of acute infectious colitis.  The patient's tachycardia resolved when her pain was controlled and after getting fluids.  The patient had a repeat set of labs, which showed resolution of the leukocytosis, which lowered the suspicion for a systemic infection cause in this patient.  The patient was taken off antibiotics, and her cultures later returned confirming no bacteremia.  She symptomatically improved, and her vomiting stopped.\n\nDespite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had infectious colitis; yet, she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.", "id": "29ca06971bd74ddda4b04a63feb5113a", "question": "What is the background context in this case summary?", "title": "29ca06971bd74ddda4b04a63feb5113a", "sufficiency_score": 4}
+{"answers": {"text": ["This patient presented to the emergency department with complaints of three days of intermittent shortness of breath and chest pain. His blood pressure was 119/80 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. His room air oxygen saturation was 96%. His cardiovascular exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal. His hemoglobin level was increased at 19.9 grams per deciliter (g/dl). A chest x-ray showed no acute disease. He was treated with nitroglycerin and intravenous hydration and admitted to the hospital to rule out acute coronary syndrome."], "answer_start": [0]}, "context": "This patient presented to the emergency department with complaints of three days of intermittent shortness of breath and chest pain. His blood pressure was 119/80 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. His room air oxygen saturation was 96%. His cardiovascular exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal. His hemoglobin level was increased at 19.9 grams per deciliter (g/dl). A chest x-ray showed no acute disease. He was treated with nitroglycerin and intravenous hydration and admitted to the hospital to rule out acute coronary syndrome. The health plan's determination is upheld.  Observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. A myocardial perfusion study was performed and was normal. He was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. There is no indication in the records provided that other potentially life-threatening causes of his chest pain were thought to be likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.", "id": "beae253faaec4184aef906d21fecee01", "question": "What is the background context in this case summary?", "title": "beae253faaec4184aef906d21fecee01", "sufficiency_score": 4}
+{"answers": {"text": ["The patient underwent upper and lower jaw surgery and went home the next day. There were no complications noted. The inpatient admission is under review. "], "answer_start": [0]}, "context": "The patient underwent upper and lower jaw surgery and went home the next day. There were no complications noted. The inpatient admission is under review. \n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. Most patients with this surgery (orthognathic) are treated, observed and discharged the same day or the following day as long as discharge criteria is met. The surgery is accomplished in an operating room (OR) setting and the minimum required to accomplish the surgery. An inpatient setting would not be necessary unless discharge criteria is not met. In the United States, it has been reported that between 46% and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. A study of patients who underwent orthognathic surgery at Massachusetts General Hospital between January 1994 and July 2006 found that individual variables associated with duration of length of stay (LOS) are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination. In this patient's case, there were no postoperative complications, therefore the patient could have been cared for at a lower level of care.\n", "id": "5971f31f01d941bea3ad960ecef6a31c", "question": "What is the background context in this case summary?", "title": "5971f31f01d941bea3ad960ecef6a31c", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder", "Treatment:  Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS)", "The insurer has denied Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS).", "The patient is a male child with diagnoses of ADHD, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder.  The patient is prescribed Seroquel, Clonidine, and Methylphenidate.  The request was for RN assessment for recertification of CDPAS.  It was reported that the patient could not self-administer medications, needed reminders and redirections to accomplish daily tasks and activities, did not cope well when frustrated or angry, had run away from the classroom, and had a history of throwing objects and pushing students.  It was stated that a personal aide could help manage behaviors.", "The insurer denied coverage for RN assessment for recertification of CDPAS.  It was reported that he had this service for 41 1/2 hours from late 2018 to mid-2019."], "answer_start": [0, 184, 308, 468, 1129]}, "context": "Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder\n\nTreatment:  Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS)\n\nThe insurer has denied Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS).  The denial was upheld.\n\nThe patient is a male child with diagnoses of ADHD, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder.  The patient is prescribed Seroquel, Clonidine, and Methylphenidate.  The request was for RN assessment for recertification of CDPAS.  It was reported that the patient could not self-administer medications, needed reminders and redirections to accomplish daily tasks and activities, did not cope well when frustrated or angry, had run away from the classroom, and had a history of throwing objects and pushing students.  It was stated that a personal aide could help manage behaviors.\n\nThe insurer denied coverage for RN assessment for recertification of CDPAS.  It was reported that he had this service for 41 1/2 hours from late 2018 to mid-2019.  \n\nThis reviewer agrees with the decision to deny coverage for RN assessment for recertification of CDPAS.  The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks.  It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves.  Such activities of daily living (ADLs) include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation.\n\nThe American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder does not mention personal care assistance services as a standard for treatment.  It mentions pharmacotherapy, and also behavioral therapy and parent training as standards of treatment.  This service is not indicated for reminders and redirections to accomplish daily tasks and activities; therefore, it is not medically necessary for this child. \n\nAs a result, uphold the previous decision and deny coverage for RN assessment for recertification of CDPAS.  The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.\n\nBased on the above, the medical necessity for the RN assessment for recertification of CDPAS is not substantiated.  The insurer's denial is upheld. \n\n", "id": "1ff7019d698e44c79bae1c342a15b5cb", "question": "What is the background context in this case summary?", "title": "1ff7019d698e44c79bae1c342a15b5cb", "sufficiency_score": 4}
+{"answers": {"text": ["The patient  was admitted to the hospital and discharged the following day. The patient was admitted for diagnostic evaluation of episodes of jerking of the  body which had started 1 week prior to admission. The movements were initially left sided but had been bilateral for the previous 2 days. They decreased with activity and did not occur during sleep. There was no associated loss of consciousness, urinary incontinence, tongue biting or post-ictal confusion. The patient dropped items that they were  holding during an episode.The patient was admitted to the hospital for a diagnostic workup which included an magnetic resonance imaging (MRI) brain, video electroencephalogram (EEG) telemetry, lumbar puncture, blood and urine testing."], "answer_start": [0]}, "context": "The patient  was admitted to the hospital and discharged the following day. The patient was admitted for diagnostic evaluation of episodes of jerking of the  body which had started 1 week prior to admission. The movements were initially left sided but had been bilateral for the previous 2 days. They decreased with activity and did not occur during sleep. There was no associated loss of consciousness, urinary incontinence, tongue biting or post-ictal confusion. The patient dropped items that they were  holding during an episode.The patient was admitted to the hospital for a diagnostic workup which included an magnetic resonance imaging (MRI) brain, video electroencephalogram (EEG) telemetry, lumbar puncture, blood and urine testing. The health plans determination of medical necessity is  overturned in whole. the requested health service/treatment of the inpatient hospital stay was medically necessary for this patient.\n The inpatient stay was medically necessary, and met the criteria for Inpatient Admission for Neurology under the Milliman Care Guidelines  Health Inpatient & Surgical Care,  which states:\n\"Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: New onset severe neurologic finding requiring inpatient care indicated by 1 or more of the following: Involuntary movements. The differential diagnosis of the onset of involuntary movements , and included seizures, movement disorder which can be due to underlying infectious or autoimmune illness, or tics.,The  inpatient admission for video EEG telemetry and diagnostic workup including lumbar puncture with sedation was medically necessary in order to correctly diagnose the paroxysmal events that the patient was exhibiting. and prevent the patient  from being inappropriately treated.", "id": "c4b91dc479e54baeb7d7c670da694a59", "question": "What is the background context in this case summary?", "title": "c4b91dc479e54baeb7d7c670da694a59", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Abnormal pap smear\nTreatment:  Inpatient admission", "The patient in question was taken to the operating room and underwent an uncomplicated fractional dilation and curettage with hysteroscopy procedure for an abnormal pap smear of atypical glandular cells of undetermined significance.  After surgery she was not ready for discharge same day.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea."], "answer_start": [0, 442]}, "context": "Diagnosis:  Abnormal pap smear\nTreatment:  Inpatient admission\nThe inpatient admission was not medically necessary.\n \nAn outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  \nThe patient in question was taken to the operating room and underwent an uncomplicated fractional dilation and curettage with hysteroscopy procedure for an abnormal pap smear of atypical glandular cells of undetermined significance.  After surgery she was not ready for discharge same day.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea.   This could have been done in an observation status.  By post-operative day #1 the patient was ready for discharge, requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.\n\n", "id": "55760962602a4c8982ab2729ebfbc8e8", "question": "What is the background context in this case summary?", "title": "55760962602a4c8982ab2729ebfbc8e8", "sufficiency_score": 4}
+{"answers": {"text": ["The patient with no significant past medical history who presented to the emergency department with complaints of nausea, vomiting, and abdominal discomfort that had been going on for 2-3 days. At the time of the initial evaluation, the patient denied fever, chills. The patient was evaluated by general surgery and was found to have no surgical cause of pain."], "answer_start": [0]}, "context": "The patient with no significant past medical history who presented to the emergency department with complaints of nausea, vomiting, and abdominal discomfort that had been going on for 2-3 days. At the time of the initial evaluation, the patient denied fever, chills. The patient was evaluated by general surgery and was found to have no surgical cause of pain. the health plans determination of medical necessity is upheld in whole. The patient's clinical symptoms, including mild dehydration and mild electrolyte derangements, could have been handled at a lower level of care. The lower level of care was justified to ensure clinical stability and to ensure reliable oral intake. The inpatient level of care was not medically necessary for this patient, based on the severity of the patient's condition and the complexity of services.", "id": "4bc44b7b080b4994bceefe4d9f4f8697", "question": "What is the background context in this case summary?", "title": "4bc44b7b080b4994bceefe4d9f4f8697", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who presented with severe diarrhea after traveling out of the country. By the time of presentation he was having up to 12 episodes of diarrhea per day.  He had decreased urine output and had developed dehydration.  In the emergency department he was found to have orthostatic hypotension and abnormal laboratory values.", "The patient is a male who presented with vomiting and diarrhea.  He was well until the week prior to admission when he was traveling to New York after a visit to Peru.  At that time he began to have multiple episodes of emesis.  The emesis continued for 2 days before subsiding, and shortly after he developed diarrhea.  He described an average of 8 episodes of watery, non-bloody diarrhea with mucus every day.  This was accompanied by diffuse abdominal pain.", "He was admitted for treatment of gastroenteritis with moderate dehydration.  He was given intravenous fluids as well as Zofran when necessary and bowel rest.  He continued to have diarrhea after admission and was started on a clear liquid diet.  His stool polymerase chain reaction (PCR) was found to be positive for rotavirus.  With hydration during the hospitalization, his electrolyte abnormalities resolved, and he was able to advance his diet.  His diarrhea had decreased, and he was stable for discharge to home."], "answer_start": [1030, 0, 461]}, "context": "The patient is a male who presented with vomiting and diarrhea.  He was well until the week prior to admission when he was traveling to New York after a visit to Peru.  At that time he began to have multiple episodes of emesis.  The emesis continued for 2 days before subsiding, and shortly after he developed diarrhea.  He described an average of 8 episodes of watery, non-bloody diarrhea with mucus every day.  This was accompanied by diffuse abdominal pain.\nHe was admitted for treatment of gastroenteritis with moderate dehydration.  He was given intravenous fluids as well as Zofran when necessary and bowel rest.  He continued to have diarrhea after admission and was started on a clear liquid diet.  His stool polymerase chain reaction (PCR) was found to be positive for rotavirus.  With hydration during the hospitalization, his electrolyte abnormalities resolved, and he was able to advance his diet.  His diarrhea had decreased, and he was stable for discharge to home.\n\nThe health plan's determination is overturned. \n\nThis is a patient who presented with severe diarrhea after traveling out of the country. By the time of presentation he was having up to 12 episodes of diarrhea per day.  He had decreased urine output and had developed dehydration.  In the emergency department he was found to have orthostatic hypotension and abnormal laboratory values.  He required prompt initiation of intravenous hydration, as well as antiemetics as needed and close monitoring in an inpatient setting.\nThe decision-making at the time of admission was consistent with his young age, the presence of severe diarrhea in the setting of travel to different country, the presence of symptomatic dehydration, and the need for prompt initiation of treatment with close monitoring for potential deterioration of clinical status.", "id": "15849b9e24474226a7e82aef7efe6573", "question": "What is the background context in this case summary?", "title": "15849b9e24474226a7e82aef7efe6573", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a history of end stage renal disease and hyperphosphatemia; also noted to have hypercalcemia and is not a candidate for PhosLo. Treating provider is requesting Renvela for her condition.", "Diagnosis: ESRD, hyperphosphatemia, hypercalcemia", "Treatment: Medication- Renvela", "The insurer denied coverage for Renvela."], "answer_start": [149, 0, 52, 84]}, "context": "Diagnosis: ESRD, hyperphosphatemia, hypercalcemia\n \nTreatment: Medication- Renvela\n\nThe insurer denied coverage for Renvela. The denial was upheld.\n\nThe patient has a history of end stage renal disease and hyperphosphatemia; also noted to have hypercalcemia and is not a candidate for PhosLo. Treating provider is requesting Renvela for her condition.\n\nRenvela is not considered medically necessary for this patient. There is no current evidence-based literature that Renvela is safer or more effective than available preferred medications (Sevelamer carbonate, Fosrenol and Velphoro).  Based on documentation submitted, the patient has not tried and failed the preferred medications.     \n\n", "id": "6afafcd804994dd084d2a684d5ef9986", "question": "What is the background context in this case summary?", "title": "6afafcd804994dd084d2a684d5ef9986", "sufficiency_score": 3}
+{"answers": {"text": ["This is a patient with a past medical history of hyperlipidemia, osteoporosis, vertigo, who presented to the emergency room (ER) with vertigo, headache, nausea and vomiting. She had these symptoms on and off for two months, but she had worsening vertigo pulling to her left side, and a headache which localized to the right frontal area, for one hour prior to presentation. She had a National Institute of Health Stroke Scale (NIHSS) of 0 on admission.", "She  was hemodynamically stable, without a major electrolyte abnormality, cardiac or respiratory issues, and without focal weakness, sensory changes, altered mental status, or slurred speech. The initial workup included a CT scan of the head and a CT angiogram of the head and neck was unrevealing. The neurologist's initial assessment was of a peripheral cause of the patient's symptoms as opposed to a central etiology."], "answer_start": [0, 517]}, "context": "This is a patient with a past medical history of hyperlipidemia, osteoporosis, vertigo, who presented to the emergency room (ER) with vertigo, headache, nausea and vomiting. She had these symptoms on and off for two months, but she had worsening vertigo pulling to her left side, and a headache which localized to the right frontal area, for one hour prior to presentation. She had a National Institute of Health Stroke Scale (NIHSS) of 0 on admission.\nThe health plan's determination of medical necessity is upheld. She  was hemodynamically stable, without a major electrolyte abnormality, cardiac or respiratory issues, and without focal weakness, sensory changes, altered mental status, or slurred speech. The initial workup included a CT scan of the head and a CT angiogram of the head and neck was unrevealing. The neurologist's initial assessment was of a peripheral cause of the patient's symptoms as opposed to a central etiology.\nAccording to an American Family Physician (AFP) review article on dizziness: \"Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment.\"", "id": "aee71c762661488bb9f929e0c037e196", "question": "What is the background context in this case summary?", "title": "aee71c762661488bb9f929e0c037e196", "sufficiency_score": 4}
+{"answers": {"text": ["This is a young female patient who presented to the Emergency Department with complaints of worsening abdominal pain following a recent diagnosis and treatment for a Campylobacter infection. She reports a benign medical history. Vital signs on presentation included: a temperature of 37C, a blood pressure of 108/74, a pulse of 74, a respiratory rate of 18, and an oxygen saturation of 99% on room air.  The patient was given intravenous (IV) fluids and started on intravenous antibiotics (Azithromycin). She was kept nothing by mouth (NPO). A Computerized Tomography (CT) scan of the abdomen showed changes consistent with colitis. Gastroenterology consulted and recommended slowly advancing the diet as tolerated. Infectious Diseases was also consulted and recommended continuation of antibiotics. She underwent a colonoscopy. The patient remained afebrile and hemodynamically stable and was discharged to continue antibiotics as an outpatient.  ", "Diagnosis: Colitis and Campylobacter Infection", "Treatment: Inpatient Admission", "The insurer denied the Inpatient Admission."], "answer_start": [152, 0, 48, 80]}, "context": "Diagnosis: Colitis and Campylobacter Infection\n\nTreatment: Inpatient Admission\n\nThe insurer denied the Inpatient Admission. The denial was reversed.  \n\nThis is a young female patient who presented to the Emergency Department with complaints of worsening abdominal pain following a recent diagnosis and treatment for a Campylobacter infection. She reports a benign medical history. Vital signs on presentation included: a temperature of 37C, a blood pressure of 108/74, a pulse of 74, a respiratory rate of 18, and an oxygen saturation of 99% on room air.  The patient was given intravenous (IV) fluids and started on intravenous antibiotics (Azithromycin). She was kept nothing by mouth (NPO). A Computerized Tomography (CT) scan of the abdomen showed changes consistent with colitis. Gastroenterology consulted and recommended slowly advancing the diet as tolerated. Infectious Diseases was also consulted and recommended continuation of antibiotics. She underwent a colonoscopy. The patient remained afebrile and hemodynamically stable and was discharged to continue antibiotics as an outpatient.  \nA Campylobacter infection is an important cause of acute diarrhea and may produce systemic illness, as well as other complications. Based on patient's documented failure of outpatient management, the need for IV fluids, maintaining NPO status, IV antibiotics, and a diagnostic procedure (colonoscopy), the hospital admission was medically necessary. \n\nBased on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.\n", "id": "a8b8bcf424af41d38231c7e2ec2c1cfc", "question": "What is the background context in this case summary?", "title": "a8b8bcf424af41d38231c7e2ec2c1cfc", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Obesity\nTreatment: Saxenda"], "answer_start": [0]}, "context": "Diagnosis: Obesity\nTreatment: Saxenda\nThe treatment with Saxenda is medically necessary.\n\nSaxenda is a GLP1 (glucagon-like peptide-1) agonist that is used in the treatment of obesity [1-3]. The FDA label is below [4]. \n\n-INDICATIONS AND USAGE\nSaxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of \n- 30 kg/m2 or greater (obese) (1) or\n- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (1).\nLimitations of Use: \n- Saxenda is not indicated for the treatment of type 2 diabetes (1). \n- Saxenda should not be used in combination with any other GLP-1 receptor agonist (1).\n- Saxenda should not be used with insulin (1, 5.4).\n- The effects of Saxenda on cardiovascular morbidity and mortality have not been established (1).\n- The safety and efficacy of coadministration with other products for weight loss have not been established (1).\n- Saxenda has not been studied in patients with a history of pancreatitis (1, 5.2). \n\nThe patient meets accepted criteria for use of the requested medication. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.\n\nThe health plan's requirement of documentation of current and prior enrollment in a comprehensive weight management program like Weight Watchers or Curves Complete is not consistent with the FDA-approved indications for Saxenda.\n\n", "id": "56872e9785b740198e0429d4bf4adeab", "question": "What is the background context in this case summary?", "title": "56872e9785b740198e0429d4bf4adeab", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Chest pain\nTreatment: Inpatient admission", "The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, consistent with ischemic changes. The presentation was in the setting of hypertensive urgency. A stress test was abnormal as well, consistent with ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended."], "answer_start": [0, 103]}, "context": "Diagnosis: Chest pain\nTreatment: Inpatient admission\nThe Inpatient admission was medically necessary.\n\nThe patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, consistent with ischemic changes. The presentation was in the setting of hypertensive urgency. A stress test was abnormal as well, consistent with ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit.  It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.\n\n", "id": "1c675a48a4604ef1875badad5eebb5c2", "question": "What is the background context in this case summary?", "title": "1c675a48a4604ef1875badad5eebb5c2", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented with rectal bleeding. The patient initially had dizziness, but at the time of admission the dizziness had resolved. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam did not reveal any bleeding. The hemoglobin was 13.8. The bleeding was felt to be due to hemorrhoids. The patient was treated for constipation and referred to Gastrointestinal (GI) clinic.", "Diagnosis: Rectal bleeding", "Treatment: Inpatient admission, monitoring", "The insurer denied the inpatient hospital admission.", "This patient had minor self-limited bleeding. The patient remained hemodynamically stable and there was no evidence of active ongoing bleeding."], "answer_start": [150, 0, 29, 73, 974]}, "context": "Diagnosis: Rectal bleeding\n \nTreatment: Inpatient admission, monitoring\n\nThe insurer denied the inpatient hospital admission. The denial was upheld.\n\nThe patient presented with rectal bleeding. The patient initially had dizziness, but at the time of admission the dizziness had resolved. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam did not reveal any bleeding. The hemoglobin was 13.8. The bleeding was felt to be due to hemorrhoids. The patient was treated for constipation and referred to Gastrointestinal (GI) clinic. \n\nClinical indications for admission for lower GI bleeding (M-182) include having ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, intestinal obstruction, and severe thrombocytopenia. The patient did not have these conditions. The patient also did not have hemodynamic instability, severe anemia, severe pain or an inability to maintain oral hydration. \n\nThis patient had minor self-limited bleeding. The patient remained hemodynamically stable and there was no evidence of active ongoing bleeding. The patient did not meet MCG criteria for admission for lower GI bleeding. \n\nBased on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.\n\n", "id": "49730b6ecc6b45ab85f710afe365cfe6", "question": "What is the background context in this case summary?", "title": "49730b6ecc6b45ab85f710afe365cfe6", "sufficiency_score": 4}
+{"answers": {"text": ["This is a child with known sickle cell disease HbSS, who presented with fever and upper respiratory infection (URI) symptoms for 3 days along with loose stools for 4 days. The patient was with a poor appetite x 1 week. Temperature maximum was 101. A chest X-ray showed questionable pneumonia. The patient was given intravenous (IV) Ceftriaxone and admitted to the hospital. The patient had multiple admissions since birth. The patient received packed red blood cells (PRBC) in the past. On this admission the white blood cell count (WBC) was 15,100 and hemoglobin (Hgb) was low at 6.4. The liver function tests (LFTs) were normal. The respiratory syncytial virus (RSV) and flu tests were negative. Blood cultures were done. On physical exam the patient was in no acute distress. The lips were mildly dry. The patient had harsh breath sounds. The Abdomen revealed a liver 2cm below the right costal margin. The registered nurse (RN) documented the child to have dry cracked lips with furred tongue and also looking weak. After admission the spleen was palpable at the left costal margin with inspiration. His WBC increased to 23.3 later on the day of admission. The patient was followed and intravenous fluids (IVF) were administered. The Hgb went up to 7.0 during admission.", "There was a new infiltrate on X-Ray.", "This patient has had transfusion of PRBCs in the past."], "answer_start": [0, 1465, 1810]}, "context": "This is a child with known sickle cell disease HbSS, who presented with fever and upper respiratory infection (URI) symptoms for 3 days along with loose stools for 4 days. The patient was with a poor appetite x 1 week. Temperature maximum was 101. A chest X-ray showed questionable pneumonia. The patient was given intravenous (IV) Ceftriaxone and admitted to the hospital. The patient had multiple admissions since birth. The patient received packed red blood cells (PRBC) in the past. On this admission the white blood cell count (WBC) was 15,100 and hemoglobin (Hgb) was low at 6.4. The liver function tests (LFTs) were normal. The respiratory syncytial virus (RSV) and flu tests were negative. Blood cultures were done. On physical exam the patient was in no acute distress. The lips were mildly dry. The patient had harsh breath sounds. The Abdomen revealed a liver 2cm below the right costal margin. The registered nurse (RN) documented the child to have dry cracked lips with furred tongue and also looking weak. After admission the spleen was palpable at the left costal margin with inspiration. His WBC increased to 23.3 later on the day of admission. The patient was followed and intravenous fluids (IVF) were administered. The Hgb went up to 7.0 during admission.  The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Inpatient Hospital Admission is medically necessary for this patient. There was a new infiltrate on X-Ray. This would be indicative of acute chest syndrome (ACS). \"Clinically, ACS is defined by a new pulmonary infiltrate on chest radiograph in addition to one or more of the following: fever, tachypnea, dyspnea, hypoxia, and chest pain. ACS is a common and potentially lethal complication of sickle cell disease.\" This patient has had transfusion of PRBCs in the past. The low hemoglobin coupled with diarrhea, poor (PO) intake and physical signs of dehydration would also predispose the patient to crisis due to  sickle cell. IV hydration, monitoring  Intake's and Output's, (PO) intake, stool output as well as fever curve and O2 saturation would be proper care for this patient. ", "id": "c9b8a30793444468967e430951e10e66", "question": "What is the background context in this case summary?", "title": "c9b8a30793444468967e430951e10e66", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Issue conceiving\nTreatment:  IUI", "This patient was able to conceive following donor insemination but had a miscarriage."], "answer_start": [0, 525]}, "context": "Diagnosis:  Issue conceiving\nTreatment:  IUI\nThe proposed treatment with IUI was not medically necessary.\n\nAccording to the American Society for Reproductive Medicine (ASRM), infertility is a disease, defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination.  Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35 years.\n\nThis patient was able to conceive following donor insemination but had a miscarriage.  In other words, she did not fail to conceive after six therapeutic donor inseminations, and, therefore, she does not have a diagnosis of infertility.  In the absence of such a diagnosis, treatment for infertility including the intrauterine insemination performed is not medically necessary.\n\nThe request is not medically necessary, since this patient did not have an illness, injury or disease:  She has inability to conceive due to non-exposure to sperm and due to aging a normal, natural physiological process.  The standard of care is for this patient to fail six inseminations (i.e. fail to get pregnant) before she is considered infertile and eligible for coverage of infertility services.\n\nIn summary, this patient's inability to conceive is due to natural aging and non-exposure to sperm.  She does not have a diagnosis of infertility, and the requested coverage for IUI was not medically necessary. \n\n\n", "id": "fdc50fc111de45559c478c5d96966cac", "question": "What is the background context in this case summary?", "title": "fdc50fc111de45559c478c5d96966cac", "sufficiency_score": 3}
+{"answers": {"text": ["The patient was admitted to the hospital. The patient has a past medical history of Parkinson's disease and hypertension and presented after a syncopal episode. The patient was noted to be unresponsive and cardiopulmonary resuscitation (CPR) was initiated. Vital signs showed a blood pressure of 185/71, pulse 97, respiratory rate 18 and oxygen saturation 96%. Labs showed a white blood cell count of 7.3, hemoglobin 9.2, platelets 158, sodium 140, potassium 3.6, creatinine 0.8 and a glucose of 113. An electrocardiogram (EKG) showed sinus rhythm with frequent PVCs (premature ventricular contractions). A computed tomography (CT) of the brain showed no acute intracranial abnormalities. The patient was admitted for further management and evaluation. ", "The patient presented after a syncopal episode. Her EKG showed sinus rhythm. The head CT was negative for acute intracranial abnormalities. The patient was hemodynamically stable. An ultrasound (US) carotid showed no stenosis. No sustained ectopic foci were noted on Holter. Amantadine and Donepezil were discontinued per neurology recommendation. The patient was started on Ropinirole and Sinemet. She was also evaluated by physical therapy. No complicating events occurred during the stay."], "answer_start": [0, 846]}, "context": "The patient was admitted to the hospital. The patient has a past medical history of Parkinson's disease and hypertension and presented after a syncopal episode. The patient was noted to be unresponsive and cardiopulmonary resuscitation (CPR) was initiated. Vital signs showed a blood pressure of 185/71, pulse 97, respiratory rate 18 and oxygen saturation 96%. Labs showed a white blood cell count of 7.3, hemoglobin 9.2, platelets 158, sodium 140, potassium 3.6, creatinine 0.8 and a glucose of 113. An electrocardiogram (EKG) showed sinus rhythm with frequent PVCs (premature ventricular contractions). A computed tomography (CT) of the brain showed no acute intracranial abnormalities. The patient was admitted for further management and evaluation. \n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented after a syncopal episode. Her EKG showed sinus rhythm. The head CT was negative for acute intracranial abnormalities. The patient was hemodynamically stable. An ultrasound (US) carotid showed no stenosis. No sustained ectopic foci were noted on Holter. Amantadine and Donepezil were discontinued per neurology recommendation. The patient was started on Ropinirole and Sinemet. She was also evaluated by physical therapy. No complicating events occurred during the stay. This patient's care could be provided at a lower level as there was no hemodynamic instability, pulmonary embolism, arterial dissection, acute congestive heart failure exacerbation, cardiac ischemia, atrial fibrillation or need for continuous intravenous infusion.\n", "id": "e8d1cd23aa484d25b415429b30a8496e", "question": "What is the background context in this case summary?", "title": "e8d1cd23aa484d25b415429b30a8496e", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week.", "The patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services."], "answer_start": [0, 734]}, "context": "The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week. The health plan's determination is overturned, in part. The requested health service/treatment of Consumer directed personal cares assistance services increase from 17 to 40 hours per week is not medically necessary for this patient. However, an increase to 20 hours a week is medically necessary.\nThe patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services. Based upon review of the records provided along with the documents provided in regards to nursing and aid hours, the patient would need additional hours to support basic functions such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The recommended increase in the personal-care hours from 17 hours a week to 20 hours a week should be sufficient to maintain activities that were noted to be medically necessary according to the documentation provided. There is no medical need for additional hours other than 20 hours a week.", "id": "742b28b397854ab485ab487d02ec410e", "question": "What is the background context in this case summary?", "title": "742b28b397854ab485ab487d02ec410e", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Chest pain, shortness of breath", "Treatment: Inpatient admission, diagnostic testing, medication, monitoring", "The insurer denied the inpatient hospital admission.", "The patient presented to the Emergency Department (ED) with acute onset of chest pressure and diaphoresis. The patient reported right lower extremity cramping and left lower extremity swelling. The patient has a productive cough with green sputum and mild rhinorrhea. The patient has a past medical history of Marfan syndrome, Diabetes Mellitus type II, previous heart attack, status post mechanical aortic valve replacement (AVR), status post left heart catheterization with percutaneous coronary intervention (PCI) and recent admission due to melena and hematochezia. The patient had symptoms of an upper respiratory infection (URI), shortness of breath with intermittent paroxysmal nocturnal dyspnea (PND). The patient states that for the past few days The patient has had sub sternal pressure like chest pain which is similar to when The patient was diagnosed with non-ST elevated myocardial infarction (NSTEMI). The patient states that the pressure radiates to his back but only when The patient is laying down and reports that this is been ongoing for the past month. His vital signs include temperature 36.6 C, heart rate 60, blood pressure 169/80, respirations 18 and oxygen saturation 99% on room air.", "The patient's atypical chest pressure/congestion resolved after receiving intravenous (IV) Lasix.", "In the hospital The patient did not have any recurrence of significant chest pain and his workup revealed normal troponins and a BNP that was only slightly elevated. His Electrocardiogram (EKG) showed no change from previous recordings and no evidence of acute myocardial injury or ischemia. An echocardiogram and a Computer Tomogram (CT) of the chest did not reveal any significant pathology."], "answer_start": [0, 45, 121, 198, 1411, 1574]}, "context": "Diagnosis: Chest pain, shortness of breath\n \nTreatment: Inpatient admission, diagnostic testing, medication, monitoring\n\nThe insurer denied the inpatient hospital admission. The denial was upheld.\n\nThe patient presented to the Emergency Department (ED) with acute onset of chest pressure and diaphoresis. The patient reported right lower extremity cramping and left lower extremity swelling. The patient has a productive cough with green sputum and mild rhinorrhea. The patient has a past medical history of Marfan syndrome, Diabetes Mellitus type II, previous heart attack, status post mechanical aortic valve replacement (AVR), status post left heart catheterization with percutaneous coronary intervention (PCI) and recent admission due to melena and hematochezia. The patient had symptoms of an upper respiratory infection (URI), shortness of breath with intermittent paroxysmal nocturnal dyspnea (PND). The patient states that for the past few days The patient has had sub sternal pressure like chest pain which is similar to when The patient was diagnosed with non-ST elevated myocardial infarction (NSTEMI). The patient states that the pressure radiates to his back but only when The patient is laying down and reports that this is been ongoing for the past month. His vital signs include temperature 36.6 C, heart rate 60, blood pressure 169/80, respirations 18 and oxygen saturation 99% on room air. \n\nThe patient's atypical chest pressure/congestion resolved after receiving intravenous (IV) Lasix. The symptoms were not typical for acute coronary syndrome (ACS). In the hospital The patient did not have any recurrence of significant chest pain and his workup revealed normal troponins and a BNP that was only slightly elevated. His Electrocardiogram (EKG) showed no change from previous recordings and no evidence of acute myocardial injury or ischemia. An echocardiogram and a Computer Tomogram (CT) of the chest did not reveal any significant pathology. \n\nBased on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.", "id": "3211babfea58488f88fd1c471094c55b", "question": "What is the background context in this case summary?", "title": "3211babfea58488f88fd1c471094c55b", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Shortness of breath and Chest Pain\nTreatment: Inpatient admission", "This is a female with a history of pulmonary embolism who presented to the ER for further evaluation/management of dyspnea and chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air.", "Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received therapeutic anticoagulation, supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition."], "answer_start": [0, 132, 634]}, "context": "Diagnosis: Shortness of breath and Chest Pain\nTreatment: Inpatient admission\nThe inpatient admission was not medically necessary. \n\nThis is a female with a history of pulmonary embolism who presented to the ER for further evaluation/management of dyspnea and chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received therapeutic anticoagulation, supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. \n\nThere is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the inpatient admission was not medically necessary. \n", "id": "6095c31084e14bdda1fa1bc6338e1a6f", "question": "What is the background context in this case summary?", "title": "6095c31084e14bdda1fa1bc6338e1a6f", "sufficiency_score": 4}
+{"answers": {"text": ["The patient , who requests an increase in personal-care assistant hours from 70 hours a week to 112 hours a week. The patient has a past medical history significant for hyperlipidemia, diabetes mellitus type 2, hypertension, and cognitive dysfunction."], "answer_start": [0]}, "context": "The patient , who requests an increase in personal-care assistant hours from 70 hours a week to 112 hours a week. The patient has a past medical history significant for hyperlipidemia, diabetes mellitus type 2, hypertension, and cognitive dysfunction.  The health plan's determination is upheld.  The requested health service/treatment of personal care assistance increase from 70 hours per week to 112 hours per week is not medically necessary for this patient.  Additional services are not medically necessary. Typically for services to be considered medically necessary the aide must be functioning and performing ADLs and/or IADLs.  It is noted that the patient's ADLs and IADLs can be performed within the allotted time.  Services for monitoring for safety or companion care without the necessity of underlying ADLs or IADLs are not considered medically necessary.  No additional hours are medically necessary.", "id": "87b599a8888947259496d39c44d0347d", "question": "What is the background context in this case summary?", "title": "87b599a8888947259496d39c44d0347d", "sufficiency_score": 3}
+{"answers": {"text": ["The patient is a child with long standing constipation, diagnosed with Crohn's disease. His Gastroenterologist is requesting authorization for Humira.  Bloodwork showed a platelet count of 662, albumin 3.0, CRP 67.6, ESR of 53. Patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Pathology report demonstrates chronic ileitis with granuloma, colitis. Patient was started on steroids, which improved many of his symptoms. Plain x-ray shows constipation.", "Diagnosis: Crohn's Disease", "Treatment: Medication- Humira", "The insurer denied treatment with Humira."], "answer_start": [126, 0, 29, 60]}, "context": "Diagnosis: Crohn's Disease\n \nTreatment: Medication- Humira\n\nThe insurer denied treatment with Humira. The denial was upheld.\n\nThe patient is a child with long standing constipation, diagnosed with Crohn's disease. His Gastroenterologist is requesting authorization for Humira.  Bloodwork showed a platelet count of 662, albumin 3.0, CRP 67.6, ESR of 53. Patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Pathology report demonstrates chronic ileitis with granuloma, colitis. Patient was started on steroids, which improved many of his symptoms. Plain x-ray shows constipation. Recent emerging data has demonstrated disproportionate risks of hepatosplenic T-cell lymphoma among adolescent males exposed to immunomodulators. \n", "id": "6717848c7b52416f9a2ff5a246316fde", "question": "What is the background context in this case summary?", "title": "6717848c7b52416f9a2ff5a246316fde", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: SOB; Wheezing\nIssue under review: Inpatient admission", "The patient had asthma exacerbation with failed outpatient therapy, emergency room therapy. The patient had history of similar asthma exacerbations in the past with requiring mechanical ventilation."], "answer_start": [0, 131]}, "context": "Diagnosis: SOB; Wheezing\nIssue under review: Inpatient admission\n\nDetermination:\nThe Inpatient admission was medically necessary.\n\nThe patient had asthma exacerbation with failed outpatient therapy, emergency room therapy. The patient had history of similar asthma exacerbations in the past with requiring mechanical ventilation. Since the patient failed outpatient as well as emergency room treatment and had significant anxiety symptoms during early hospitalization stay, the acute in hospital level of care was medically necessary.", "id": "7b99f888fc2e4f539bd64ee1ecca4032", "question": "What is the background context in this case summary?", "title": "7b99f888fc2e4f539bd64ee1ecca4032", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Diabetes type II, status post mechanical fall\nTreatment: Inpatient admission", "The patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead.  She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes.", "The patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air.  On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead.  No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait.  She was awake, alert and oriented times three.  She had mild tenderness in the right knee.", "The patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7.  CT of the cervical spine and head demonstrated no evidence of acute pathology.  Chest x-ray showed no evidence of acute cardiopulmonary disease.  EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm.  Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion.  Impression included unspecified fall, and vertical patellar fracture.", "Medical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room.  It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement.  Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics.  While on admission, she was seen by physical therapy.", "On the day of discharge, the patient was medically stable for discharge home.   It was noted that she will receive home care.", "The patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead.  Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty.  She was hemodynamically stable when she presented to the emergency department."], "answer_start": [0, 141, 437, 890, 1556, 2086, 2214]}, "context": "Diagnosis: Diabetes type II, status post mechanical fall\nTreatment: Inpatient admission\nThe inpatient admission as not medically necessary.\n\nThe patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead.  She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes. \n\nThe patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air.  On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead.  No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait.  She was awake, alert and oriented times three.  She had mild tenderness in the right knee.  \n\nThe patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7.  CT of the cervical spine and head demonstrated no evidence of acute pathology.  Chest x-ray showed no evidence of acute cardiopulmonary disease.  EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm.  Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion.  Impression included unspecified fall, and vertical patellar fracture. \n\nMedical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room.  It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement.  Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics.  While on admission, she was seen by physical therapy. \n\nOn the day of discharge, the patient was medically stable for discharge home.   It was noted that she will receive home care. \n\nThe patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead.  Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty.  She was hemodynamically stable when she presented to the emergency department.  There was no evidence of altered mental status, confusion, respiratory compromise, significant persistent life-threatening arrhythmias, or sepsis.  There were no serious neurologic abnormalities like brain infection, cerebral bleeding/ischemia, increased intracranial pressure or spinal cord injury.  CAT scan of the brain did not show any acute bleed or hemorrhage.  \n\nIn view of the foregoing, the inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.  \n\n\n", "id": "dcf4a8904fe940c4b03612515b1f19e9", "question": "What is the background context in this case summary?", "title": "dcf4a8904fe940c4b03612515b1f19e9", "sufficiency_score": 4}
+{"answers": {"text": ["Varicose veins\nSurgical services", "The patient presented with right leg symptomatic varicose veins. Main symptoms include burning, aching and throbbing. The patient has attempted and failed conservative therapy with graded compression stockings for several months' duration. The symptoms are lifestyle limiting and interfere with  activities of daily living. A duplex scan demonstrates reflux in the right accessory great saphenous vein."], "answer_start": [0, 34]}, "context": "Varicose veins\nSurgical services\n\nThe patient presented with right leg symptomatic varicose veins. Main symptoms include burning, aching and throbbing. The patient has attempted and failed conservative therapy with graded compression stockings for several months' duration. The symptoms are lifestyle limiting and interfere with  activities of daily living. A duplex scan demonstrates reflux in the right accessory great saphenous vein. The health plan's determination of medical necessity is overturned in whole. Endovenous ablation of the right accessory great saphenous vein for this patient is the current standard of care treatment for symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year.", "id": "bbed3be6b6eb401a915e4f97470b64c2", "question": "What is the background context in this case summary?", "title": "bbed3be6b6eb401a915e4f97470b64c2", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Oligometastatic lesion in the abdominal wall\nTreatment: SBRT", "In this case, the patient is a male with a history of lung cancer s/p definitive chemoradiotherapy.  The patient developed brain metastasis s/p resection.  The patient was recently found to have an oligometastatic lesion in the abdominal wall.   Local therapy to the oligometastatic abdominal wall lesion was recommended, and stereotactic body radiosurgery was requested.", "This patient has an oligometastatic abdominal wall lesion with any active disease elsewhere"], "answer_start": [0, 1251, 2810]}, "context": "Diagnosis: Oligometastatic lesion in the abdominal wall\nTreatment: SBRT\nThe SBRT is medically necessary.\n\nStereotactic radiosurgery (SRS) is a highly precise form of radiation therapy used primarily to treat tumors and other abnormalities of the brain. The treatment involves the delivery of a single high-dose, or sometimes smaller, multiple doses, of radiation beams that converge on the specific area where the tumor or other abnormality resides.   It is a highly precise treatment, is able to minimize the amount of radiation to surrounding healthy and critical tissues.  Extracranial stereotactic radiosurgery or stereotactic body radiotherapy (SBRT) for certain conditions has also been shown to be safe and effective as compared to the standard radiation therapy.  Some of the conditions that have shown the most potential include spinal tumors, liver tumors and inoperable stage I lung cancers.  Other conditions include re-treatment of previous treated areas where conventional radiation in is inadequate in sparing surrounding normal tissues.  SBRT is FDA-approved.  It is not subject to IRB (institutional review board) review, and its effectiveness has been proven based on clinical evidence reported in peer-reviewed medical literature.\n\nIn this case, the patient is a male with a history of lung cancer s/p definitive chemoradiotherapy.  The patient developed brain metastasis s/p resection.  The patient was recently found to have an oligometastatic lesion in the abdominal wall.   Local therapy to the oligometastatic abdominal wall lesion was recommended, and stereotactic body radiosurgery was requested.  \n\nThere is clinical data demonstrating the safety and effectiveness of stereotactic radiosurgery for oligometastatic lesions.  In fact, SBRT may provide a better local control compared to standard fractionated radiation therapy.  \n\nA 2013 review article by Tree et al. evaluated studies on SBRT for oligometastatic disease.  The authors stated, \"Many non-randomised studies have shown that SBRT for oligometastases is safe and effective, with local control rates of about 80%\", and concluded that \"SBRT offers durable local control and the potential for progression-free survival in non-liver, non-lung oligometastatic disease at a range of sites.\"\n\nIn addition, a 2019 multi-institution randomized trial (SABR-COMET trial) randomized 99 patients with oligometastatic lesions (1-5 lesions) into control group vs SBRT.  Median overall survival was 28 months in the control group versus 41 months in the SABR (SBRT) group (p=0090). Treatment-related deaths occurred in three (45%) of 66 patients after SABR, compared with none in the control group.  The authors concluded, \"SABR (SBRT) was associated with an improvement in overall survival, meeting the primary endpoint of this trial.\"\n\nThis patient has an oligometastatic abdominal wall lesion with any active disease elsewhere, and if they are controlled with SBRT, the patient may have a prolonged survival.  Stereotactic radiosurgery has been shown to be safe and effective for the treatment of oligometastatic/solitary lesions, and in this case, is the best option that can help with disease control.  Stereotactic body radiotherapy (SBRT) is, therefore, considered medically necessary for this patient at this time. \n\n\n\n", "id": "3f318b8003454fb7ba0930bd4d91905d", "question": "What is the background context in this case summary?", "title": "3f318b8003454fb7ba0930bd4d91905d", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient with a history of substance use disorder who presented  with a request for detoxification services after relapsing. The patient was using heroin with up to 5 bags with intranasal administration on a continuous daily basis together with use of a prescribed benzodiazepine. She has a history of a mental disorder best characterized as schizophrenia treated with quetiapine, and major depressive disorder. She has a history of psychiatric hospitalizations."], "answer_start": [0]}, "context": "This is a patient with a history of substance use disorder who presented  with a request for detoxification services after relapsing. The patient was using heroin with up to 5 bags with intranasal administration on a continuous daily basis together with use of a prescribed benzodiazepine. She has a history of a mental disorder best characterized as schizophrenia treated with quetiapine, and major depressive disorder. She has a history of psychiatric hospitalizations. The health plan's determination of medical necessity is upheld.\nThe continued treatment could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of schizophrenia and ongoing substance use disorder with heroin and a prescribed benzodiazepine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or acute symptoms of psychosis, or perceptual disturbance that would have warranted inpatient level treatment for the time interval under review. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had no complications that required continued withdrawal management or general medical services, as noted in the clinical summary. The patient had fair insight and control of impulses and was cooperative and generally motivated to continue with substance use disorder treatment.", "id": "c01763f5060f461e9730ba5e9270e1ec", "question": "What is the background context in this case summary?", "title": "c01763f5060f461e9730ba5e9270e1ec", "sufficiency_score": 4}
+{"answers": {"text": ["In this case, this patient had", "pneumonia and sepsis. He had methadone for heroin detoxification and had been drinking alcohol and using cocaine. He had worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia, as well and was non-compliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in three months. He also received intravenous (IV) antibiotics", "Diagnosis: Pneumonia and sepsis", "Treatment: Inpatient admission", "The insurer has denied Inpatient admission.", "This patient is a male who was admitted to the inpatient medical hospital as he had pneumonia and sepsis and was also getting methadone for heroin detoxification. He also had alcohol and cocaine use. He had requested heroin detoxification. Medical issues included worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia as well and was noncompliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in 3 months. He also received IV antibiotics but signed out AMA.", "The insurer denied coverage for inpatient medical hospital treatment as not medically necessary treatment. They stated that he had no hemodynamic, pulmonary, neurological, or metabolic reason for hospitalization, and they recommended a less restrictive level of care."], "answer_start": [1577, 1644, 0, 33, 65, 135, 706]}, "context": "Diagnosis: Pneumonia and sepsis\n\nTreatment: Inpatient admission\n\nThe insurer has denied Inpatient admission. The denial was reversed.\n\nThis patient is a male who was admitted to the inpatient medical hospital as he had pneumonia and sepsis and was also getting methadone for heroin detoxification. He also had alcohol and cocaine use. He had requested heroin detoxification. Medical issues included worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia as well and was noncompliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in 3 months. He also received IV antibiotics but signed out AMA.\n\nThe insurer denied coverage for inpatient medical hospital treatment as not medically necessary treatment. They stated that he had no hemodynamic, pulmonary, neurological, or metabolic reason for hospitalization, and they recommended a less restrictive level of care. \n\nChart notes provided enough specific evidence to support the patient required 24-hour hospital treatment during the period in question. The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate those patients who exhibit failure to achieve abstinence or patients who relapse frequently, or fail to be cooperative with or benefit from outpatient detoxification; currently abuse other substances, very heavy use or tolerance, putting one at high risk for complicated withdrawal; are candidates for inpatient detoxification treatment. \n\nIn this case, this patient had serious medical problems, including pneumonia and sepsis. He had methadone for heroin detoxification and had been drinking alcohol and using cocaine. He had worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia, as well and was non-compliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in three months. He also received intravenous (IV) antibiotics, so he could not safely and effectively be treated for heroin detoxification in an outpatient setting. He required 24-hour medical hospital treatment then. \n\nAccording to the LOCADTR, he did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings, as he continued to use heroin, alcohol, and cocaine, despite multiple serious medical issues, and he required and needed methadone for heroin detoxification. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting; including severe withdrawal symptoms. He had serious medical issues complicating treatment for heroin detoxification. Inpatient medical hospital treatment was medically necessary. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.\n\nBased on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.\n", "id": "a0b507cba4a54db8b3cb4e831bdca044", "question": "What is the background context in this case summary?", "title": "a0b507cba4a54db8b3cb4e831bdca044", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient who was seen in the hospital.  He had a past medical history of hypertension, hyperlipidemia, chronic kidney disease, cervical stenosis of spine and an immune disorder.  The patient was noted to have recently started dialysis.  The patient complained of progressively worsening kidney function and right knee pain.  The patient recently left earlier in the day against medical advice and came back for treatment.  The patient was evaluated by surgery to have an arteriovenous (AV) fistula placed as a better method of hemodialysis treatment.  The patient had a PermaCath placed.  He patient complained of right knee pain that comes and goes on its own, but has gotten worse in the last three to four days prior to presentation.  His pain level was a 10/10.  The patient admitted to a history of dry cough on and off.  The patient had a white blood cell count of 15.3, a red blood cell count of 3.06, a hemoglobin of 9.1, a hematocrit of 28.5%, platelets 338, a sodium of 138, a potassium of 3.6, a chloride of 100, a dioxide level of 25, a blood urea nitrogen (BUN) level of 52, a creatinine of 3.02, a glucose of 112, a calcium of 8, a phosphorus of 2, and a magnesium of 1.9.  The patient had a blood pressure of 108/70 with a pulse of 78, respirations of 18, an oxygen saturation of 98% and a temperature of 98.1.  On examination, the right knee was tender and painful, as well as warm.  The patient was having an acute gout flare.  The patient received methadone, Keppra, prednisone, Renagel, Os-Cal, and Procardia.  The patient was then discharged.", "Diagnosis:  Chronic kidney disease", "Treatment:  Inpatient hospital services", "The insurer has denied inpatient hospital services.", "The documentation indicated that the patient was seen for progressively worsening kidney function, as well as right knee pain.  The patient recently started dialysis."], "answer_start": [154, 0, 36, 77, 2737]}, "context": "Diagnosis:  Chronic kidney disease\n\nTreatment:  Inpatient hospital services\n\nThe insurer has denied inpatient hospital services.  The denial was upheld.\n\nThis is a male patient who was seen in the hospital.  He had a past medical history of hypertension, hyperlipidemia, chronic kidney disease, cervical stenosis of spine and an immune disorder.  The patient was noted to have recently started dialysis.  The patient complained of progressively worsening kidney function and right knee pain.  The patient recently left earlier in the day against medical advice and came back for treatment.  The patient was evaluated by surgery to have an arteriovenous (AV) fistula placed as a better method of hemodialysis treatment.  The patient had a PermaCath placed.  He patient complained of right knee pain that comes and goes on its own, but has gotten worse in the last three to four days prior to presentation.  His pain level was a 10/10.  The patient admitted to a history of dry cough on and off.  The patient had a white blood cell count of 15.3, a red blood cell count of 3.06, a hemoglobin of 9.1, a hematocrit of 28.5%, platelets 338, a sodium of 138, a potassium of 3.6, a chloride of 100, a dioxide level of 25, a blood urea nitrogen (BUN) level of 52, a creatinine of 3.02, a glucose of 112, a calcium of 8, a phosphorus of 2, and a magnesium of 1.9.  The patient had a blood pressure of 108/70 with a pulse of 78, respirations of 18, an oxygen saturation of 98% and a temperature of 98.1.  On examination, the right knee was tender and painful, as well as warm.  The patient was having an acute gout flare.  The patient received methadone, Keppra, prednisone, Renagel, Os-Cal, and Procardia.  The patient was then discharged.\n\nAnalysis and Rationale:\n  \nThe medical literature indicates that admission is indicated for patients with chronic renal failure if there is evidence of cardiac arrhythmias of immediate concern, recurrent seizures, encephalopathy, impaired hemostasis with active bleeding, superinfection not treatable in an outpatient setting, unexplained syncope, hemodynamic instability, uremic symptoms that are severe or persistent despite observational care treatment, significant respiratory findings that are severe or persistent despite observational care treatment, clinically significant metabolic or electrolyte abnormality that are severe or persistent despite observational care treatment, urgent treatment of renal failure necessary on an inpatient basis due to vascular access not previously established or not usable, continuous intravenous infusion of anticoagulant, vasoactive or antiarrhythmic medication needed, pulmonary artery catheter monitoring needed or temporary pacemaker placement required.  \n\nThe documentation indicated that the patient was seen for progressively worsening kidney function, as well as right knee pain.  The patient recently started dialysis.  The patient had none of the above medical indications for inpatient admission to an acute care hospital.  The patient's condition was appropriate for a level of observational care rather than inpatient level of care.  As such, the inpatient hospital services at the acute level of care are not medically necessary and the prior determination is upheld.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. \n\nThe carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.\n", "id": "cb5d009fc219454aa1dd63b7fe94c288", "question": "What is the background context in this case summary?", "title": "cb5d009fc219454aa1dd63b7fe94c288", "sufficiency_score": 4}
+{"answers": {"text": ["This case involves a male who was brought to the hospital by ambulance with a complaint of pain in his low back, knees, hip, and chest. He complained of sickle cell crisis at presentation.  The patient had no cardiac history and was compliant with his medications. He was alert and oriented; he had no shortness of breath, no loss of consciousness, and lung sounds were clear and equal.  The abdomen was flat and soft.  The patient had no rigidity.  His pain was rated 10/10, blood pressure was 117/73, respiratory rate was 18, pulse rate was 90 and oxygen saturation was 100%.  Upon reevaluation, the patient's blood pressure was 93/55 and oxygen saturation on room air was 94%.  The patient was admitted for sickle cell crisis.  This was the patient's usual sickle cell crisis presentation. He had 2 rounds of pain medication and stated he still had his crisis pain. The patient underwent a chest x-ray which was normal.  The EKG showed normal sinus rhythm.  He refused intravenous fluids.  The patient was treated with pain medications. His pain improved and he was discharged.", "Diagnosis: Sickle cell crisis", "Treatment: Inpatient admission, medication, monitoring", "The insurer denied the inpatient admission.", "He responded to pain medications."], "answer_start": [156, 0, 32, 88, 1681]}, "context": "Diagnosis: Sickle cell crisis\n \nTreatment: Inpatient admission, medication, monitoring\n\nThe insurer denied the inpatient admission. The denial was upheld.\n\nThis case involves a male who was brought to the hospital by ambulance with a complaint of pain in his low back, knees, hip, and chest. He complained of sickle cell crisis at presentation.  The patient had no cardiac history and was compliant with his medications. He was alert and oriented; he had no shortness of breath, no loss of consciousness, and lung sounds were clear and equal.  The abdomen was flat and soft.  The patient had no rigidity.  His pain was rated 10/10, blood pressure was 117/73, respiratory rate was 18, pulse rate was 90 and oxygen saturation was 100%.  Upon reevaluation, the patient's blood pressure was 93/55 and oxygen saturation on room air was 94%.  The patient was admitted for sickle cell crisis.  This was the patient's usual sickle cell crisis presentation. He had 2 rounds of pain medication and stated he still had his crisis pain. The patient underwent a chest x-ray which was normal.  The EKG showed normal sinus rhythm.  He refused intravenous fluids.  The patient was treated with pain medications. His pain improved and he was discharged.\n\nMCG indicates that admission for sickle cell may be appropriate for patients who have acute pulmonary symptoms, hypoxemia or acidosis, and altered mental status, respiratory treatments needed that can only be performed in an acute inpatient setting, or pain insufficiently responsive to observation care that requires treatment in inpatient setting, such as parenteral opioids.  The patient did not have hypoxemia or an altered mental status. He responded to pain medications. The records failed to support the patient could not have been treated at a lower level of care, such as observation.  The patient was not noted to have failed observation care.    \n\nBased on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.\n", "id": "ac3b1d6d8e7940b48df3194df033e3b1", "question": "What is the background context in this case summary?", "title": "ac3b1d6d8e7940b48df3194df033e3b1", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Septicemia", "Treatment: Inpatient Admission", "The insurer denied Inpatient Admission.", "This is a middle aged patient who was referred to the emergency department (ED) from a nursing home. He presented with complaints of fever, anemia, and left foot ulcer. The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for a chronic left foot infection/foot ulcer; a foul smelling discharge was noted from his left extremity. In addition, the patient required hemodialysis. An x-ray of the foot showed diffuse tissue swelling; an osteomyelitis could not be ruled out. A chest x-ray revealed moderate bilateral pleural effusions with underlying atelectasis or infiltrate.", "According to the documentation, the patient was referred to the hospital from nursing home after developing fever (100.4 F) at hemodialysis and was noted to have severe anemia. The patient had numerous laboratory abnormalities including leukocytosis (WBC 16.4), anemia (Hgb 7.3), chest x-ray findings, as well as a chronic left foot infection. He required hemodialysis and had co-morbid risk factors."], "answer_start": [0, 23, 55, 122, 730]}, "context": "Diagnosis: Septicemia\n\nTreatment: Inpatient Admission\n\nThe insurer denied Inpatient Admission. The denial was reversed. \n\nThis is a middle aged patient who was referred to the emergency department (ED) from a nursing home. He presented with complaints of fever, anemia, and left foot ulcer. The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for a chronic left foot infection/foot ulcer; a foul smelling discharge was noted from his left extremity. In addition, the patient required hemodialysis. An x-ray of the foot showed diffuse tissue swelling; an osteomyelitis could not be ruled out. A chest x-ray revealed moderate bilateral pleural effusions with underlying atelectasis or infiltrate.\n\nAccording to the documentation, the patient was referred to the hospital from nursing home after developing fever (100.4 F) at hemodialysis and was noted to have severe anemia. The patient had numerous laboratory abnormalities including leukocytosis (WBC 16.4), anemia (Hgb 7.3), chest x-ray findings, as well as a chronic left foot infection. He required hemodialysis and had co-morbid risk factors.\n\nBased on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated. The insurer's denial is reversed.\n", "id": "c78eb373f2f147f6b1fa818ba3e984c6", "question": "What is the background context in this case summary?", "title": "c78eb373f2f147f6b1fa818ba3e984c6", "sufficiency_score": 4}
+{"answers": {"text": ["This is a middle age male who presented to the Emergency Department in early 2019 by Emergency Medical Services for a syncopal episode.  Per the patient's wife, the patient was out of consciousness until Emergency Medical Services arrived for approximately 10 minutes later. The patient complained of a headache upon arrival, however, he denied chest pain, shortness of breath, and palpitations. It was noted that Cardiopulmonary resuscitation was performed by bystanders at the scene. His physical examination revealed the patient was awake and oriented x 3. The patient had no focal deficits and had a normal motor and sensory examination. He had an EKG which was normal and a computerized tomography scan of his head which was unremarkable; no intracerebral hemorrhage or contusion was identified. The patient was consulted by neurology for questionable seizure activity. The patient was discharged on Keppra after neurology confirmed the patient was stable. He was instructed to follow-up in one week.", "Diagnosis: Seizure Disorder", "Treatment: Inpatient Admission", "The insurer denied the Inpatient Admission."], "answer_start": [130, 0, 29, 61]}, "context": "Diagnosis: Seizure Disorder\n\nTreatment: Inpatient Admission\n\nThe insurer denied the Inpatient Admission. The denial was upheld. \n\nThis is a middle age male who presented to the Emergency Department in early 2019 by Emergency Medical Services for a syncopal episode.  Per the patient's wife, the patient was out of consciousness until Emergency Medical Services arrived for approximately 10 minutes later. The patient complained of a headache upon arrival, however, he denied chest pain, shortness of breath, and palpitations. It was noted that Cardiopulmonary resuscitation was performed by bystanders at the scene. His physical examination revealed the patient was awake and oriented x 3. The patient had no focal deficits and had a normal motor and sensory examination. He had an EKG which was normal and a computerized tomography scan of his head which was unremarkable; no intracerebral hemorrhage or contusion was identified. The patient was consulted by neurology for questionable seizure activity. The patient was discharged on Keppra after neurology confirmed the patient was stable. He was instructed to follow-up in one week.  \n\nMCG indicate that admission may be appropriate for patients who have a new onset severe neurologic finding requiring inpatient care, a neurological trauma requiring inpatient treatment, or for a neurologic condition, symptoms, or finding for which emergency and observation have failed or are not considered appropriate. Additionally, admission for seizure would be appropriate for patients who had status epilepticus or repetitive seizures not controlled with emergent treatment, brain disorder, cardiac arrhythmia of immediate concern, altered mental status that is severe or persistent, a new focal neurologic deficit, or for a recurrent seizure. The records supported that the patient had a syncopal episode, rule out seizure. The patient was admitted with the diagnosis of seizure. At the time of admission, the patient did not have focal deficits and had not failed Emergency Department care. The records failed to support that the patient had hemodynamic instability, status epilepticus, repetitive seizures or recurrent seizures.  The records failed to support that the patient could not have been placed at a lower level of care, such as observation.\n\nBased on the above, the medical necessity for the inpatient admission to is not substantiated. The insurer's denial is upheld.\n\n", "id": "53f50e22c0574e62a9918391451f1799", "question": "What is the background context in this case summary?", "title": "53f50e22c0574e62a9918391451f1799", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Possible Sepsis/Pneumonia/Bronchitis\n\nTreatment: Inpatient admission\n\nThe insurer denied inpatient admission.", "This is a female who presented to the Emergency Department (ED) with complaints of fever, chills, muscle aches and pains, along with some blood streaked yellow sputum.  The patient has a past medical history of diabetes mellitus, hypertension, hernia repair, status post Cesarean section and myomectomy.", "At presentation to the ED, vital signs included a temperature of 101F, a heart rate of 105, a respiratory rate of 20, and a blood pressure of 144/90 mm Hg.  Oxygen saturation on room air was 99%.  The patient was awake and alert.  Head, ears, eyes, nose, and throat (HEENT) exam was within normal limits.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 was normal.  The abdomen was soft and non-tender.  The patient was alert and oriented x3. The white blood cell (WBC) count was 5.18K, the hemoglobin was 12.3 and electrolytes were within normal limits. The blood urea nitrogen (BUN)/Creatinine was 12/0.7 respectively. A respiratory syncytial virus (RSV) panel was negative, as was influenza.  The lactate was 1.4, the procalcitonin level was 0.15 and the urinalysis (UA) was negative. A chest x-ray had no acute infiltrate noted.", "The patient was empirically started on broad spectrum antibiotics - Vancomycin/Cefepime for possible Sepsis/Pneumonia/Bronchitis.  The patient remained stable after presentation.", "She was hemodynamically stable and not hypoxic.  Lungs were clear.  The WBC count was normal.  The chest x-ray was negative.  The patient's fever came down.  She remained afebrile and hemodynamically stable with oxygen saturations of 96-99% on room air.  The patient was subsequently switched to Rocephin and Azithromycin.", "The patient remained stable after admission.  An additional WBC count was normal at 4.4K.  Blood and urine culture & sensitivity were negative.", "The patient had bronchitis and no evidence of pneumonia radiologically.  The WBC count was normal.  The patient was not hypoxic.  The CURB 65 score was Zero.", "The patient was tolerating oral intake"], "answer_start": [0, 145, 450, 1290, 1540, 1864, 2354, 2198]}, "context": "Diagnosis: Possible Sepsis/Pneumonia/Bronchitis\n\nTreatment: Inpatient admission\n\nThe insurer denied inpatient admission. The denial was upheld.\n\nThis is a female who presented to the Emergency Department (ED) with complaints of fever, chills, muscle aches and pains, along with some blood streaked yellow sputum.  The patient has a past medical history of diabetes mellitus, hypertension, hernia repair, status post Cesarean section and myomectomy.\n\nAt presentation to the ED, vital signs included a temperature of 101F, a heart rate of 105, a respiratory rate of 20, and a blood pressure of 144/90 mm Hg.  Oxygen saturation on room air was 99%.  The patient was awake and alert.  Head, ears, eyes, nose, and throat (HEENT) exam was within normal limits.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 was normal.  The abdomen was soft and non-tender.  The patient was alert and oriented x3. The white blood cell (WBC) count was 5.18K, the hemoglobin was 12.3 and electrolytes were within normal limits. The blood urea nitrogen (BUN)/Creatinine was 12/0.7 respectively. A respiratory syncytial virus (RSV) panel was negative, as was influenza.  The lactate was 1.4, the procalcitonin level was 0.15 and the urinalysis (UA) was negative. A chest x-ray had no acute infiltrate noted.\n\nThe patient was empirically started on broad spectrum antibiotics - Vancomycin/Cefepime for possible Sepsis/Pneumonia/Bronchitis.  The patient remained stable after presentation.  As per the history & physical, the patient was in no acute distress.  She was hemodynamically stable and not hypoxic.  Lungs were clear.  The WBC count was normal.  The chest x-ray was negative.  The patient's fever came down.  She remained afebrile and hemodynamically stable with oxygen saturations of 96-99% on room air.  The patient was subsequently switched to Rocephin and Azithromycin.\n\nThe patient remained stable after admission.  An additional WBC count was normal at 4.4K.  Blood and urine culture & sensitivity were negative.  There were no signs of sepsis.  The patient did not need acute hospitalization.  She could have been placed under observation status while diagnostic testing and treatment were initiated.  The patient was tolerating oral intake and could have been switched to oral antibiotics and discharged home with close follow-up in an outpatient setting.  The patient had bronchitis and no evidence of pneumonia radiologically.  The WBC count was normal.  The patient was not hypoxic.  The CURB 65 score was Zero.  \n\nThe prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.\n\nBased on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated.  The insurer's denial is upheld.\n", "id": "10a4e789aea3432eb57fce8fb60d9ce0", "question": "What is the background context in this case summary?", "title": "10a4e789aea3432eb57fce8fb60d9ce0", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female patient who has successfully undergone 2 frozen embryo transfers. She is planning another attempt for in vitro fertilization pregnancy. She would like to have pre- implantation diagnosis for fetal aneuploidy using polar body biopsy."], "answer_start": [15]}, "context": "Reviewer # 3:\n\nThis is a female patient who has successfully undergone 2 frozen embryo transfers. She is planning another attempt for in vitro fertilization pregnancy. She would like to have pre- implantation diagnosis for fetal aneuploidy using polar body biopsy.\n\nThe test is recommended for the member in expert guidelines and is the most appropriate test in these circumstances, and is shown to improve the rate of success for pregnancies in these circumstances and it also helps prevent pregnancies with aneuploidy. \n \nAccording to Vitez, S. F., et al. (2019), \"Miscarriage is a frequent outcome seen in obstetrics with 1 in 5 pregnancies ending in an early pregnancy loss.  Aneuploidy is the most significant single factor affecting early pregnancy failure and miscarriage.  The risk of aneuploidy increases significantly with increasing maternal age.  There has been tremendous advancement in technology that has made preimplantation genetic testing for aneuploidy reliable and accessible.  For women in their mid-to-late 30s there is great utility in the use of PGT-A to facilitate single embryo transfer, reduce the risk of clinical miscarriage and ongoing aneuploidy gestations.  The current data supports use of preimplantation genetic testing for aneuploidy and single embryo transfer for this population of women.\"\n\nThe carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed, as this procedure is likely to be more beneficial than any of the standard testing / procedures.\n", "id": "660e272e8e3545518af5f3e0b90cf859", "question": "What is the background context in this case summary?", "title": "660e272e8e3545518af5f3e0b90cf859", "sufficiency_score": 3}
+{"answers": {"text": ["This is a female patient, gravida 3 para 1. She has twins who were previously conceived with in vitro fertilization of cryo preserved embryos from her original in vitro fertilization cycle with oocyte polar body pre-implantation genetic testing for aneuploidy.", "The patient", "is at increased risk of conceiving embryos with fetal aneuploidy due to her history of infertility and advanced maternal age."], "answer_start": [14, 806, 869]}, "context": "Reviewer # 2:\nThis is a female patient, gravida 3 para 1. She has twins who were previously conceived with in vitro fertilization of cryo preserved embryos from her original in vitro fertilization cycle with oocyte polar body pre-implantation genetic testing for aneuploidy.\n\nAccording to Capalbo, A., et al. (2016) states, \"Blastocyst biopsy is now widely used for both preimplantation genetic screening (PGS) for aneuploidies and preimplantation genetic diagnosis (PGD) of single gene defects.  In particular, trophectoderm biopsy coupled with comprehensive chromosome screening (CCS) now represents the most promising approach for PGS to detect aneuploidies coming from both male and female meiosis, as well as clinically relevant mitotic errors fixed during preimplantation embryo development.\"      \n\nThe patient is a good candidate for this procedure because she is at increased risk of conceiving embryos with fetal aneuploidy due to her history of infertility and advanced maternal age.     \n\nThe carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed.\n\n", "id": "46370c5d503b4be9b6b3d0cabca08be4", "question": "What is the background context in this case summary?", "title": "46370c5d503b4be9b6b3d0cabca08be4", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female patient G3P1 who previously received in vitro fertilization. She has a history of frozen embryo transfer twice without success. Her last attempt of frozen embryo transfer resulted in a biochemical pregnancy.  She would like to attempt another in vitro fertilization cycle with preimplantation genetic screening.", "Diagnosis: IVF with preimplantation genetic screening.", "Treatment: 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.", "The insurer denied the 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos."], "answer_start": [701, 0, 58, 354]}, "context": "Diagnosis: IVF with preimplantation genetic screening. \n \nTreatment: 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.  \n\nThe insurer denied the 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos. The denial was reversed. \n\nReviewer #1: \n\nThis is a female patient G3P1 who previously received in vitro fertilization. She has a history of frozen embryo transfer twice without success. Her last attempt of frozen embryo transfer resulted in a biochemical pregnancy.  She would like to attempt another in vitro fertilization cycle with preimplantation genetic screening.\nAmerican Society of Reproductive Medicine (ASRM) also stated the following:\" A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age.\"\n\nAt this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent. \n\nThis patient is not a good candidate for the procedure, as the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.\n\n89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos does not have final approval from the appropriate regulatory bodies for this diagnosis.\nThe requested service is not the best available treatment for this patient at this time, and is not likely to be more beneficial than any of the standard treatments/procedures for this patient.\n\nThe carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be upheld.\n", "id": "824b9c9e0b0243b592bbb307ae488a0a", "question": "What is the background context in this case summary?", "title": "824b9c9e0b0243b592bbb307ae488a0a", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Back pain\nIssue under review: Intracept procedure\n"], "answer_start": [0]}, "context": "Diagnosis: Back pain\nIssue under review: Intracept procedure\n\nDetermination:\nThe health plan should not cover the intracept procedure.\n\nThe health plan should not cover the proposed treatment based on general standard of care for vertebrogenic pain, and based on the patient not meeting the following recommended requirements by RELIEVANT, the Intracept Medical device manufacturer (source: https://www.relievant.com/wp-content/uploads/2019/05/MKT_0066-RevD_-_Reimbursement_Guide.pdf):\n\n Intracept is medically indicated in patients who have\n- A history of low back pain of at least 6 months duration; and\n- Failed to respond to at least 6 months of non-surgical management; and - MRI demonstrated Modic Type 1 or Type 2 changes* at one or more vertebrae from L3 to S1; and\n- Activities of daily living that are limited by persistent low back pain; and \n- All other reasonable sources of pain have been ruled out.\n\nThe above-recommended requirements have not been met for the INTRACEPT procedure, because despite history of chronic low back pain of more than six months, the MRI findings did not point to any evidence of Modic type 1 or type 2  changes at any vertebra. There is also no documented evidence of limitation of ADLs (activities of daily living) by the patient, and that all other reasonable sources of the chronic low back pain have been ruled out.\n", "id": "97804f7a0d6a4579b569765e6cef8d3f", "question": "What is the background context in this case summary?", "title": "97804f7a0d6a4579b569765e6cef8d3f", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Back pain\nIssue under review: Intracept Procedure"], "answer_start": [0]}, "context": "Diagnosis: Back pain\nIssue under review: Intracept Procedure\n\nDetermination:\nThe health plan should cover the Intracept procedure.\n\nAlthough intraosseus radiofrequency treatment of the basivertebral nerve (Intracept procedure) is a relatively new treatment for low back pain with Modic endplate changes, there is adequate evidence from randomized controlled trials, cited below, including a multi-center trial, to substantiate its effectiveness.  The patient's symptoms and the MRI evidence of Modic endplate changes confirm that the patient suffers from the type of back pain that has been shown to benefit from this treatment. ", "id": "717a5cfa86fa4da888ffc9fa039f9dc6", "question": "What is the background context in this case summary?", "title": "717a5cfa86fa4da888ffc9fa039f9dc6", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Back pain\nIssue under review: Intracept procedure", "The patient has failed conventional treatment, including PT (physical therapy), Medial branch blocks, and medications. "], "answer_start": [0, 619]}, "context": "Diagnosis: Back pain\nIssue under review: Intracept procedure\n\nDetermination:\nThe health plan should cover the Intracept procedure.\n\nThe requested procedure is a new, albeit FDA-approved procedure with this patient's indication in mind. There are RCT (randomized controlled trials) that show its effectiveness at two years.  In fact, there is another follow-up study where it was recommended that patients cross over to the treatment arm due to effectiveness early on.  The indication is for back pain that is thought to be originating from endplate degeneration (modic changes), which is what is shown in this patient. The patient has failed conventional treatment, including PT (physical therapy), Medial branch blocks, and medications. \n\nGiven that the alternative options (lumbar fusion), have not shown to have favorable responses for axial low back pain in the literature and is much more invasive, the requested Intracept procedure should be approved. \n", "id": "a8197125bbec40f8bc3a438f28f8e6bb", "question": "What is the background context in this case summary?", "title": "a8197125bbec40f8bc3a438f28f8e6bb", "sufficiency_score": 4}
+{"answers": {"text": ["This patient has a past medical history of atrial fibrillation, multiple myeloma, deep venous thrombosis and recently had surgery for a leg fracture. The patients physician submitted a letter in support of increasing home care hours from 7 hours per day, 7 days per week to 10 hours per day, 7 days per week, and includes the following: Over the past year, the patient has had multiple hospitalizations and admissions for rehabilitation.", "The insurer denied coverage for personal care aide (PCA) services 10 hours per day, 7 days per week (total 70 hours per week).", "This patient has extensive health problems and functional impairments.  She lives in a private home with her son and is dependent on assistance from others for all instrumental activities of daily living (IADLs) and needs extensive to maximal assistance for all activities of daily living (ADLs), except eating (limited assistance).  Based on her medical history, it appears the patients functional limitations are associated with various medical conditions, e.g. heart failure (may cause dyspnea, fatigue); arthritis (pain, decreased range of motion, unsteady gait); multiple myeloma (back pain, fatigue); obesity, body mass index (BMI 34.2; obesity is associated with risk for progression of osteoarthritis, and increased functional limitations and disability in the elderly). In addition, the patient needs assistance for locomotion/walking, transfers, toileting, incontinence care which occur at various and unscheduled times during the day and night.  The level of assistance needed by the patient for most ADLs requires substantial physical assistance from the caregiver (weight-bearing support).  Even when the patient is in bed, she needs extensive assistance for bed mobility.  This is an important aspect of her care, as immobility increases risk of pressure ulcers, so she needs help repositioning when in bed. The patient cannot prepare her meals; and she needs some assistance with eating.", "the patient would not be able to effectively manage having a meal, snack or fluids when she is alone.", "The patients son is the only informal caregiver identified in the 2019 Uniform Assessment System.", "The son is requesting PCA services 10 hours per day (3 more hours per day than currently approved)."], "answer_start": [0, 441, 594, 2009, 2224, 2614]}, "context": "This patient has a past medical history of atrial fibrillation, multiple myeloma, deep venous thrombosis and recently had surgery for a leg fracture. The patients physician submitted a letter in support of increasing home care hours from 7 hours per day, 7 days per week to 10 hours per day, 7 days per week, and includes the following: Over the past year, the patient has had multiple hospitalizations and admissions for rehabilitation. \n \nThe insurer denied coverage for personal care aide (PCA) services 10 hours per day, 7 days per week (total 70 hours per week). The denial was reversed.\n\nThis patient has extensive health problems and functional impairments.  She lives in a private home with her son and is dependent on assistance from others for all instrumental activities of daily living (IADLs) and needs extensive to maximal assistance for all activities of daily living (ADLs), except eating (limited assistance).  Based on her medical history, it appears the patients functional limitations are associated with various medical conditions, e.g. heart failure (may cause dyspnea, fatigue); arthritis (pain, decreased range of motion, unsteady gait); multiple myeloma (back pain, fatigue); obesity, body mass index (BMI 34.2; obesity is associated with risk for progression of osteoarthritis, and increased functional limitations and disability in the elderly). In addition, the patient needs assistance for locomotion/walking, transfers, toileting, incontinence care which occur at various and unscheduled times during the day and night.  The level of assistance needed by the patient for most ADLs requires substantial physical assistance from the caregiver (weight-bearing support).  Even when the patient is in bed, she needs extensive assistance for bed mobility.  This is an important aspect of her care, as immobility increases risk of pressure ulcers, so she needs help repositioning when in bed. The patient cannot prepare her meals; and she needs some assistance with eating.  Therefore, the patient would not be able to effectively manage having a meal, snack or fluids when she is alone. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary.  The patients son is the only informal caregiver identified in the 2019 Uniform Assessment System. The patient needs a caregiver (paid or voluntary) present in her home to provide assistance with ADLs (including toileting, incontinence care, transfers, locomotion, bed mobility) during the day and night as a result of her functional impairments associated with multiple medical conditions. The son is requesting PCA services 10 hours per day (3 more hours per day than currently approved).  It is reasonable to conclude that he cannot provide care on a consistent basis for 10 hours per day. Therefore, it is medically necessary for PCA services to provide the assistance the patient requires during those 10 hours.", "id": "0b2a5978d46842e097ab8abe49db7d38", "question": "What is the background context in this case summary?", "title": "0b2a5978d46842e097ab8abe49db7d38", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented to the ER with a 3 day history of nausea, vomiting, and diarrhea and was subsequently admitted to inpatient.  The health plan has denied the inpatient stay as not medically necessary.", "This patient with nausea, vomiting, and diarrhea had moderate dehydration based on both clinical and laboratory evaluation and failed prior outpatient and ED management."], "answer_start": [0, 255]}, "context": "The patient presented to the ER with a 3 day history of nausea, vomiting, and diarrhea and was subsequently admitted to inpatient.  The health plan has denied the inpatient stay as not medically necessary.  The health plan's determination is overturned.  This patient with nausea, vomiting, and diarrhea had moderate dehydration based on both clinical and laboratory evaluation and failed prior outpatient and ED management.  She required overnight hospitalization for continued IVF hydration to ensure safe discharge. ", "id": "bc4bb2395f724582b46b1d3364bdda57", "question": "What is the background context in this case summary?", "title": "bc4bb2395f724582b46b1d3364bdda57", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a past medical history significant for hypertension, gastroesophageal reflux disease, cataract, hypercholesterolemia, anxiety disorder and polyarthritis. She requests personal care service hours. These services were denied as not medically necessary.", "She is able to ambulate, toilet, and eat independently."], "answer_start": [0, 447]}, "context": "The patient has a past medical history significant for hypertension, gastroesophageal reflux disease, cataract, hypercholesterolemia, anxiety disorder and polyarthritis. She requests personal care service hours. These services were denied as not medically necessary. The health plan's determination is upheld. The personal care hours are not medically necessary. The patient can perform many of the tasks independently - at least 50% of the task. She is able to ambulate, toilet, and eat independently. There are no noted additional services that were noted to be medically necessary.", "id": "423ebac0ad184cf0a35abb1d1a18d3ec", "question": "What is the background context in this case summary?", "title": "423ebac0ad184cf0a35abb1d1a18d3ec", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient with a medical history of hypertension, hyperlipidemia, coronary artery disease (CAD), a myocardial infarction (MI); status post cardiac stent, renal colic with stent placement, prostate cancer status post prostatectomy. Due to the patient's rising PSA of 0.06 several years ago to 0.32 in early 2019, a positron emission tomography (PET) Flucicovine Axumin scan was performed. The test revealed no evidence of metastatic disease or local reoccurrence.", "Diagnosis: Prostate Cancer", "Treatment: Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815)", "The insurer denied the Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815).", "The patient's PSA had shown an increase over several years.", "In this case", "the patient had radiation therapy after the negative PET Scan."], "answer_start": [234, 0, 29, 113, 1441, 1765, 1788]}, "context": "Diagnosis: Prostate Cancer\n \nTreatment: Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815)\n\nThe insurer denied the Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815). The denial was upheld. \n\nThis is a male patient with a medical history of hypertension, hyperlipidemia, coronary artery disease (CAD), a myocardial infarction (MI); status post cardiac stent, renal colic with stent placement, prostate cancer status post prostatectomy. Due to the patient's rising PSA of 0.06 several years ago to 0.32 in early 2019, a positron emission tomography (PET) Flucicovine Axumin scan was performed. The test revealed no evidence of metastatic disease or local reoccurrence.  \n\nAxumin PET scans were FDA approved in 2016 for biochemical recurrence of prostate cancer, namely a rising PSA noted after definitive local therapy, such as radical prostatectomy or radiation therapy. FDA approval of Axumin included a trial showing it to perform as well, if not better, than C11 Choline scans in patients with median PSA value of 1.44. The optimal utilization of Axumin PET scans has yet to be fully delineated by NCCN or American Urological Association (AUA) guidelines. NCCN also notes it is unclear what to do when such imaging is positive in setting of negative conventional imaging. However, imaging with this modality is felt to be most useful early in the course of a suspected biochemical recurrence.  \n\nThe patient's PSA had shown an increase over several years. In any event, in the setting of BCR (biochemical recurrence) for previously treated prostate cancer, CT scan and bone scan remain first line imaging, despite their limitations in limited volume disease recurrence. As noted, the role of Axumin PET remains unclear. In this case, in fact, the patient had radiation therapy after the negative PET Scan. This is consistent with the lack of clarity of how this test affects therapy in setting of suspected recurrence.  \n\nThe healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.\n\nThe carrier's denial of coverage for the Positron Emission Tomography (PET) scan skull base to mid-thigh (78815) performed is upheld. The medical necessity is not substantiated.", "id": "50b618ded6d04a8da936e57df628cc84", "question": "What is the background context in this case summary?", "title": "50b618ded6d04a8da936e57df628cc84", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Substance abuse\nTreatment:  Inpatient rehabilitation", "The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use.  He self-referred and received inpatient level rehabilitation treatment.  He readily engaged in treatment and had no biomedical or psychiatric treatment issues.  During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers.  Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues"], "answer_start": [0, 174]}, "context": "Diagnosis:  Substance abuse\nTreatment:  Inpatient rehabilitation\nThe inpatient rehabilitation substance use disorder treatment was not medically necessary for this patient.\n\nThe patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use.  He self-referred and received inpatient level rehabilitation treatment.  He readily engaged in treatment and had no biomedical or psychiatric treatment issues.  During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers.  Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring.  The application of NY State OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts.  Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.\n\nThe patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review.  The patient had presented with a level of stability and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care.  He did not need 24-hour monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment.  He readily engaged with treatment and was involved with peer supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living.  Thus, the health plan's determination is reasonable in this case scenario.  This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY State OASAS LOCADTR 3.0 Guidelines.", "id": "2ef846f132da48ce868bcbcda0af1525", "question": "What is the background context in this case summary?", "title": "2ef846f132da48ce868bcbcda0af1525", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with medical history of gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and colitis treated with antibiotics 2 months prior. She presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea with scant red blood since the night before, as well as weakness and a feeling of dehydration. Vital signs were unremarkable. Physical examination was notable for tenderness in the left lower quadrant of the abdomen. She was admitted to the hospital.", "The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or colitis. Computed tomography scan of the abdomen and pelvis showed enteritis and possible colitis", "gastroenteritis and/or colitis may have been present", "She was", "treated with intravenous fluids and antibiotics.", "Abdominal pain\nInpatient hospital"], "answer_start": [35, 664, 1017, 1211, 1233, 0]}, "context": "Abdominal pain\nInpatient hospital\n\nThe patient is a female with medical history of gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and colitis treated with antibiotics 2 months prior. She presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea with scant red blood since the night before, as well as weakness and a feeling of dehydration. Vital signs were unremarkable. Physical examination was notable for tenderness in the left lower quadrant of the abdomen. She was admitted to the hospital.\n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or colitis. Computed tomography scan of the abdomen and pelvis showed enteritis and possible colitis but was not consistent with pathology such as gastrointestinal perforation, pancreatitis, abscess, toxic megacolon, or bowel obstruction. Although uncomplicated gastroenteritis and/or colitis may have been present, the patient did not have peritonitis, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care. She was appropriately treated with intravenous fluids and antibiotics. The measures which were undertaken, such as observation, monitoring, labs, antibiotic administration, intravenous fluid administration, and sitter monitoring could have been performed at a lower level of care.\n", "id": "d89e7222e1b048a1aca1980d195b00c5", "question": "What is the background context in this case summary?", "title": "d89e7222e1b048a1aca1980d195b00c5", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Dental-deep impinging overbite\nTreatment: Dental/Orthodontic Procedure", "This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of deep impinging overbite with signs of soft tissue damage.", "The insurer has denied coverage for orthodontic treatment-service codes D8080 (braces) and D8670 (monthly visit x4) as not medically necessary.", "the patient exhibits a significant malocclusion.", "In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite."], "answer_start": [0, 92, 460, 693, 1384]}, "context": "Diagnosis: Dental-deep impinging overbite\nTreatment: Dental/Orthodontic Procedure\n\nSummary: This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of deep impinging overbite with signs of soft tissue damage.\n \nThe insurer has denied coverage for orthodontic treatment-service codes D8080 (braces) and D8670 (monthly visit x4) as not medically necessary. The denial was reversed.\n\nUpon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.", "id": "d3eb9fa39e3643e7808c2a6abf84e62f", "question": "What is the background context in this case summary?", "title": "d3eb9fa39e3643e7808c2a6abf84e62f", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: pain\nIssue under review: inpatient admission", "The patient presented with lower abdominal pain off and on for three days, associated with vaginal discharge. On presentation in the ED, she was hemodynamically stable and afebrile, and her abdominal examination was remarkable for mild to moderate right lower quadrant tenderness with no signs of peritonitis. Her CBC, UA, CMP (comprehensive metabolic panel), and ABG were normal. The CT scan of the abdomen/pelvis and US pelvis were unremarkable except for appendicolith and small ovarian cyst. Her abdominal pain resolved with IV fluids and pain medication, and in the afternoon of 11/08/2018, her abdominal pain was better and she was able to tolerate diet. She slept well overnight and discharged home next day."], "answer_start": [0, 122]}, "context": "Diagnosis: pain\nIssue under review: inpatient admission\n\nDetermination:\nInpatient admission was not medically necessary.\n\nThe patient presented with lower abdominal pain off and on for three days, associated with vaginal discharge. On presentation in the ED, she was hemodynamically stable and afebrile, and her abdominal examination was remarkable for mild to moderate right lower quadrant tenderness with no signs of peritonitis. Her CBC, UA, CMP (comprehensive metabolic panel), and ABG were normal. The CT scan of the abdomen/pelvis and US pelvis were unremarkable except for appendicolith and small ovarian cyst. Her abdominal pain resolved with IV fluids and pain medication, and in the afternoon of 11/08/2018, her abdominal pain was better and she was able to tolerate diet. She slept well overnight and discharged home next day. Since she had no evidence of infection, dehydration bowel obstruction, peritonitis, and did not need any surgical or endoscopic intervention, and she felt better within 24 hours of hydration and pain management, she could have been safely managed at the lower level of care. ", "id": "7988b6bf129048fd973dd833025c08ef", "question": "What is the background context in this case summary?", "title": "7988b6bf129048fd973dd833025c08ef", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Respiratory System (Asthma)\nTreatment: Inpatient Hospital", "This patient presented to the Emergency Department (ED) for asthma exacerbation. Oxygen saturations in the field were in the 80's. He was placed on oxygen and given intravenous (IV) steroids and magnesium. He also was treated with bronchodilators. He denied cough, fever, chills or chest pain. Past medical history included asthma, history of multiple intubations, hypertension and morbid obesity. Vital signs at triage were temperature 97.7, blood pressure 169/87 mm Hg, heart rate 79, and respiratory rate 20. Oxygen saturation was 100%. The patient was alert and oriented x 3 and in no apparent distress. There was no distension of the jugular vein. There was diffuse wheezing on auscultation. Abdomen was soft. He could move all extremities. White blood count was 11.5 and hemoglobin 11.8. Lactate was normal. Electrolytes were within normal limits. Brain natriuretic peptide was 29. Troponin was < 0.015. Urine toxicology was negative. Cannabinoids was positive. Arterial blood gases were 7.392/41/106. Oxygen saturation was 98%. Chest X Ray showed no infiltrates, effusions or pneumothorax.", "The insurer has denied coverage for the inpatient hospital admission as not medically necessary.", "As per the history and physical, vital signs were temperature 98.3F, blood pressure 177/89 mm Hg, heart rate 95, respiratory rate 16, oxygen saturation 98 % on room air.", "He was speaking in full sentences.", "Lungs had a bilateral mild end expiratory wheeze. The patient's admission diagnoses were acute asthma exacerbation likely secondary to weather change and marijuana use."], "answer_start": [0, 79, 1177, 1298, 1509, 1583]}, "context": "Diagnosis: Respiratory System (Asthma)\nTreatment: Inpatient Hospital\n\nSummary: This patient presented to the Emergency Department (ED) for asthma exacerbation. Oxygen saturations in the field were in the 80's. He was placed on oxygen and given intravenous (IV) steroids and magnesium. He also was treated with bronchodilators. He denied cough, fever, chills or chest pain. Past medical history included asthma, history of multiple intubations, hypertension and morbid obesity. Vital signs at triage were temperature 97.7, blood pressure 169/87 mm Hg, heart rate 79, and respiratory rate 20. Oxygen saturation was 100%. The patient was alert and oriented x 3 and in no apparent distress. There was no distension of the jugular vein. There was diffuse wheezing on auscultation. Abdomen was soft. He could move all extremities. White blood count was 11.5 and hemoglobin 11.8. Lactate was normal. Electrolytes were within normal limits. Brain natriuretic peptide was 29. Troponin was < 0.015. Urine toxicology was negative. Cannabinoids was positive. Arterial blood gases were 7.392/41/106. Oxygen saturation was 98%. Chest X Ray showed no infiltrates, effusions or pneumothorax.\n\nThe insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.\n\nAs per the history and physical, vital signs were temperature 98.3F, blood pressure 177/89 mm Hg, heart rate 95, respiratory rate 16, oxygen saturation 98 % on room air. The patient was in no apparent distress. He was speaking in full sentences. No use of accessory muscles was noted. Lungs had a bilateral mild end expiratory wheeze. The patient's admission diagnoses were acute asthma exacerbation likely secondary to weather change and marijuana use. Based on review of the medical record, acute hospitalization was not medically necessary. The patient could have been placed in observation status. He was improving after treatment in ED. He was afebrile and hemodynamically stable as per history and physical. He was not hypoxic. Chest x-ray showed no infiltrate. This patient could have been treated with IV steroids, bronchodilators and inhaled corticosteroid combination inhalers and long acting beta agonist inhalers while under observation. The patient remained stable overnight and was discharged the next day. He could have been placed on observation status while diagnostic testing and treatment was initiated. \n", "id": "3d9afebb36c146e9abd64b79b88d46ba", "question": "What is the background context in this case summary?", "title": "3d9afebb36c146e9abd64b79b88d46ba", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: CAD\nIssue under review: Inpatient admission", "This was an elective, scheduled, uncomplicated percutaneous intervention on a patient with known anatomy.", "his CXR was negative", "the patient did complain of a brief episode of dyspnea, his CXR was negative, his ABG was normal, O2 saturation was 98%. The only treatment that was recommended was an inhaler.", "The patient was admitted for monitoring"], "answer_start": [0, 125, 522, 466, 1192]}, "context": "Diagnosis: CAD\nIssue under review: Inpatient admission\n\nDetermination:\nThe inpatient admission was not medically necessary.\n\nThis was an elective, scheduled, uncomplicated percutaneous intervention on a patient with known anatomy. Both guidelines and standard community practice would recommend that it is safely performed in an outpatient setting. In this case, there was never any hemodynamic instability, angina, ischemic changes, or an unstable situation. While the patient did complain of a brief episode of dyspnea, his CXR was negative, his ABG was normal, O2 saturation was 98%. The only treatment that was recommended was an inhaler. \n\nDetermination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. \n  \nThe letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care post-PCI that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of ischemia post procedure.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. The procedure was electively scheduled and performed without complication, and the recovery essentially uneventful. The patient's SOB was brief, reversible and did not require significant intervention. There was no requirement in any part of this admission that required acute level of care.\n\nMilliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. Neither triple vessel CAD nor being a smoker requires an inpatient level of care. There was no evidence of \"inadequate physiologic recovery.\" There is no evidence to support that the patient's potential for a complication required an inpatient level of care. Since all testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care, the inpatient level of care was thus not medically necessary.\n\nThe denial explanation was consistent with guidelines and usual community care.\n", "id": "233a48da8044495e804305c2092de0f3", "question": "What is the background context in this case summary?", "title": "233a48da8044495e804305c2092de0f3", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with systemic juvenile idiopathic arthritis who is prescribed Kineret. The health plan denied it as not medically necessary as he did not try the preferred medications, Ilaris and Actemra."], "answer_start": [0]}, "context": "The patient is a male with systemic juvenile idiopathic arthritis who is prescribed Kineret. The health plan denied it as not medically necessary as he did not try the preferred medications, Ilaris and Actemra. The health plan's determination is overturned.  The Kineret is medically necessary for the patient.\n\nAnakinra, along with Ilaris and Actemra are considered standard of care treatments for SJIA however, the American College of Rheumatology, in its most recent guidelines, recommends anakinra as initial therapy or for continued disease activity following NSAIDs as in this patient's case.", "id": "e961b4363c684fdf980dff0ade8d6fdf", "question": "What is the background context in this case summary?", "title": "e961b4363c684fdf980dff0ade8d6fdf", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Suicide attempt, hallucinations.", "Treatment: Inpatient admission, evaluation, and medication management", "The insurer has denied inpatient mental health.", "The patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.", "The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care."], "answer_start": [0, 45, 116, 191, 776]}, "context": "Diagnosis: Suicide attempt, hallucinations.\n\nTreatment: Inpatient admission, evaluation, and medication management\n\nThe insurer has denied inpatient mental health. That denial was modified.\n\nThe patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.\n\nThe insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care.\n\nThe American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and past suicide attempts are the single most reliable indicator of suicide.  It also states that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital.  This patient was considered a high risk patient and required continued inpatient acute hospital treatment in the hospital as she had three reported suicide attempts in 2018 and was considered a high risk for suicide.  She also continued with psychotic and depressive symptoms during part of the denial period.  \n\nThe documentation supports the need for approval in part.\n", "id": "e40a529f6a4249b78414ad9c2769f79d", "question": "What is the background context in this case summary?", "title": "e40a529f6a4249b78414ad9c2769f79d", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Benign prostatic hyperplasia\nTreatment: Acute Inpatient Hospital Admission"], "answer_start": [0]}, "context": "Diagnosis: Benign prostatic hyperplasia\nTreatment: Acute Inpatient Hospital Admission\n\nSummary:\nCare after an uncomplicated TURP can be provided at a lower level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  The care of his co-morbid conditions was routine.  An observation level of care was appropriate", "id": "09203ef48ceb4199bee1eee699483946", "question": "What is the background context in this case summary?", "title": "09203ef48ceb4199bee1eee699483946", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Endocrine/Metabolic/Nutritional (Morbid obesity), Digestive System/ Gastrointestinal (GERD), Respiratory System (Sleep apnea)\nTreatment:  Surgical Services (Stomach surgery for weight loss)", "The insurer has denied coverage for stomach surgery for weight loss.", "This patient has a history of morbid obesity, migraine, asthma, gastroesophageal reflux disease (GERD) without esophagitis, sleep apnea, and diabetes mellitus. Per the office note with the Bariatric Surgeon, the patient has completed all preop evaluation for bariatric surgery and is ready to proceed. The patient's body mass index (BMI) was 38.8. Per the note for the initial bariatric evaluation, the patient had a BMI of 38 and had diabetes diagnosed two to three years ago. She has had numerous weight loss attempts. The Pulmonologist/ Sleep Medicine specialist noted in a letter that the patient has morbid obesity and symptoms suggestive of obstructive sleep apnea (OSA). Her exam is significant for morbid obesity and a crowded oropharynx. The Home Sleep Apnea Testing (HSAT) showed mild OSA with an apnea hypopnea index (AHI) of 7/hr. She was not contraindicated for surgery, although deep extubation should be avoided and anesthesia consultation prior to surgery should be done. The Dietitian saw the patient for nutrition consultation and found that the patient has made significant attempts at non-surgical weight loss using a variety of methods. The patient was counseled regarding preop diet, as well as the progression of food after surgery. It was noted that the patient is required to follow up with the dietician or nutritionist both pre and post-surgery for further dietary guidance and behavioral change counseling, and it was also recommended that the patient attend support groups and educational workshops when available. Labs showed that the HbA1c was 6.2, which is considered pre diabetic. The patient was seen by the Cardiologist for preop evaluation for coronary artery disease (CAD) and was found to have no contraindication for surgery.", "At the most recent visit, the patient had a BMI of 39.2", "her HbA1C is", "6.2, which is considered pre-diabetic."], "answer_start": [0, 1977, 211, 2181, 2579, 2597]}, "context": "Diagnosis: Endocrine/Metabolic/Nutritional (Morbid obesity), Digestive System/ Gastrointestinal (GERD), Respiratory System (Sleep apnea)\nTreatment:  Surgical Services (Stomach surgery for weight loss)\n\nSummary: This patient has a history of morbid obesity, migraine, asthma, gastroesophageal reflux disease (GERD) without esophagitis, sleep apnea, and diabetes mellitus. Per the office note with the Bariatric Surgeon, the patient has completed all preop evaluation for bariatric surgery and is ready to proceed. The patient's body mass index (BMI) was 38.8. Per the note for the initial bariatric evaluation, the patient had a BMI of 38 and had diabetes diagnosed two to three years ago. She has had numerous weight loss attempts. The Pulmonologist/ Sleep Medicine specialist noted in a letter that the patient has morbid obesity and symptoms suggestive of obstructive sleep apnea (OSA). Her exam is significant for morbid obesity and a crowded oropharynx. The Home Sleep Apnea Testing (HSAT) showed mild OSA with an apnea hypopnea index (AHI) of 7/hr. She was not contraindicated for surgery, although deep extubation should be avoided and anesthesia consultation prior to surgery should be done. The Dietitian saw the patient for nutrition consultation and found that the patient has made significant attempts at non-surgical weight loss using a variety of methods. The patient was counseled regarding preop diet, as well as the progression of food after surgery. It was noted that the patient is required to follow up with the dietician or nutritionist both pre and post-surgery for further dietary guidance and behavioral change counseling, and it was also recommended that the patient attend support groups and educational workshops when available. Labs showed that the HbA1c was 6.2, which is considered pre diabetic. The patient was seen by the Cardiologist for preop evaluation for coronary artery disease (CAD) and was found to have no contraindication for surgery.\n\nThe insurer has denied coverage for stomach surgery for weight loss. The denial was upheld.\n\nBased upon the records provided, the patient does not meet the criteria and indications for bariatric surgery. At the most recent visit, the patient had a BMI of 39.2 and has never had a BMI greater than 40. She does not have severe sleep apnea/OSA but rather very mild OSA with an AHI of only 7/hour. In fact, the Pulmonologist did not confirm that she had sleep apnea, but only that she has symptoms that are suggestive of OSA and an exam significant for a crowded oropharynx. She does not have diabetes as her HbA1C is only 6.2, which is considered pre-diabetic. Although she has undergone appropriate evaluation including psychiatric and nutrition, and has followed a medically supervised program, she does not meet the BMI criteria and she does not have significant co-morbidities. The medical necessity is not substantiated.\n", "id": "b4dbcce511074e5781094a5990510ec7", "question": "What is the background context in this case summary?", "title": "b4dbcce511074e5781094a5990510ec7", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Attention and concentration deficit; major depressive disorder\nTreatment: Methylphenidate HCI 5MG", "The patient has a diagnosis of major depressive disorder, moderately severe and recurrent without psychotic features. He has a history of treatment refractory depression failing trials with six antidepressants: Lexapro, Zoloft, Wellbutrin, Cymbalta, Fetzima and Viibryd. He has experienced worsening episodes of depression over a ten year time interval associated with general medical illness. He is currently prescribed Luvox and Seroquel together with Xarelto, Losartan, atenolol-chlorthalidone and alprazolam.", "The patient's current mental status examination reflects depressed mood with associated symptoms of anxiety, low interest and motivation, decreased concentration and fatigue, and, motor retardation. He is well groomed with clear speech and no evidence for mood cycling or mania, thought disorder, psychosis or severe cognitive impairment. Insight and judgment are fair. He has sleep disturbance with low energy and volition associated with social withdrawal. PHQ-9 is at 14 reflecting moderate symptoms of depression.", "Methylphenidate 5 mg bid is prescribed for augmentation of his major depression with the treatment goal of improvement in functioning and symptoms of the major depressive disorder. Coverage for methylphenidate (Ritalin) to address the treatment-resistant depression is requested to address these target symptoms of low energy, motivation and mood, and to augment any other antidepressant medications. There are no other documented diagnoses of substance use disorder; or, co-morbid psychiatric diagnoses."], "answer_start": [0, 156, 670, 1188]}, "context": "Diagnosis: Attention and concentration deficit; major depressive disorder\nTreatment: Methylphenidate HCI 5MG\nThe proposed treatment is medically necessary.\nThe patient has a diagnosis of major depressive disorder, moderately severe and recurrent without psychotic features. He has a history of treatment refractory depression failing trials with six antidepressants: Lexapro, Zoloft, Wellbutrin, Cymbalta, Fetzima and Viibryd. He has experienced worsening episodes of depression over a ten year time interval associated with general medical illness. He is currently prescribed Luvox and Seroquel together with Xarelto, Losartan, atenolol-chlorthalidone and alprazolam. \nThe patient's current mental status examination reflects depressed mood with associated symptoms of anxiety, low interest and motivation, decreased concentration and fatigue, and, motor retardation. He is well groomed with clear speech and no evidence for mood cycling or mania, thought disorder, psychosis or severe cognitive impairment. Insight and judgment are fair. He has sleep disturbance with low energy and volition associated with social withdrawal. PHQ-9 is at 14 reflecting moderate symptoms of depression.\nMethylphenidate 5 mg bid is prescribed for augmentation of his major depression with the treatment goal of improvement in functioning and symptoms of the major depressive disorder. Coverage for methylphenidate (Ritalin) to address the treatment-resistant depression is requested to address these target symptoms of low energy, motivation and mood, and to augment any other antidepressant medications. There are no other documented diagnoses of substance use disorder; or, co-morbid psychiatric diagnoses.\nThe use of stimulant medications including methylphenidate (Ritalin) is considered a clinically appropriate and effective augmentation strategy for the treatment of major depressive disorder in patients who are refractory/resistant to treatment with antidepressant medications. Moreover, the patient in this case has a likelihood of demonstrating a response to the current regimen that includes the starting dose of 5 mg bid with regard to symptoms of fatigue, low interest and motivation, and decreased concentration or focus, as well as the core symptoms of major depressive disorder.  The requested treatment has a reasonable expectation for improvement and/or maintenance treatment of major depressive disorder in a patient with treatment refractory depressive disorder and comorbid general medical illness associated with symptoms of low energy, fatigue, mood and motivation in keeping with the scientific literature concerning treatment refractory depression and medication augmentation strategies. the requested benefit of methylphenidate to address symptoms of moderately severe and recurrent major depressive disorder and/or to augment the antidepressant medication regimen is considered medically necessary in this case scenario, in keeping with prevailing standards of professional practice.", "id": "7351750cd06d435393a452f9b19efa19", "question": "What is the background context in this case summary?", "title": "7351750cd06d435393a452f9b19efa19", "sufficiency_score": 4}
+{"answers": {"text": ["The patient was admitted from the emergency department for anemia and worsening renal failure with a plan to initiate dialysis. At issue is the medical necessity of the inpatient stay."], "answer_start": [0]}, "context": "The patient was admitted from the emergency department for anemia and worsening renal failure with a plan to initiate dialysis. At issue is the medical necessity of the inpatient stay. The health plan's determination is upheld. The patient did not have evidence of an acute process contributing to the progression of the renal disease that required inpatient treatment. ", "id": "e86a5185cd94438da659b46656af04a0", "question": "What is the background context in this case summary?", "title": "e86a5185cd94438da659b46656af04a0", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Preterm rupture of membranes, vaginal bleeding\nTreatment: Inpatient admission"], "answer_start": [0]}, "context": "Diagnosis: Preterm rupture of membranes, vaginal bleeding\nTreatment: Inpatient admission\nThe inpatient admission was medically necessary.\nRegardless of the duration of labor or hospital stay, inpatient level of labor and delivery care with associated nursing and other support is required for patient safety, pain relief, and psychological support that is not available from outpatient surgery resources for patients laboring and delivering at any gestational age.  In all cases, but especially in the circumstance of a perinatal demise and associated need for grief support and compassionate caregiving, specialized nursing support is needed for both physical and psychological wellbeing that would not be possible in an outpatient surgical unit.  Patients in this situation often are at risk for numerous hemorrhagic, infectious, and obstetrical complications that require specialized nursing and access to specialized hospital resources.  Therefore, this care should be provided in a standard labor and delivery environment and is medically necessary.\n", "id": "0e474ed88c344ac086893fac9dc73705", "question": "What is the background context in this case summary?", "title": "0e474ed88c344ac086893fac9dc73705", "sufficiency_score": 3}
+{"answers": {"text": ["This is a patient with a medical history significant for depression, hyperlipidemia, fatigue, gait mobility, hypertension, osteoarthritis, obesity, unspecified pain and stress incontinence."], "answer_start": [0]}, "context": "This is a patient with a medical history significant for depression, hyperlipidemia, fatigue, gait mobility, hypertension, osteoarthritis, obesity, unspecified pain and stress incontinence.  The health plan's determination of medical necessity is upheld.  The amount of hours provided are adequate to meet this patient's medical needs for the required services. An increase in service hours is not medically necessary for a decrease in endurance.", "id": "701dc283ff4c48af84c7caf50f30bdbd", "question": "What is the background context in this case summary?", "title": "701dc283ff4c48af84c7caf50f30bdbd", "sufficiency_score": 2}
+{"answers": {"text": ["This is a patient who presented to the emergency department (ED) with acute onset abdominal pain, nausea and vomiting (2-days duration).  The past medical history was significant for morbid obesity.  The heart rate at the time of presentation was elevated at 107 beats/minute.  The abdomen was tender and distended.  The white blood cell count (WBC) count was elevated at 13.6 thousand (K).  The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated and edematous bowel and mesentery. ", "this patient presented with an acute onset of abdominal pain, nausea and vomiting.  She had a leukocytosis of 13.6 K and pathology identified on a CT scan that indicated possible bowel obstruction.  She was monitored with daily examination and follow up lab assessment.  She underwent a colonoscopy on 12/6/18.  Her condition did gradually improve over 72 hours.  On 12/7/18 she reported less pain and there was improvement with regard to the abdominal pain."], "answer_start": [0, 649]}, "context": "This is a patient who presented to the emergency department (ED) with acute onset abdominal pain, nausea and vomiting (2-days duration).  The past medical history was significant for morbid obesity.  The heart rate at the time of presentation was elevated at 107 beats/minute.  The abdomen was tender and distended.  The white blood cell count (WBC) count was elevated at 13.6 thousand (K).  The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated and edematous bowel and mesentery.  The health plan's determination of medical necessity is overturned in whole.\nThe submitted records support that this patient presented with an acute onset of abdominal pain, nausea and vomiting.  She had a leukocytosis of 13.6 K and pathology identified on a CT scan that indicated possible bowel obstruction.  She was monitored with daily examination and follow up lab assessment.  She underwent a colonoscopy on 12/6/18.  Her condition did gradually improve over 72 hours.  On 12/7/18 she reported less pain and there was improvement with regard to the abdominal pain.  Inpatient admission for the condition of intestinal obstruction was consistent with medical standards, as the period of inpatient confinement was anticipated to last more than 2-days.", "id": "08a849ccbb034d88a76c28c6c93cfae9", "question": "What is the background context in this case summary?", "title": "08a849ccbb034d88a76c28c6c93cfae9", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient with ankylosing hyperostosis (Forestier), site unspecified spondylopathy, unspecified vs. inflammatory disease. The patient also has gout. The patient has tried and failed Motrin, ibuprofen, Aleve, naproxen and Enbrel. Patient has also tried physical therapy (PT) and does stretching exercises. Per chart review patient is human leukocyte antigen B27 and inflammatory markers are normal, new findings of (sacroiliac)si joint (jt) ankylosis/sacroiliitis.", "The patient has tried and failed conservative treatment with Motrin, ibuprofen, Aleve, naproxen and PT. The patient has even tried Enbrel. The provider believes there may be an inflammatory component to the back pain, which is why the provider tried Enbrel and is now requesting Cosentyx. Per chart review, the patient has sacroiliitis"], "answer_start": [31, 580]}, "context": "Other\nPrescription medication\n\nThis is a patient with ankylosing hyperostosis (Forestier), site unspecified spondylopathy, unspecified vs. inflammatory disease. The patient also has gout. The patient has tried and failed Motrin, ibuprofen, Aleve, naproxen and Enbrel. Patient has also tried physical therapy (PT) and does stretching exercises. Per chart review patient is human leukocyte antigen B27 and inflammatory markers are normal, new findings of (sacroiliac)si joint (jt) ankylosis/sacroiliitis. The health plan's determination of medical necessity is overturned in whole. The patient has tried and failed conservative treatment with Motrin, ibuprofen, Aleve, naproxen and PT. The patient has even tried Enbrel. The provider believes there may be an inflammatory component to the back pain, which is why the provider tried Enbrel and is now requesting Cosentyx. Per chart review, the patient has sacroiliitis in which case a trial of Cosentyx is a reasonable next step in the treatment of this patient. According to the literature, in patients with AS who often have sacroiliitis, \"secukinumab at a subcutaneous dose of 150 mg, with either subcutaneous or intravenous loading, provided significant reductions in the signs and symptoms of ankylosing spondylitis at week 16\" (3).", "id": "2fcfbd530507497cac1c9aa115c57e69", "question": "What is the background context in this case summary?", "title": "2fcfbd530507497cac1c9aa115c57e69", "sufficiency_score": 4}
+{"answers": {"text": ["The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF as not medically necessary."], "answer_start": [0]}, "context": "The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF as not medically necessary. The health plan's determination is overturned. IVF is medically necessary for this patient. If services are not provided, the couple have a 25% chance of having a child with a fatal childhood disease. With the testing the chances of having a child with Tay-Sachs are less than 1%. IVF with PGT-M is in accordance with accepted standards of medical practice for this patient's circumstances. ", "id": "4d6f137b0cba4abe836a2062440f2e41", "question": "What is the background context in this case summary?", "title": "4d6f137b0cba4abe836a2062440f2e41", "sufficiency_score": 3}
+{"answers": {"text": ["This is a patient with a history of a heart murmur who presented with difficulty breathing, who was well until 2 days prior to presentation when he developed a cough and difficulty breathing. During that night and into the early morning he had 2 episodes of post-tussive emesis. He continued to worsen throughout the following day, when his mother noted that he continued to have respiratory symptoms as well as a fever. He was brought in for evaluation and was diagnosed with croup.", "The patient had worsening symptoms despite", "therapy as an outpatient, and continued to have stridor and increased work of breathing after receiving", "intensive treatment in the emergency department. He required several doses of racemic epinephrine, as well as intravenous fluids to maintain his hydration status in the setting of multiple episodes of posttussive emesis."], "answer_start": [0, 553, 608, 728]}, "context": "This is a patient with a history of a heart murmur who presented with difficulty breathing, who was well until 2 days prior to presentation when he developed a cough and difficulty breathing. During that night and into the early morning he had 2 episodes of post-tussive emesis. He continued to worsen throughout the following day, when his mother noted that he continued to have respiratory symptoms as well as a fever. He was brought in for evaluation and was diagnosed with croup. The health plan's determination of medical necessity is overturned.  The patient had worsening symptoms despite appropriate therapy as an outpatient, and continued to have stridor and increased work of breathing after receiving appropriate and intensive treatment in the emergency department. He required several doses of racemic epinephrine, as well as intravenous fluids to maintain his hydration status in the setting of multiple episodes of posttussive emesis. \n", "id": "9d251bfa34fb4d399a6c7870d9e80f1a", "question": "What is the background context in this case summary?", "title": "9d251bfa34fb4d399a6c7870d9e80f1a", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Painful breast implants\nIssue under review: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk, 19371 - Periprosthetic capsulectomy, breast", "The patient has periprosthetic capsular contracture, which is a known complication of breast implants.", "The original procedure was for cosmetic purposes."], "answer_start": [0, 219, 435]}, "context": "Diagnosis: Painful breast implants\nIssue under review: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk, 19371 - Periprosthetic capsulectomy, breast\n\nDetermination: \nThe surgery is not medically necessary.\n\nThe patient has periprosthetic capsular contracture, which is a known complication of breast implants.  A study by Dancey et al found a 26.9% incidence of capsular contracture following breast augmentation surgery.  The original procedure was for cosmetic purposes.  Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated.  \nThe standard of care indicates that when implants are placed for reconstructive purposes, then treatment of these complications should be a covered service. However, in this case, the initial procedure of breast augmentation was a strictly a cosmetic procedure.  Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer.   The ASPS position paper goes on to say that insurance carriers, \"respond thoughtfully and with compassion on an individual basis,\" for several other conditions, including, \"mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography).\" \nCapsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger.  The surgeon's note indicate that her breasts are soft and, based on this description and the photos, she does not have Baker IV capsular contracture.  Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not necessary to prevent a disease or illness or to treat a functional problem.\n", "id": "553552972c444b80978281dba72d99fb", "question": "What is the background context in this case summary?", "title": "553552972c444b80978281dba72d99fb", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Substance abuse disorder\nTreatment: Inpatient detox", "The patient is an adult male who presented with a request for detoxification services. The patient reported that he was using alcohol, cannabis, and opioids (heroin), as well as a past history of sedative-hypnotic-anxiolytic use (benzodiazepine) and tobacco.", "The patient displayed", "a history of PTSD and depressive disorder and", "ongoing substance use disorder with multiple substances of abuse.", "the patient had received detoxification treatment and rehabilitation substance use treatment recently with discharge from another facility five days prior to admission. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with an extensive past history of multiple treatment episodes."], "answer_start": [0, 73, 624, 701, 755, 1182]}, "context": "Diagnosis: Substance abuse disorder\nTreatment: Inpatient detox\n\nSummary:\nThe patient is an adult male who presented with a request for detoxification services. The patient reported that he was using alcohol, cannabis, and opioids (heroin), as well as a past history of sedative-hypnotic-anxiolytic use (benzodiazepine) and tobacco. \n\nThe proposed inpatient stay and detoxification treatment and other medical services could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of PTSD and depressive disorder and despite ongoing substance use disorder with multiple substances of abuse. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and detoxification treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently with discharge from another facility five days prior to admission. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with an extensive past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.", "id": "0b2cf3392e35483abce79646dc19957c", "question": "What is the background context in this case summary?", "title": "0b2cf3392e35483abce79646dc19957c", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Cholecystitis\nIssue under review: Inpatient admission\n", "In this case, the patient was young, healthy, with no comorbid conditions.", "she was not septic, had a normal white count and had a routine surgery without untoward events. She recovered as expected, and she exhibited no signs or symptoms of any complications in the immediate postoperative period."], "answer_start": [0, 2142, 2230]}, "context": "Diagnosis: Cholecystitis\nIssue under review: Inpatient admission\n\nDetermination:\nThe inpatient admission was not medically necessary. \n\nThe timing of cholecystectomy in patients presenting with acute cholecystitis has been under intense investigation, with \"early\" cholecystectomy variably defined in the literature as gallbladder surgery performed within three, seven, or 10 days of symptom onset, and \"delayed\" cholecystectomy as that performed seven or 45 days, or six weeks, after initial diagnosis. Evidence from large database reviews and randomized trials generally associates cholecystectomy performed early during the initial hospitalization with better outcomes.\n\nAfter an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.\n\nMost otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.\n\nThe patient should have no activity restriction unless the umbilical incision was particularly large. Then, limited heavy lifting for a few weeks is advisable. Most patients are able to return to work within one week. Patients follow up in clinic two to four weeks after their operation.\n\nMost patients have some abdominal pain that resolves within two to three days after surgery and can be managed with analgesics. Occasionally, patients have referred shoulder and neck pain from the CO2 insufflation causing diaphragmatic irritation.\n\nIn this case, the patient was young, healthy, with no comorbid conditions. In addition, she was not septic, had a normal white count and had a routine surgery without untoward events. She recovered as expected, and she exhibited no signs or symptoms of any complications in the immediate postoperative period. \n", "id": "1ce1a4f537694627ac3e2cf652401b16", "question": "What is the background context in this case summary?", "title": "1ce1a4f537694627ac3e2cf652401b16", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is an adult who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. He reported a past history of severe withdrawal symptoms when attempting to curtail use, and undergone multiple detoxification and rehabilitation treatments with relapses.", "the patient had an extensive treatment history with relapses", "and presented with moderately severe withdrawal symptoms."], "answer_start": [0, 759, 881]}, "context": "The patient is an adult who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. He reported a past history of severe withdrawal symptoms when attempting to curtail use, and undergone multiple detoxification and rehabilitation treatments with relapses.\n\nThe health plan's determination is overturned. The treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment. Additionally, the patient had an extensive treatment history with relapses that supported the necessity for an inpatient level of care, and presented with moderately severe withdrawal symptoms. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications. ", "id": "16bc0d6b35c84081ac91ec00e0892118", "question": "What is the background context in this case summary?", "title": "16bc0d6b35c84081ac91ec00e0892118", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who presented with a subjective fever, diarrhea for three days, and vomiting for two days. Four days prior to admission he had a cough and nasal congestion which cleared up with Saline nose spray and suction. He had 4-5 episodes of diarrhea each day for the last three days prior to admission. His mother noticed some bright red streaking in his diapers with almost every diarrheal stool. She also noted some hard stool chunks mixed with loose stool. She also noted that he seemed to cry in pain with passage of stool. He also had 5 episodes of non-bilious non-bloody emesis over the past two days prior to admission."], "answer_start": [0]}, "context": "This is a patient who presented with a subjective fever, diarrhea for three days, and vomiting for two days. Four days prior to admission he had a cough and nasal congestion which cleared up with Saline nose spray and suction. He had 4-5 episodes of diarrhea each day for the last three days prior to admission. His mother noticed some bright red streaking in his diapers with almost every diarrheal stool. She also noted some hard stool chunks mixed with loose stool. She also noted that he seemed to cry in pain with passage of stool. He also had 5 episodes of non-bilious non-bloody emesis over the past two days prior to admission. The health plan's determination is upheld. His clinical findings, described in the chart, along with his laboratory findings support a mild degree of dehydration. There was no mention of a PO trial in the emergency room after he received an IV fluid bolus as oral rehydration therapy is the recommended first line for mild to moderate dehydration. He did not meet currently accepted criteria for admission to the hospital for dehydration. ", "id": "ec39e316db834192a627136c2c128b87", "question": "What is the background context in this case summary?", "title": "ec39e316db834192a627136c2c128b87", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Foot pain\nIssue under review: Custom shoe orthotics", "The patient has been using custom orthotics for several years and they have worn out, and the treatment has", "been shown to be effective for the patient."], "answer_start": [0, 327, 443]}, "context": "Diagnosis: Foot pain\nIssue under review: Custom shoe orthotics\n\nDetermination:\nThe Custom shoe orthotics are medically necessary.\n\nThe treatment delivered is in keeping with reasonable acceptable standard of medical care for this condition.  Typically for plantar fasciitis, conservative care involves using custom orthotics.  The patient has been using custom orthotics for several years and they have worn out, and the treatment has already been shown to be effective for the patient.\n\nPlantar fasciitis is typically treated with orthotics conservatively prior to more invasive treatment, such as corticosteroid injection and surgery.", "id": "9202baea27834f919b3b96e38cfd5d4c", "question": "What is the background context in this case summary?", "title": "9202baea27834f919b3b96e38cfd5d4c", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who presented to the emergency department with persistent fevers and rash. He was well until approximately 5 days prior to admission when his mother noticed a red rash starting on his legs. The rash progressed to involve his back and stomach as well as his hands and feet. He also developed fever with a maximum temperature of 103.6 degrees Fahrenheit (F). He had been receiving ibuprofen at home with little relief, and he continued to have fevers. He was tolerating some oral intake, but had intermittent episodes of decreased activity. He was seen at his primary care provider's office where there was a concern for Kawasaki disease, and he was referred to the emergency department for further care."], "answer_start": [0]}, "context": "This is a patient who presented to the emergency department with persistent fevers and rash. He was well until approximately 5 days prior to admission when his mother noticed a red rash starting on his legs. The rash progressed to involve his back and stomach as well as his hands and feet. He also developed fever with a maximum temperature of 103.6 degrees Fahrenheit (F). He had been receiving ibuprofen at home with little relief, and he continued to have fevers. He was tolerating some oral intake, but had intermittent episodes of decreased activity. He was seen at his primary care provider's office where there was a concern for Kawasaki disease, and he was referred to the emergency department for further care.\nThe health plan's determination is overturned. The patient required prompt initiation of IVIG therapy along with high-dose aspirin in an inpatient setting to treat his symptoms and prevent the potentially serious complications of Kawasaki disease. He also had a blood culture sent that was pending. He required consultation from both infectious disease and cardiology, along with cardiorespiratory monitoring with further treatment as needed. Prompt treatment with intravenous immune globulin (IVIG) reduces the prevalence of coronary artery aneurysms fivefold in patients with Kawasaki Disease. Despite its advantages, IVIG is a potentially toxic intervention, and requires careful monitoring. ", "id": "0b0a4fc271574503ae0b59571b82aacf", "question": "What is the background context in this case summary?", "title": "0b0a4fc271574503ae0b59571b82aacf", "sufficiency_score": 4}
+{"answers": {"text": ["This a female patient admitted to this inpatient mental health treatment in this hospital on in early 2019 due to psychotic and manic symptoms, including paranoid and grandiose delusional thinking, disorganized thinking, racing thoughts, flight of ideas, poor reality testing, agitation, and feelings of hopelessness and helplessness. It was reported that she took Zyprexa and Klonopin. Health care provider stated that she was free of suicidal ideation or psychosis and was able to care for self. They stated that she no longer required 24-hour hospital treatment then, and they recommended a less restrictive level of care. She improved and was discharged.", "Diagnosis:  Paranoid Delusions and Worsening Mania", "Treatment: Inpatient Hospitalization", "The insurer denied the Inpatient Hospitalization.", "In this case, this patient had initially presented with manic and psychotic symptoms", "Further documentation reports that the patient was stable over the past week, and she did not have a labile mood, aggression, suicidal or homicidal ideation, or hallucinations. It was noted that her speech was linear and not pressured."], "answer_start": [168, 0, 53, 91, 1241, 1425]}, "context": "Diagnosis:  Paranoid Delusions and Worsening Mania\n \nTreatment: Inpatient Hospitalization\n\nThe insurer denied the Inpatient Hospitalization. \nThe denial was upheld.  \n\nThis a female patient admitted to this inpatient mental health treatment in this hospital on in early 2019 due to psychotic and manic symptoms, including paranoid and grandiose delusional thinking, disorganized thinking, racing thoughts, flight of ideas, poor reality testing, agitation, and feelings of hopelessness and helplessness. It was reported that she took Zyprexa and Klonopin. Health care provider stated that she was free of suicidal ideation or psychosis and was able to care for self. They stated that she no longer required 24-hour hospital treatment then, and they recommended a less restrictive level of care. She improved and was discharged.\n\nThe American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. They also report that patients with aggression, homicidal or suicidal intent, plan, or behavior, manic episodes, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case, this patient had initially presented with manic and psychotic symptoms, but during hospitalization there were no further reports of manic episodes or psychotic symptoms. Further documentation reports that the patient was stable over the past week, and she did not have a labile mood, aggression, suicidal or homicidal ideation, or hallucinations. It was noted that her speech was linear and not pressured. There were no reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, homicidal ideation, plan, or intent, or severe agitation, acute medical instability or severe withdrawal requiring hospital treatment. The patient had no further severe psychiatric symptoms reported. Additionally, there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or achieved in a less restrictive level of care. \n\nBased on the above, the medical necessity for the continued inpatient hospital stay is not substantiated.  The insurer's denial is upheld. \n", "id": "0c224b350e6d469d9c36930177626f3f", "question": "What is the background context in this case summary?", "title": "0c224b350e6d469d9c36930177626f3f", "sufficiency_score": 4}
+{"answers": {"text": ["This is a middle age female who was admitted to an inpatient psychiatric hospital due to depressive symptoms that include depressed mood, suicidal ideation of not wanting to live but had no plan or intent. She also expressed feelings of worthlessness and isolation.  She had past history of Major Depression Disorder, seizures, cerebral palsy, and overactive bladder. She reports no previous psychiatric hospitalizations or treatments. The patient was treated with Lexapro, Abilify, Trazodone, Haldol, and Ativan. She was isolative but did participate in art group. While hospitalized, she remained depressed and suicidal. She was discharged after a period of stability.", "Diagnosis: Major Depressive Disorders", "Treatment: Continued Inpatient Hospital Admission", "The insurer denied the Continued Inpatient Hospital Admission.", "She reportedly had suicidal ideation with depressed mood and feelings of worthlessness and was approved for hospital treatment.", "She had no past suicide attempts, and no past psychiatric hospitalizations. She reportedly was living in a shelter but the chart notes that there was not specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs."], "answer_start": [184, 0, 40, 91, 1209, 1629]}, "context": "Diagnosis: Major Depressive Disorders\n \nTreatment: Continued Inpatient Hospital Admission\n\nThe insurer denied the Continued Inpatient Hospital Admission. The denial was upheld.      \n\nThis is a middle age female who was admitted to an inpatient psychiatric hospital due to depressive symptoms that include depressed mood, suicidal ideation of not wanting to live but had no plan or intent. She also expressed feelings of worthlessness and isolation.  She had past history of Major Depression Disorder, seizures, cerebral palsy, and overactive bladder. She reports no previous psychiatric hospitalizations or treatments. The patient was treated with Lexapro, Abilify, Trazodone, Haldol, and Ativan. She was isolative but did participate in art group. While hospitalized, she remained depressed and suicidal. She was discharged after a period of stability.\n\nPsychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. She reportedly had suicidal ideation with depressed mood and feelings of worthlessness and was approved for hospital treatment. There were no reports of suicidal plan, intent, or behavior, self-injurious behavior, inability to adequately care for basic needs, psychotic or manic symptoms, aggressive, severely agitated, or threatening behavior, acute medical issues, or substance use issues as she denied substance use. She had no past suicide attempts, and no past psychiatric hospitalizations. She reportedly was living in a shelter but the chart notes that there was not specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs. Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.\n\nThe carrier's denial of coverage for the continued inpatient hospital admission is upheld. The medical necessity is not substantiated. \n", "id": "2a73c99734ef4a03ac1fb52957e5e3b1", "question": "What is the background context in this case summary?", "title": "2a73c99734ef4a03ac1fb52957e5e3b1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient's orthodontist has documented that the patient is damaging the soft tissue of her palate due to her deep overbite, and her cephalometric radiograph confirms this.", "The patient is a old female with a Class I, crowded occlusion and a deep bite causing soft tissue damage on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion which was denied based on lack of medical necessity.", "The subject under review is the medical necessity of treatment with braces for this patient."], "answer_start": [525, 49, 308]}, "context": "Overbite/Underbite\nDental/Orthodontic Procedure\n\nThe patient is a old female with a Class I, crowded occlusion and a deep bite causing soft tissue damage on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion which was denied based on lack of medical necessity.\nThe subject under review is the medical necessity of treatment with braces for this patient.\n\nThe health plan's determination is overturned.\n\nThe requested treatment of braces is medically necessary for this patient.\nThe patient's orthodontist has documented that the patient is damaging the soft tissue of her palate due to her deep overbite, and her cephalometric radiograph confirms this. Palatal tissue damage is a known side effect of deep bite malocclusions.(1)\n\nA deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of her palate. Studies show deep anterior overbite is associated with periodontal attachment loss.(1) If left untreated this will compromise the bony attachment of the maxillary anterior teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive to correct than the orthodontic problem she currently has.", "id": "28fb8f832cf74d63962e4d122a340f92", "question": "What is the background context in this case summary?", "title": "28fb8f832cf74d63962e4d122a340f92", "sufficiency_score": 4}
+{"answers": {"text": ["The patient who presented to the dental office of the  provider for the evaluation and treatment of teeth #5 and 29. Provided for review are a narrative from the dental provider explaining radiographic opening under current restoration for #5 and 29 along with recurrent decay, full mouth radiographic images from 05/02/18, bite-wing images from 07/09/19, panoramic radiographs from 05/02/18, and American Dental Association (ADA) Dental Claim Forms.", "In question is the medical necessity of the planned treatment of (2751) porcelain crown and (2954) prefabricated post and core for teeth #5 and 29."], "answer_start": [56, 507]}, "context": "Decay, Root Involvement\nDental /Orthodontic Procedure \n\nThe patient who presented to the dental office of the  provider for the evaluation and treatment of teeth #5 and 29. Provided for review are a narrative from the dental provider explaining radiographic opening under current restoration for #5 and 29 along with recurrent decay, full mouth radiographic images from 05/02/18, bite-wing images from 07/09/19, panoramic radiographs from 05/02/18, and American Dental Association (ADA) Dental Claim Forms.\nIn question is the medical necessity of the planned treatment of (2751) porcelain crown and (2954) prefabricated post and core for teeth #5 and 29.\nThe health plans determination of medical necessity is upheld in whole .\nBased on the provided documentation there is no evidence of decay radiographically nor clinically to support the need for the requested treatment of (2751) porcelain crown and (2954) pre-fabricated post and core for teeth #5 and 29.The current documentation does not support the presence of decay at the margins of #5 and 29 neither clinically nor radiographically, hence removing any rationale for the replacement of the current crowns on those teeth. Because there is not a medical necessity need for the porcelain crowns, there is also not the need for post core and buildup for either teeth. Without evidence of decay radiographically or clinically to support the need for the planned treatment of porcelain crown and prefabricated post and core for teeth #5 and #29,  medical necessity cannot be established.", "id": "2ed8a91d7c2e42a98ff459e6ef98b7aa", "question": "What is the background context in this case summary?", "title": "2ed8a91d7c2e42a98ff459e6ef98b7aa", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Chest pain\nTreatment: Inpatient admission", "The patient is a woman who presented to the hospital complaining of chest pain for over one year. On examination vital signs were stable and chest pain was reproducible when palpating the sternum.  No other abnormal findings were noted. Past medical history was significant for diabetes mellitus.  Electrocardiogram revealed no evidence of ischemic changes and serial cardiac enzymes were within normal limits.  Computed tomography (CT) of the chest to rule out pulmonary embolism was normal.  The patient was ultimately discharged with outpatient follow up.", "This patient presented with atypical chest pain that was present for one year's time.  Chest pain was reproducible when the sternum was palpated."], "answer_start": [0, 128, 688]}, "context": "Diagnosis: Chest pain\nTreatment: Inpatient admission\nThe proposed treatment, inpatient admission, was not medically necessary.\n\nThe patient is a woman who presented to the hospital complaining of chest pain for over one year. On examination vital signs were stable and chest pain was reproducible when palpating the sternum.  No other abnormal findings were noted. Past medical history was significant for diabetes mellitus.  Electrocardiogram revealed no evidence of ischemic changes and serial cardiac enzymes were within normal limits.  Computed tomography (CT) of the chest to rule out pulmonary embolism was normal.  The patient was ultimately discharged with outpatient follow up.\n\nThis patient presented with atypical chest pain that was present for one year's time.  Chest pain was reproducible when the sternum was palpated. Based on history and physical examination her pretest probability of coronary artery disease is low. (Reference 1)  Utilizing the HEART score she was considered low risk (three points). (Reference 2)  Utilizing the TIMI risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) \n\nRisk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.\n\n\n\n\n", "id": "3159a0d33b43484aa7caedd3e5ab3eef", "question": "What is the background context in this case summary?", "title": "3159a0d33b43484aa7caedd3e5ab3eef", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Psoriasis Vulgaris\nTreatment:  Consentyx\n", "The patient is a male with psoriasis, treated with topicals, methotrexate, phototherapy, and Skyrizi.  The patient has cleared on Cosentyx samples.", "The patient has already tried methotrexate."], "answer_start": [0, 103, 728]}, "context": "Diagnosis:  Psoriasis Vulgaris\nTreatment:  Consentyx\n\nThe proposed Cosentyx is medically necessary.  \n\nThe patient is a male with psoriasis, treated with topicals, methotrexate, phototherapy, and Skyrizi.  The patient has cleared on Cosentyx samples.\n\nCosentyx is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis.  Currently, the selection of the first biologic and the choice of sequential biologics in the event of efficacy/tolerability concerns is made using a limited evidence base.  It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded. \n\nThe patient has already tried methotrexate.  Cyclosporine is not used for plaque psoriasis.", "id": "823cabdf11574fd6aa9a7b64091d4c64", "question": "What is the background context in this case summary?", "title": "823cabdf11574fd6aa9a7b64091d4c64", "sufficiency_score": 4}
+{"answers": {"text": ["The patient presented to the oral surgeon for dental implant placement at the site of missing tooth #19.  The implant was performed.  At issue is the medical necessity of the dental implant for tooth # 19.", "Diagnosis:  Dental Disorder.\nTreatment:  Dental Implant Tooth #19.", "The insurer denied the Dental Implant for Tooth #19."], "answer_start": [156, 0, 68]}, "context": "Diagnosis:  Dental Disorder.\nTreatment:  Dental Implant Tooth #19.\n\nThe insurer denied the Dental Implant for Tooth #19.  The determination is overturned.\n\nThe patient presented to the oral surgeon for dental implant placement at the site of missing tooth #19.  The implant was performed.  At issue is the medical necessity of the dental implant for tooth # 19.\n\nIt is reasonable to restore a patient's dentition to first molar occlusion, which this procedure did.  It is considered a fairly predicable surgery with a high success rates with a variety of implant systems and applications (89 to 98 percent).  Replacement of missing teeth with dental implants is common practice in dentistry.  Loss of teeth without replacement may have several adverse outcomes, including among others masticatory dysfunction, speech and articulation errors, and pain secondary to chronic mucosal irritation and ulceration.  Since there is no tooth posterior to tooth #19, there is only a removable option, which is a partial denture, which is considered less ideal because it is removable versus fixed (which an implant is) and also because it is more suited to replacement of multiple teeth versus just one.  Therefore, the dental implant for tooth number 19 is medically necessary.", "id": "cf5deee06cca4fe0ad8cd93a5852986e", "question": "What is the background context in this case summary?", "title": "cf5deee06cca4fe0ad8cd93a5852986e", "sufficiency_score": 3}
+{"answers": {"text": ["The patient has a history of hypertrophic cardiomyopathy and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He also reported having had a few days of chills, cough and myalgias. He denied chest pain or dyspnea. His blood pressure was 115/86 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. He was afebrile. His physical exam was unremarkable. Testing was positive for Influenza A. His serum troponin level was mildly elevated. He was treated with Tamiflu and intravenous digoxin and admitted to the hospital due to concern for acute coronary syndrome (ACS) based on the elevated troponin level. He was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome (ACS). The patient was discharged. The medical necessity of an inpatient admission is at issue.", "Diagnosis: Atrial Fibrillation", "Treatment: Inpatient Hospital Stay", "The insurer denied the Inpatient Hospital Stay.", "This patient was hemodynamically stable", "This patient's serum troponin level was mildly elevated.", "In this case, per the cardiologist, there was no evidence of ACS and no treatment for ACS was instituted."], "answer_start": [144, 0, 31, 66, 1094, 2293, 2558]}, "context": "Diagnosis: Atrial Fibrillation\nTreatment: Inpatient Hospital Stay\nThe insurer denied the Inpatient Hospital Stay.\nThe determination is upheld.\n\nThe patient has a history of hypertrophic cardiomyopathy and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He also reported having had a few days of chills, cough and myalgias. He denied chest pain or dyspnea. His blood pressure was 115/86 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. He was afebrile. His physical exam was unremarkable. Testing was positive for Influenza A. His serum troponin level was mildly elevated. He was treated with Tamiflu and intravenous digoxin and admitted to the hospital due to concern for acute coronary syndrome (ACS) based on the elevated troponin level. He was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome (ACS). The patient was discharged. The medical necessity of an inpatient admission is at issue.\n\nThe inpatient stay was not medically necessary.\nThis patient was hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, and was not at high risk for thromboembolism. For patients presenting with acute atrial fibrillation (AF), the safety a lower level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, \"There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al, based on an observational study of 3475 patients concluded, \"In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations.\"\nThis patient's serum troponin level was mildly elevated. This is a common finding in patients presenting with supraventricular tachyarrhythmias, including atrial fibrillation, and is not necessarily indicative of coronary artery disease or acute coronary syndrome. In this case, per the cardiologist, there was no evidence of ACS and no treatment for ACS was instituted. Thus, the troponin elevation in this case did not warrant an inpatient level of care.", "id": "224924922e02439592e72fbd62f692f8", "question": "What is the background context in this case summary?", "title": "224924922e02439592e72fbd62f692f8", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female with a history of Alzheimer's dementia. Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs).", "documentation from the patient's physician indicates that the patient's functionality and clinical status have progressively declined and she currently requires assistance with all ADLs including eating, cooking, bathing, toileting and laundry/housekeeping.", "Diagnosis: Alzheimer's dementia", "Treatment: Consumer directed personal assistance services 50 hours per week"], "answer_start": [118, 394, 0, 32]}, "context": "Diagnosis: Alzheimer's dementia\nTreatment: Consumer directed personal assistance services 50 hours per week\n\nSummary:\nThis is a female with a history of Alzheimer's dementia. Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs). The currently approved plan of 35 CDPAS hours/week is not sufficient to meet the patient's needs. Specifically, documentation from the patient's physician indicates that the patient's functionality and clinical status have progressively declined and she currently requires assistance with all ADLs including eating, cooking, bathing, toileting and laundry/housekeeping. For these reasons, the CDPAS at 50 hours per week is deemed medically necessary. ", "id": "c084ada5a20f40488cc266bf9ee58036", "question": "What is the background context in this case summary?", "title": "c084ada5a20f40488cc266bf9ee58036", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has Crohn's, and she has failed Remicade and Humira.", "Diagnosis: Chron's Disease.", "Treatment: Stelara (ustekinumab).", "The insurer denied the Stelara (ustekinumab).", "The patient is a female with ileocolonic Crohn's. She has failed treatment with ", "sulfasalazine, 6-MP (mercaptopurine), Methotrexate, Remicade and Humira. Her MD is requesting treatment with Stelara."], "answer_start": [411, 0, 29, 64, 135, 216]}, "context": "Diagnosis: Chron's Disease. \nTreatment: Stelara (ustekinumab). \nThe insurer denied the Stelara (ustekinumab). \nThe denial is upheld. \n\nThe patient is a female with ileocolonic Crohn's. She has failed treatment with \nsulfasalazine, 6-MP (mercaptopurine), Methotrexate, Remicade and Humira. Her MD is requesting treatment with Stelara. \n\nNo, the treatment with Stelara (ustekinumab) is not medically necessary. \n\nThe patient has Crohn's, and she has failed Remicade and Humira. Per plan guideline, in order for criteria for Stelara to be met, the patient must have tried and failed Entyvio. As Entyvio is safe and effective treatment in patients with Crohn's who have failed an anti-TNF (tumor necrosis factor), and as there is no consensus in the literature supporting that Stelara is more effective than Entyvio for the treatment of Crohn's, the proposed Stelara is not medically necessary over the plan-preferred Entyvio, and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying it. \n", "id": "0c1ce9fca42447e69f787421b92361b7", "question": "What is the background context in this case summary?", "title": "0c1ce9fca42447e69f787421b92361b7", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who presented to the Emergency Department with complaints of abdominal pain.  The patient reported that he had constant and moderate abdominal pain with loose bowel movements in the morning.  The physical examination revealed right lower quadrant abdominal tenderness and suprapubic region tenderness to palpation with no rebound or guarding.  The white blood cell count was 15.5.  CT scan of the abdomen and pelvis revealed acute appendicitis.  The patient decided to undergo non-surgical management and was treated with intravenous (IV) fluids, IV antibiotics, and pain medications.  The patient was discharged with follow-up for appendectomy planning with the general surgeon.", "Diagnosis:  Appendicitis.", "Treatment:  Inpatient hospital admission.", "The insurer denied the inpatient hospital admission.", "This patient had fever up to 102.", "He was started on clear diet in the morning, and his diet was advanced that evening."], "answer_start": [154, 0, 28, 71, 1390, 1528]}, "context": "Diagnosis:  Appendicitis.  \nTreatment:  Inpatient hospital admission.\n\nThe insurer denied the inpatient hospital admission.  The denial was overturned. \n\nThis is a patient who presented to the Emergency Department with complaints of abdominal pain.  The patient reported that he had constant and moderate abdominal pain with loose bowel movements in the morning.  The physical examination revealed right lower quadrant abdominal tenderness and suprapubic region tenderness to palpation with no rebound or guarding.  The white blood cell count was 15.5.  CT scan of the abdomen and pelvis revealed acute appendicitis.  The patient decided to undergo non-surgical management and was treated with intravenous (IV) fluids, IV antibiotics, and pain medications.  The patient was discharged with follow-up for appendectomy planning with the general surgeon.\n\nThe length of hospital stay for this patient is consistent with what is seen in most studies on patients with uncomplicated appendicitis treated non-operatively.  Intravenous (IV) antibiotics is generally recommended for 3 days, typically on an inpatient basis, then followed by 7 days of oral antibiotics on an outpatient basis if patient responds to IV antibiotics.  Discharge criteria for patients with uncomplicated appendicitis treated non-operatively is antibiotics, control of pain with oral analgesics, and resolution of fever.  This patient had fever up to 102.  Another criteria that has been looked at for discharge is that the patient tolerates their diet (3).   He was started on clear diet in the morning, and his diet was advanced that evening.  Discharge the following day is reasonable, as it allowed for 24 hours of being afebrile, insured that he tolerated diet, and also that his WBC was improving.\n\nThe health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.\n\nThe carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.", "id": "6695ba58b686403595e9d81be1effe9d", "question": "What is the background context in this case summary?", "title": "6695ba58b686403595e9d81be1effe9d", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Obstruction of vision", "Treatment: Blepharoplasty", "The insurer denied the Blepharoplasty.", "The patient is a female for whom coverage of blepharoplasty (15823) is requested. Coverage was previously denied for lack of photos to support policy criteria.", "According to the provider, the patient had been complaining of obstruction of her vision for some time and had noticed that when physically holding up her forehead, she could see better, experiencing less fatigue and improved field of vision.  Marginal reflex distances were reported as 0.5 millimeters (mm) both eyes (OU).  Visual fields also reportedly improve by more than 30% with taping of the eyelids. An exam documents vision corrected to 20/25 OU. Dermatochalasis was characterized as three-plus (3+) OU with 3+ tenting temporally. One-plus (1+) cortical and nuclear sclerotic cataracts were noted OU.", "In this case, visual field testing performed within 30 degrees found superior visual fields restricted to near zero degrees OU, increasing to at least 30 degrees OU with taping of the eyelids. Black and white copies of external photos confirmed dermatochalasis with excess upper eyelid skin resting on the base of the lashes temporally and weighing down eyelids.  Marginal reflex distances are estimated as one mm OU."], "answer_start": [0, 33, 59, 127, 289, 2472]}, "context": "Diagnosis: Obstruction of vision\nTreatment: Blepharoplasty\nThe insurer denied the Blepharoplasty. \nThe denial is overturned. \n\nThe patient is a female for whom coverage of blepharoplasty (15823) is requested. Coverage was previously denied for lack of photos to support policy criteria. \n\nAccording to the provider, the patient had been complaining of obstruction of her vision for some time and had noticed that when physically holding up her forehead, she could see better, experiencing less fatigue and improved field of vision.  Marginal reflex distances were reported as 0.5 millimeters (mm) both eyes (OU).  Visual fields also reportedly improve by more than 30% with taping of the eyelids. An exam documents vision corrected to 20/25 OU. Dermatochalasis was characterized as three-plus (3+) OU with 3+ tenting temporally. One-plus (1+) cortical and nuclear sclerotic cataracts were noted OU.  \n\nYes, the blepharoplasty performed 06/10/2019 was medically necessary.\n\nNo, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  However, it should be noted that the health plan reportedly did not have the external photos that were provided for this current review.\n\nAccording to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes. Typically, patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin. Photos should correlate with visual field testing.\n\nA task force from the American Academy of Ophthalmology reviewed the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.  Ptosis and upper eyelid blepharoplasty surgery were found to be functionally beneficial for each of these quantitative findings:\n\n1) Marginal reflex distance one (MRD1) of two mm measured in primary gaze (MET)\n2) Superior visual field loss of 12 degrees or 24% (MET)\n3) Down-gaze ptosis impairing reading documented by MRD1 of two mm measured in down gaze.\n\nIn this case, visual field testing performed within 30 degrees found superior visual fields restricted to near zero degrees OU, increasing to at least 30 degrees OU with taping of the eyelids. Black and white copies of external photos confirmed dermatochalasis with excess upper eyelid skin resting on the base of the lashes temporally and weighing down eyelids.  Marginal reflex distances are estimated as one mm OU. Photos correlate with the required superior visual field loss.  Therefore, medical necessity of bilateral upper eyelid blepharoplasty is established per standard of care.  ", "id": "e2b1008a39444d27a67465efef8d7fe3", "question": "What is the background context in this case summary?", "title": "e2b1008a39444d27a67465efef8d7fe3", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with a history of significant multivessel coronary artery disease, coronary stents to the right coronary artery (RCA), left anterior descending (LAD), and first obtuse marginal (OM1), hypertension, type 2 diabetes mellitus, hyperlipidemia who presented to the emergency room (ER) with progressive exertional chest pain consistent with unstable angina. The patient underwent urgent coronary angiography demonstrating severe stenosis of the right patent ductus arteriosus (PDA) requiring drug-eluting stent (DES) placement. The patient was discharged the following day in stable condition.", "This patient with known significant multivessel coronary disease requiring stents in the past and multiple risk factors for CAD presented with unstable angina in the setting of severe hypertension requiring urgent coronary angiography under the inpatient level of care.", "The patient presented with an elevated thrombolysis in myocardial infarction (TIMI) risk score (4) with an approximate 20% risk of future adverse cardiac events (all-cause mortality, new or recurrent myocardial infarction [MI], or recurrent ischemia requiring urgent revascularization)", "Diagnosis: Cardiac / Circulatory Problems.", "Treatment: Inpatient Hospital.", "The insurer denied: Inpatient stay."], "answer_start": [151, 880, 1296, 0, 44, 76]}, "context": "Diagnosis: Cardiac / Circulatory Problems. \nTreatment: Inpatient Hospital. \nThe insurer denied: Inpatient stay. \nThe denial was overturned in whole. \n\nThe patient is a male with a history of significant multivessel coronary artery disease, coronary stents to the right coronary artery (RCA), left anterior descending (LAD), and first obtuse marginal (OM1), hypertension, type 2 diabetes mellitus, hyperlipidemia who presented to the emergency room (ER) with progressive exertional chest pain consistent with unstable angina. The patient underwent urgent coronary angiography demonstrating severe stenosis of the right patent ductus arteriosus (PDA) requiring drug-eluting stent (DES) placement. The patient was discharged the following day in stable condition.\n\nThe health plan's determination is overturned in whole. \n\nAn inpatient stay was medically necessary for this patient.\nThis patient with known significant multivessel coronary disease requiring stents in the past and multiple risk factors for CAD presented with unstable angina in the setting of severe hypertension requiring urgent coronary angiography under the inpatient level of care. Urgent coronary angiography was medically appropriate with the goal of treating ischemic symptoms and reducing the risk of myocardial infarction. The patient presented with an elevated thrombolysis in myocardial infarction (TIMI) risk score (4) with an approximate 20% risk of future adverse cardiac events (all-cause mortality, new or recurrent myocardial infarction [MI], or recurrent ischemia requiring urgent revascularization) favoring benefit with urgent coronary angiography (1). Furthermore, according to the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guideline for the management of patients with non-ST-elevation acute coronary syndromes, the standard of care for patients with unstable angina, as in this case, is admission for inpatient management to reduce ischemic symptoms and prevent myocardial infarction and death (2). For these reasons, inpatient level of care was medically appropriate and necessary in the best interest of this patient's safety.", "id": "8236bfba1d9c40b5b4c767995e17759b", "question": "What is the background context in this case summary?", "title": "8236bfba1d9c40b5b4c767995e17759b", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Autism spectrum disorder", "Treatment: 97153 - ABA therapy, five hours/week", "This is an adult male diagnosed with autism spectrum disorder (ASD) at age three years"], "answer_start": [0, 36, 151]}, "context": "Diagnosis: Autism spectrum disorder\nTreatment: 97153 - ABA therapy, five hours/week \nThe proposed treatment, ABA therapy, is not medically necessary.\n\nThis is an adult male diagnosed with autism spectrum disorder (ASD) at age three years; the source of that diagnosis is not documented. \n\nDespite the lack of evidence from randomized controlled trials, there is growing evidence from observational studies and systematic reviews and a consensus in the professional community that children with autism spectrum disorder (ASD) should participate in therapeutic programs as early as possible.  Almost all evidence concerning efficacy of psychosocial interventions in ASD is based on studies of children 18 months to seven years of age.  A systematic review concluded there was insufficient evidence (ie, not studied, poor-quality studies) to support the use of ABA therapy in the treatment of adolescents (such as this patient) or adults with ASD.  A systematic review of the effectiveness of behavioral, educational, life skills, or vocational interventions in people with ASD found variable effects on activities of daily living (ADLs), and have indicated that generalizability of positive findings in this area is limited due to insufficient evidence (ie, lack of study of some domains, poor quality studies).  Thus, the use of ABA for children age 12 years and older (such as this patient) must focus on the core features of ASD rather than on ADLs (which is not the case for this patient) [Smith 2015, Murza 2016, Reichow 2018, Volkmar 2018].\n...\nDURATION OF THERAPY.\nThe patient should receive ABA therapy for a minimum of 12 months, until:\n1) Treatment goals are reached\n2) Patient plateaus and fails to progress (i.e., maintenance therapy)\n3) Four years of therapy\n\nThe diagnosis of ASD is not substantiated for this patient because clinical records fail to document a diagnostic evaluation for ASD by a qualified diagnostician (e.g., clinical child psychologist, board-certified child psychiatrist, board-certified child neurologist, board-certified developmental-behavioral pediatrician, board-certified neurodevelopmental pediatrician) administering an appropriate module of the ADOS-2 accompanied by review of the DSM-5tm diagnostic criteria along with standardized testing of intelligence and language.  Even if the diagnosis of ASD were substantiated, continued ABA therapy for more than four years is not medically necessary, appropriate, or standard of care.  Finally, the patient has shown poor RTI despite many years of ABA therapy, further supporting that the requested services are not medically necessary.", "id": "5f148345fe1e4e3eaf4b35afd5ad9c09", "question": "What is the background context in this case summary?", "title": "5f148345fe1e4e3eaf4b35afd5ad9c09", "sufficiency_score": 3}
+{"answers": {"text": ["This is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs.", "The patient has a diagnosis of hypertensive urgency or emergency"], "answer_start": [49, 1165]}, "context": "Cardiac/Circulatory Problems\nInpatient hospital\n\nThis is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs. The pulmonary exam was fairly unremarkable, and so was the rest of the exam. \n\nThe health plan's determination is upheld. The inpatient stay was not medically necessary. This presentation of hypertensive urgency can be managed under at a lower level of care. The presentation does not satisfy clinical indications for admission to inpatient care. The patient has a diagnosis of hypertensive urgency or emergency, without evidence of target organ damage. There is no evidence of hypertensive encephalopathy or cerebral infarction. There is no evidence that the patient suffered from myocardial ischemia or infarct. There is no evidence of heart failure or aortic dissection. There is no evidence of seizure activity associated with hypertensive urgency. Within 24 hours, the addition of antihypertensive medications produced adequate control of blood pressures. This type of presentation is typically managed at a lower level of care for chest pain rule out protocol.", "id": "3186e1b24f564930a28a0171d35ac273", "question": "What is the background context in this case summary?", "title": "3186e1b24f564930a28a0171d35ac273", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Rectal bleeding", "Issue Under Review: Inpatient admission", "The patient is a male. He was admitted via the emergency department to the hospital.  The patient noted rectal bleeding and generalized weakness the morning of presentation. The impression was hemorrhoidal bleeding as the most likely cause. The patient evidenced anemia.", "On presentation, the patient had a hemoglobin of 6. He received two units of blood and evidenced no bleeding during the hospitalization. The patient was discharged with a plan for close follow-up.", "The patient presented with anemia and received two units of blood. The patient evidenced", "generalized weakness from the anemia."], "answer_start": [0, 28, 140, 413, 612, 706]}, "context": "Diagnosis: Rectal bleeding \nIssue Under Review: Inpatient admission \n\nDetermination: The inpatient admission was not medically necessary. \n\nThe patient is a male. He was admitted via the emergency department to the hospital.  The patient noted rectal bleeding and generalized weakness the morning of presentation. The impression was hemorrhoidal bleeding as the most likely cause. The patient evidenced anemia. \n\nOn presentation, the patient had a hemoglobin of 6. He received two units of blood and evidenced no bleeding during the hospitalization. The patient was discharged with a plan for close follow-up. \n\nThe patient presented with anemia and received two units of blood. The patient evidenced only generalized weakness from the anemia. There was no reported hypoxia, active bleeding, coagulopathy, or planned surgery. The care as rendered could have been delivered at a lower level of care in its entirety.", "id": "726bb74cd9264f338eb35321313110f7", "question": "What is the background context in this case summary?", "title": "726bb74cd9264f338eb35321313110f7", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female patient with a medical history of hemorrhoidectomy and an abdominoplasty. The patient presented to the Emergency Department (ED) with complaints that she had not had a bowel movement since the hemorrhoidectomy. The patient had been diligently taking her opioids and eating regularly.  The patient denied abdominal pain, but did complain of nausea. She reported that sometimes she passed gas but had not passed gas on the date of presentation. Her presenting vital signs were: blood pressure 106/71 and temperature 36.7 C.  A physical examination was performed that revealed her abdomen was soft and non-tender. An abdominal x-ray was done that revealed no evidence of free air or obstruction. The patient's surgeon recommended she come to the ED for an enema under sedation. The patient underwent an examination under anesthesia, minimal fecal disimpaction, and irrigation of the rectum with saline and Betadine. The patient was discharged in stable condition.", "Diagnosis: Fecal Impaction", "Treatment: Inpatient admission", "The insurer denied the inpatient admission.", "The patient had post-operative constipation compounded by opiate use. The patient was hemodynamically stable and her labs were unremarkable. The patient's abdominal imaging did not reveal ileus or obstruction."], "answer_start": [129, 0, 28, 60, 1219]}, "context": "Diagnosis: Fecal Impaction\n\nTreatment: Inpatient admission\n\nThe insurer denied the inpatient admission.\n\nThe denial was upheld.\n\nThis is a female patient with a medical history of hemorrhoidectomy and an abdominoplasty. The patient presented to the Emergency Department (ED) with complaints that she had not had a bowel movement since the hemorrhoidectomy. The patient had been diligently taking her opioids and eating regularly.  The patient denied abdominal pain, but did complain of nausea. She reported that sometimes she passed gas but had not passed gas on the date of presentation. Her presenting vital signs were: blood pressure 106/71 and temperature 36.7 C.  A physical examination was performed that revealed her abdomen was soft and non-tender. An abdominal x-ray was done that revealed no evidence of free air or obstruction. The patient's surgeon recommended she come to the ED for an enema under sedation. The patient underwent an examination under anesthesia, minimal fecal disimpaction, and irrigation of the rectum with saline and Betadine. The patient was discharged in stable condition.\n\nBased on the review of the medical record and literature, the inpatient admission was not medically necessary. The patient had post-operative constipation compounded by opiate use. The patient was hemodynamically stable and her labs were unremarkable. The patient's abdominal imaging did not reveal ileus or obstruction. While fecal disimpaction was appropriate, inpatient admission was not medically necessary. The patient could have received her care in the Emergency Room (ER) or at Observation level of care. \n\nBased on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.\n", "id": "a2bbed9d4f4a4661aa5a8f5cf6869de1", "question": "What is the background context in this case summary?", "title": "a2bbed9d4f4a4661aa5a8f5cf6869de1", "sufficiency_score": 4}
+{"answers": {"text": ["The documentation indicated the recent emergent admission in response to Solu-Medrol, as well as worsening seizures with steroid discontinuation, supports the autoimmune etiology of epilepsy.  It was recommended the patient continue multiple medications and begin IVIG.", "Diagnosis: Autoimmune encephalitis with refractory seizures \n Treatment: Octagam", "The insurer denied coverage for Octagam.", "This patient is a male who has been previously diagnosed with Crohn's disease.  A letter of medical necessity indicates the patient was also being seen by Neurology for a complex neurological condition.  The patient was noted to have autoimmune encephalitis with secondary intractable epilepsy.  The patient had an explosive onset 6 months prior with multiple and refractory focal seizures with secondary generalization captured during a prolonged hospital stay.  The patient has undergone extensive evaluation to include CSF examination which returned a positive result for high levels of myelin basic protein.  The patient did respond well to an initial course of Solu-Medrol and an attempt to taper then led to worsening seizure frequency.  The patient was utilizing 2 AEDs at very high doses in combination with oral prednisone.  The patient was recommended to continue chronic immunosuppression.", "Additional submitted documentation does include a chart note when the patient was seen for a follow-up.  The documentation did detail the patient was recently admitted for an episode worsening seizures.  The patient responded well to Solu-Medrol in addition to valproic acid (VPA).  The patient did attempt to taper off steroids as noted above however this worsened the seizures.  The documentation detailed the patient was feeling okay since the hospital visit.  The physician indicated the patient presented with a new onset seizure-like event following a fall."], "answer_start": [1745, 0, 83, 150, 1054]}, "context": "Diagnosis: Autoimmune encephalitis with refractory seizures \n Treatment: Octagam \n\nThe insurer denied coverage for Octagam. The denial is reversed. \n\nThis patient is a male who has been previously diagnosed with Crohn's disease.  A letter of medical necessity indicates the patient was also being seen by Neurology for a complex neurological condition.  The patient was noted to have autoimmune encephalitis with secondary intractable epilepsy.  The patient had an explosive onset 6 months prior with multiple and refractory focal seizures with secondary generalization captured during a prolonged hospital stay.  The patient has undergone extensive evaluation to include CSF examination which returned a positive result for high levels of myelin basic protein.  The patient did respond well to an initial course of Solu-Medrol and an attempt to taper then led to worsening seizure frequency.  The patient was utilizing 2 AEDs at very high doses in combination with oral prednisone.  The patient was recommended to continue chronic immunosuppression.  \n\nAdditional submitted documentation does include a chart note when the patient was seen for a follow-up.  The documentation did detail the patient was recently admitted for an episode worsening seizures.  The patient responded well to Solu-Medrol in addition to valproic acid (VPA).  The patient did attempt to taper off steroids as noted above however this worsened the seizures.  The documentation detailed the patient was feeling okay since the hospital visit.  The physician indicated the patient presented with a new onset seizure-like event following a fall.  By description and video review, events are atypical for seizures; however recent evaluation confirmed the epileptic nature.  The documentation indicated the recent emergent admission in response to Solu-Medrol, as well as worsening seizures with steroid discontinuation, supports the autoimmune etiology of epilepsy.  It was recommended the patient continue multiple medications and begin IVIG.  \n\nIVIG is commonly used for cases of autoimmune encephalitis with refractory seizures and is in the standard of care. A variety of clinical studies, some randomized, blinded studies have shown efficacy with IVIG.  Therefore, the use of Octagam is medically necessary in this case for this patient with treatment failure with steroids and multiple anticonvulsant medications.  The decision is overturned and Octagam should be approved in this case.  \n\nThe health plan did not act reasonably and with sound medical judgment in the best interest of the patient.  \n\nBased on the above, the medical necessity for Octagam is substantiated.  The insurer's denial is reversed.  \n\n", "id": "8ca13aa6307141b7818e8ef3bb86609f", "question": "What is the background context in this case summary?", "title": "8ca13aa6307141b7818e8ef3bb86609f", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has failed topical steroids, calcineurin inhibitors, and systemic steroids.", "The patient is not a candidate for conventional systemic therapy (methotrexate, azathioprine, mycophenolate) due to her gender and childbearing age.", "Diagnosis: Atopic dermatitis", "Treatment: Dupixent Syn 300\nThe insurer denied the Dupixent Syn 300.", "The patient is a female with a history of moderate to severe atopic dermatitis (AD) since adolescence. She has failed topical therapy. She has severe fissuring of the hands and ears. Her EASI (Eczema Area and Severity Index) score is 18.7, and IGA (Investigator's Global Assessment) is four. The medical chart note documents that she was not treated for 1.5 years and is currently looking for a new job, so cannot do phototherapy. She drinks alcohol and has a family history of hypertension. At that visit, she was prescribed tacrolimus, Eucrisa, halobetasol and Dupixent.", "The patient has severe atopic dermatitis affecting multiple areas of the body, including the hands and ears. She is a candidate for systemic therapy, as the BSA (body surface area) is too large for reasonable control with topical medications."], "answer_start": [2532, 3186, 0, 29, 192, 766]}, "context": "Diagnosis: Atopic dermatitis\nTreatment: Dupixent Syn 300\nThe insurer denied the Dupixent Syn 300. \nThe denial is overturned.\n\nYes, the treatment with Dupixent Syn 300 is medically necessary.\n\nThe patient is a female with a history of moderate to severe atopic dermatitis (AD) since adolescence. She has failed topical therapy. She has severe fissuring of the hands and ears. Her EASI (Eczema Area and Severity Index) score is 18.7, and IGA (Investigator's Global Assessment) is four. The medical chart note documents that she was not treated for 1.5 years and is currently looking for a new job, so cannot do phototherapy. She drinks alcohol and has a family history of hypertension. At that visit, she was prescribed tacrolimus, Eucrisa, halobetasol and Dupixent.\n\nThe patient has severe atopic dermatitis affecting multiple areas of the body, including the hands and ears. She is a candidate for systemic therapy, as the BSA (body surface area) is too large for reasonable control with topical medications. Topical calcineurin inhibitors (tacrolimus) and topical steroids are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. \n\nDupilumab is a monoclonal antibody that inhibits IL-4 and IL-13 signaling by blocking the shared IL-4Ra and originally demonstrated efficacy in phase 2 clinical trials. In March 2017, it was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 mg and then every two weeks thereafter.\n\nApproval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of 0 or 1 (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001).\n\nGiven its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD. The patient has failed topical steroids, calcineurin inhibitors, and systemic steroids. Additionally, topical calcineurin inhibitors are not indicated for severe disease.\n\nPhototherapy is not appropriate for sensitive areas and impossible to obtain during the COVID-19 pandemic. Cyclosporine, azathioprine, methotrexate, mycophenolate mofetil  are not FDA-approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. The patient is not a candidate for conventional systemic therapy (methotrexate, azathioprine, mycophenolate) due to her gender and childbearing age. Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.\n\n", "id": "460c2ee9a49d4c71ae566b1180f9f542", "question": "What is the background context in this case summary?", "title": "460c2ee9a49d4c71ae566b1180f9f542", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Malocclusion", "Treatment: Braces and monthly visits", "The insurer is denied coverage for the braces (D8080) and monthly visits (D8670).", "the patient exhibited a malocclusion.", "this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the HLD index attaining 11 total points to support orthodontic care."], "answer_start": [0, 25, 63, 734, 413]}, "context": "Diagnosis: Malocclusion\n\nTreatment: Braces and monthly visits\n\nThe insurer is denied coverage for the braces (D8080) and monthly visits (D8670). \n\nThe denial is upheld. \n\nThe patient was a male child. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the HLD index attaining 11 total points to support orthodontic care.  \n\nIt is evident that the patient exhibited a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.\n\nIn this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 11 points to justify for this patient's orthodontic care.  This reviewer concurs with the index completed by this patient's orthodontist attaining a total of 11 points on the HLD index (1 points overjet, 1 points overbite, 5 points anterior crowding, 4 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Since this patient's HLD index total score was 11, which was below the threshold of 26 points to justify for orthodontic care, the braces and the monthly visits associated with braces are not medically necessary for this patient.\n\nThe health plan acted reasonably with sound medical judgment, and in the best interest of the patient. \n\nThe carrier's denial of coverage for the braces (D8080) and monthly visits (D8670) should be upheld.  The medical necessity is not substantiated.\n", "id": "266e607f72a84eb5a27f1cea1126d9b3", "question": "What is the background context in this case summary?", "title": "266e607f72a84eb5a27f1cea1126d9b3", "sufficiency_score": 4}
+{"answers": {"text": ["The patient who has been diagnosed with type 1 diabetes since the age of 10 years.  The patient has been treated with multiple daily insulin injections.", "This patient has been diagnosed with type 1 diabetes, and control has been excellent; however, she has developed lipoatrophy associated with multiple daily insulin injections, so the patient is on inhaled insulin to minimize the number of injections that are medically necessary and reasonable, as the patient had developed lipohypertrophy from insulin injections, which ultimately led to lipoatrophy.", "Diagnosis:  Endocrine/Metabolic - Diabetes.", "Treatment:  Pharmacy Prescription drugs.", "The insurer denied medication Afrezza."], "answer_start": [156, 965, 0, 45, 88]}, "context": "Diagnosis:  Endocrine/Metabolic - Diabetes. \nTreatment:  Pharmacy Prescription drugs.  \nThe insurer denied medication Afrezza.  The denial is overturned.\n\n\nThe patient who has been diagnosed with type 1 diabetes since the age of 10 years.  The patient has been treated with multiple daily insulin injections.\n\nThe requested health service treatment of Afrezza is medically necessary for this patient.  Glycemic control is fundamental to the management of diabetes.  The Diabetes Control & Complications Trial (DCCT) study showed definitively that improved glycemic control is associated with significantly decreased rates of microvascular (retinopathy and nephropathy) and neuropathic complications.  As intensive diabetes management is associated with significantly decreased rates of microvascular and neuropathic complications, target HbA1C should be < 7% and achievement of HbA1C < 6.5%, if achieved safely without significant hypoglycemia, may be acceptable.\n\nThis patient has been diagnosed with type 1 diabetes, and control has been excellent; however, she has developed lipoatrophy associated with multiple daily insulin injections, so the patient is on inhaled insulin to minimize the number of injections that are medically necessary and reasonable, as the patient had developed lipohypertrophy from insulin injections, which ultimately led to lipoatrophy.", "id": "58a6360c84254fa8bdcf04f6813a2e2c", "question": "What is the background context in this case summary?", "title": "58a6360c84254fa8bdcf04f6813a2e2c", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with a history of polysubstance abuse. She was admitted to the medical floor from detox for alcohol withdrawal after wanting to sign out AMA (against medical advice).", "The patient's VS (vital signs) were as follows: 97.9, 77, 18, 148/92, 96%. Her exam was unremarkable. She exhibited no signs of DTs (delirium tremens). She had no neurologic deficit. CBC (complete blood count) and BMP (basic metabolic panel) was unremarkable. EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Head CT showed NAD (no active disease). The plan was for management with Librium tapering dose. The patient had no capacity per Psych evaluation. The patient was placed on one-to-one for elopement risk per psych. The plan was for consult psych for reevaluation. The patient's alcohol withdrawal resolved. She was cleared for discharge.", "Diagnosis: Alcohol withdrawal; history of polysubstance abuse", "Treatment: Inpatient admission", "The insurer denied the inpatient admission.", "This patient was admitted for management of alcohol withdrawal and discharged. The patient was hemodynamically stable and afebrile.", "The plan was for management with Librium taper. The patient was clinically stable and did not have findings of alcohol withdrawal."], "answer_start": [161, 355, 0, 62, 93, 1013, 1268]}, "context": "Diagnosis: Alcohol withdrawal; history of polysubstance abuse\nTreatment: Inpatient admission\nThe insurer denied the inpatient admission.\nThe denial is upheld. \n\nThe patient is a female with a history of polysubstance abuse. She was admitted to the medical floor from detox for alcohol withdrawal after wanting to sign out AMA (against medical advice).  \n\nThe patient's VS (vital signs) were as follows: 97.9, 77, 18, 148/92, 96%. Her exam was unremarkable. She exhibited no signs of DTs (delirium tremens). She had no neurologic deficit. CBC (complete blood count) and BMP (basic metabolic panel) was unremarkable. EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Head CT showed NAD (no active disease). The plan was for management with Librium tapering dose. The patient had no capacity per Psych evaluation. The patient was placed on one-to-one for elopement risk per psych. The plan was for consult psych for reevaluation. The patient's alcohol withdrawal resolved. She was cleared for discharge. \n\nThis patient was admitted for management of alcohol withdrawal and discharged. The patient was hemodynamically stable and afebrile. She did not have tachycardia. She did not have persistent vomiting. She did not have gross tremor. Labs were unremarkable. The plan was for management with Librium taper. The patient was clinically stable and did not have findings of alcohol withdrawal. She did not have symptoms that required an acute inpatient level of care. The requested inpatient admission was not medically necessary.", "id": "d2b47bf85116416da70d03dfa9685181", "question": "What is the background context in this case summary?", "title": "d2b47bf85116416da70d03dfa9685181", "sufficiency_score": 4}
+{"answers": {"text": ["the patient exhibited endodontic therapy on #30 completed in Russia.  Based on these clinical findings, the dentist recommended core buildup on this tooth, presumably prior to crown placement. The insurer has denied this service stating that the quality of the endodontic therapy, i.e. poor quality obturation and fill, does not support these treatments.  The treating dentist states that the \"cement\" used as a filling material does not negatively affect long term tooth retention/health.", "The existing restoration placed on this endodontically treated tooth appears to be failing.", "Diagnosis: Dental issue", "Treatment: Dental core buildup on tooth #30", "The insurer denied coverage for D2950, (core buildup, including pins) on tooth #30", "This is a female patient who was seen for evaluation of dental issues.  The treating dentist is requesting authorization for D2950 (core build up, including pins) for tooth #30."], "answer_start": [406, 897, 0, 25, 70, 181]}, "context": "Diagnosis: Dental issue\n\nTreatment: Dental core buildup on tooth #30\n\nThe insurer denied coverage for D2950, (core buildup, including pins) on tooth #30\n\nThe denial is overturned.\n\nThis is a female patient who was seen for evaluation of dental issues.  The treating dentist is requesting authorization for D2950 (core build up, including pins) for tooth #30.  \n\nUpon review of the submitted documentation, the patient exhibited endodontic therapy on #30 completed in Russia.  Based on these clinical findings, the dentist recommended core buildup on this tooth, presumably prior to crown placement. The insurer has denied this service stating that the quality of the endodontic therapy, i.e. poor quality obturation and fill, does not support these treatments.  The treating dentist states that the \"cement\" used as a filling material does not negatively affect long term tooth retention/health.\n\nThe existing restoration placed on this endodontically treated tooth appears to be failing. Given this clinical circumstance, core buildup and placement of full coverage crown is indicated and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice. As such the service noted above, which is a covered service for this individual, is deemed medically necessary.\n\nThe health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. \n\nThe carrier's denial of coverage for D2950 (build-up) on tooth #30 is overturned.  The medical necessity is substantiated.\n", "id": "6859f68efdc34aa6973cec246c3c88e6", "question": "What is the background context in this case summary?", "title": "6859f68efdc34aa6973cec246c3c88e6", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Cellulitis, Abscess", "Treatment: Inpatient admission", "The insurer denied the inpatient admission.", "This is female patient with immunocompromised status and a past medical history significant for substance abuse and depression. The patient presented to the Emergency Department (ED) with complaints of right ankle swelling and erythema.  The patient's vital signs on presentation were: temperature 98.2 F, blood pressure 147/76, pulse 86, respiratory rate 20, and oxygen (O2) sat-99% on room air. The patient's laboratory results included the following: white blood cell (WBC)-11.4, hemoglobin-11.6, hematocrit-36.3, creatinine-0.91, glucose-167, ESR-69, CRP-1.1, and urine toxicology positive for cocaine and opiates. The patient was admitted to the hospital for cellulitis/abscess of the right ankle; she received intravenous (IV) antibiotics. Surgery was consulted and an incision and drainage (I&D) was performed. The patient's wound culture grew methicillin-resistant staphylococcus aureus (MRSA). The patient refused magnetic resonance imaging (MRI). The patient received wound care. The patient had an episode of hypotension prior to signing out against medical advice (AMA).", "the patient presented with a right ankle abscess. The patient's laboratory results showed elevated white blood cell (WBC) count, anemia, and increased ESR. The patient's urine toxicology was positive for substance abuse."], "answer_start": [0, 31, 62, 134, 1249]}, "context": "Diagnosis: Cellulitis, Abscess\nTreatment: Inpatient admission\nThe insurer denied the inpatient admission.\nThe denial was overturned.\n\nThis is female patient with immunocompromised status and a past medical history significant for substance abuse and depression. The patient presented to the Emergency Department (ED) with complaints of right ankle swelling and erythema.  The patient's vital signs on presentation were: temperature 98.2 F, blood pressure 147/76, pulse 86, respiratory rate 20, and oxygen (O2) sat-99% on room air. The patient's laboratory results included the following: white blood cell (WBC)-11.4, hemoglobin-11.6, hematocrit-36.3, creatinine-0.91, glucose-167, ESR-69, CRP-1.1, and urine toxicology positive for cocaine and opiates. The patient was admitted to the hospital for cellulitis/abscess of the right ankle; she received intravenous (IV) antibiotics. Surgery was consulted and an incision and drainage (I&D) was performed. The patient's wound culture grew methicillin-resistant staphylococcus aureus (MRSA). The patient refused magnetic resonance imaging (MRI). The patient received wound care. The patient had an episode of hypotension prior to signing out against medical advice (AMA).  \n\nAccording to medical record, the patient presented with a right ankle abscess. The patient's laboratory results showed elevated white blood cell (WBC) count, anemia, and increased ESR. The patient's urine toxicology was positive for substance abuse. Based on these clinical findings in a high-risk patient with immunocompromised status, inpatient admission was medically necessary for administration of intravenous antibiotics and surgical intervention.    \n\nThe health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.\n\nBased on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is overturned.", "id": "494803d560134cab8f55bb7f9be7e9ba", "question": "What is the background context in this case summary?", "title": "494803d560134cab8f55bb7f9be7e9ba", "sufficiency_score": 4}
+{"answers": {"text": ["This patient is a female diagnosed with both celiac disease and intestinal metaplasia in the gastric antrum on biopsies performed during endoscopy a few years ago. The patient had been on a strict gluten-free diet and her symptoms have improved. ", "Diagnosis: Celiac disease and intestinal metaplasia", "Treatment: 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple)", "The insurer denied coverage for 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple)."], "answer_start": [273, 0, 53, 140]}, "context": "Diagnosis: Celiac disease and intestinal metaplasia \nTreatment: 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) \n\nThe insurer denied coverage for 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple). The denial is reversed. \n\nThis patient is a female diagnosed with both celiac disease and intestinal metaplasia in the gastric antrum on biopsies performed during endoscopy a few years ago. The patient had been on a strict gluten-free diet and her symptoms have improved. \n\nAccording to UptoDate article on gastric intestinal metaplasia, endoscopic surveillance with gastric biopsies is advised for this patient. Literature evidence suggests that surveillance may lead to early detection of gastric cancer and improved survival. However, the optimal surveillance interval has not been fully determined. UpToDate article on \"Management of celiac disease in adult\" states that the consensus is that re-biopsy should be undertaken after commencing a gluten-free diet to confirm a satisfactory response to the diet. \n\nThis patient had two conditions which required careful follow up. Both intestinal metaplasia and celiac disease diagnoses increase this patient's risk for malignancy, and a close follow-up with endoscopic monitoring was medically necessary. \n\nThus, esophagogastroduodenoscopy (EGD) with biopsy was medically necessary to properly monitor and treat this patient's medical condition. \n\nThe health did not act reasonably with sound medical judgment, and in the best interest of the patient. \n\nThe carrier's denial of coverage for procedure Code 4323 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) is reversed. The medical necessity is substantiated.", "id": "d73b605592204dab8ba094811156765a", "question": "What is the background context in this case summary?", "title": "d73b605592204dab8ba094811156765a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with a history of chronic deep vein thrombosis.  The patient is stated to be refractory to Eliquis and Xarelto.  The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin.  Pradaxa has been recommended and is under review.", "Diagnosis:  Blood Disorder.\nTreatment:  Pharmacy/Prescription Drugs (Pradaxa).", "The insurer denied the Pradaxa.", "The patient has failed the formulary drugs Eliquis and Xarelto"], "answer_start": [145, 0, 80, 482]}, "context": "Diagnosis:  Blood Disorder.\nTreatment:  Pharmacy/Prescription Drugs (Pradaxa).\n\nThe insurer denied the Pradaxa.  The denial is upheld in whole.\n\nThe patient is a male with a history of chronic deep vein thrombosis.  The patient is stated to be refractory to Eliquis and Xarelto.  The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin.  Pradaxa has been recommended and is under review.\n\nThe health plan's determination is upheld. \n\nThe patient has failed the formulary drugs Eliquis and Xarelto, and, thus, they are not appropriate for this patient.  The formulary drug warfarin has similar clinical efficacy to the non-formulary Pradaxa and is not contraindicated in this clinical scenario.  A LexiDrugs interaction check states \"...Acetaminophen may enhance the anticoagulant effect of Vitamin K Antagonists.  This appears most likely with daily acetaminophen doses exceeding 1.3 or 2 grams per day (g/day) for multiple consecutive days....  Monitor for increased therapeutic effects of anticoagulants if acetaminophen is initiated/dose increased, or decreased effects, if acetaminophen is discontinued/dose decreased....  Use for more than 3 consecutive days may warrant additional international normalized ratio (INR) testing....\".\n\nTherefore, if this patient is intensively monitored, there is likely minimal risk to the use of warfarin with his current medical regimen.", "id": "5b447f01a8c8456f928fac5576a9daeb", "question": "What is the background context in this case summary?", "title": "5b447f01a8c8456f928fac5576a9daeb", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female who was born following a premature birth at over 30 weeks gestation.  The patient's history was significant for Pierre-Robin syndrome, seizures, developmental delay, scoliosis, dysphagia and chronic aspiration from sialorrhea. The patient had chronic lung disease and required Bilevel Positive Airway Pressure (BIPAP) when sleeping and had episodes of low oxygen saturations. The patient was treated with cough assist and Vest daily.  The patient had been treated with hypertonic saline, albuterol and Pulmozyme which the patient had been receiving twice a day for. The medical record indicates that this patient was at risk of prolonged hospitalizations prior to starting Pulmozyme and based on the impression of the patient's mother and the treating physician, the patient's respiratory condition improved on Pulmozyme.  The patient's mother indicated that the patient had clinically worsened since this patient's Pulmozyme was discontinued coverage by her insurance. The patient had been requiring additional chest physical therapy because of increased chest congestion and episodes of oxygen desaturation. The patient was seen and was not seen for a visit again until several months after.  The medical record notes that the patient had not required any Emergency Room (ER) visits or hospitalizations and she had only a few upper respiratory infection (URI) illnesses in the winter. The patient only required one course of antibiotics and treatment with 3 liters of oxygen on one occasion.", "Diagnosis: Chronic lung disease", "Treatment: Pulmozyme", "The insurer is denied coverage for Pulmozyme.", "The patient had a complicated history of chronic lung disease and aspiration pneumonia and required airway clearance treatments on a daily basis.", "this patient had been stable over several months with no hospitalizations or Emergency Room (ER) visits."], "answer_start": [126, 0, 33, 55, 1757, 2230]}, "context": "Diagnosis: Chronic lung disease\n\nTreatment: Pulmozyme\n\nThe insurer is denied coverage for Pulmozyme. The denial is upheld.  \n\nThe patient is a female who was born following a premature birth at over 30 weeks gestation.  The patient's history was significant for Pierre-Robin syndrome, seizures, developmental delay, scoliosis, dysphagia and chronic aspiration from sialorrhea. The patient had chronic lung disease and required Bilevel Positive Airway Pressure (BIPAP) when sleeping and had episodes of low oxygen saturations. The patient was treated with cough assist and Vest daily.  The patient had been treated with hypertonic saline, albuterol and Pulmozyme which the patient had been receiving twice a day for. The medical record indicates that this patient was at risk of prolonged hospitalizations prior to starting Pulmozyme and based on the impression of the patient's mother and the treating physician, the patient's respiratory condition improved on Pulmozyme.  The patient's mother indicated that the patient had clinically worsened since this patient's Pulmozyme was discontinued coverage by her insurance. The patient had been requiring additional chest physical therapy because of increased chest congestion and episodes of oxygen desaturation. The patient was seen and was not seen for a visit again until several months after.  The medical record notes that the patient had not required any Emergency Room (ER) visits or hospitalizations and she had only a few upper respiratory infection (URI) illnesses in the winter. The patient only required one course of antibiotics and treatment with 3 liters of oxygen on one occasion. \n\nBased on the review of the medical record and literature, Pulmozyme (dornase alfa) is not medically necessary. The patient had a complicated history of chronic lung disease and aspiration pneumonia and required airway clearance treatments on a daily basis.  There was no indication that the patient produced purulent sputum or had chronic bacterial lung infection.  There had not been a computed tomography (CT) scan or chest x-ray to document the presence of atelectasis or bronchiectasis.  The patient had not required a bronchoscopy.  In addition the medical record indicates that this patient had been stable over several months with no hospitalizations or Emergency Room (ER) visits.  The medical history does not support the need for ongoing daily therapy with Pulmozyme twice daily (BID) at home.  It is not the standard of care to prescribe Pulmozyme for lung disease related to chronic aspiration in the absence of persistent bacterial bronchitis, bronchiectasis and purulent sputum. \n\nThe health plan acted reasonably with sound medical judgment, and in the best interest of the patient.\n\nThe carrier's denial of coverage for Pulmozyme should be upheld.  The medical necessity is not substantiated.", "id": "5150330c849b4c6e9954f1ad62b4fe3e", "question": "What is the background context in this case summary?", "title": "5150330c849b4c6e9954f1ad62b4fe3e", "sufficiency_score": 4}
+{"answers": {"text": ["This patient with a past medical history of polysubstance use with alcohol, heroin, marijuana, and benzodiazepines, also on suboxone with last use several days prior, in addition to anxiety,  presented to the emergency department  with alcohol withdrawal after being evicted from friend's house. On presentation to the emergency department, patient was afebrile with blood pressure 135/96, heart rate 67, respiratory rate 18, sat 97% on room air. Exam otherwise noted dilated pupils. Labs showed white blood cell count (WBC) 8.16, Hemoglobin (HGB) 13, Platelets 304, sodium 147, potassium 4, blood urea nitrogen (BUN) 10, creatinine 0.8, aspartate aminotransferase (AST) 43, alanine aminotransferase (ALT) 31, and alcohol level of 281.3. Urine drug screen was positive for tetrahydrocannabinol (THC). Clinical Institute Withdrawal Assessment (CIWA) score was 9 in the emergency department. Patient was seen by psychiatry in the emergency department, given an initial report of suicidal and homicidal ideation and was cleared for discharge. The patient was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, folic acid, and laboratory monitoring. 2 days after presentation the patient was noted to have a CIWA score of 15.  was alert and oriented. The patient wanted to leave and was deemed to have capacity to leave against medical advice.", "This patient presented with mild alcohol withdrawal with a CIWA of 9", "It is noted", "that the patient remained alert and oriented throughout  hospitalization without ongoing nausea, vomiting, or inability to take oral medications. The maximum CIWA score was 15. Though ongoing observation was recommended on the last day, the patient wanted to leave and was deemed to have the capacity to leave against medical advice."], "answer_start": [41, 1577, 1962, 1984]}, "context": "Substance Abuse\nInpatient Hospital Stay\n\nThis patient with a past medical history of polysubstance use with alcohol, heroin, marijuana, and benzodiazepines, also on suboxone with last use several days prior, in addition to anxiety,  presented to the emergency department  with alcohol withdrawal after being evicted from friend's house. On presentation to the emergency department, patient was afebrile with blood pressure 135/96, heart rate 67, respiratory rate 18, sat 97% on room air. Exam otherwise noted dilated pupils. Labs showed white blood cell count (WBC) 8.16, Hemoglobin (HGB) 13, Platelets 304, sodium 147, potassium 4, blood urea nitrogen (BUN) 10, creatinine 0.8, aspartate aminotransferase (AST) 43, alanine aminotransferase (ALT) 31, and alcohol level of 281.3. Urine drug screen was positive for tetrahydrocannabinol (THC). Clinical Institute Withdrawal Assessment (CIWA) score was 9 in the emergency department. Patient was seen by psychiatry in the emergency department, given an initial report of suicidal and homicidal ideation and was cleared for discharge. The patient was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, folic acid, and laboratory monitoring. 2 days after presentation the patient was noted to have a CIWA score of 15.  was alert and oriented. The patient wanted to leave and was deemed to have capacity to leave against medical advice. The health plan's determination of medical necessity is upheld in whole. The inpatient stay was not medically necessary. This patient presented with mild alcohol withdrawal with a CIWA of 9 in the setting of no known prior history of seizures or delirium tremens during withdrawal. It was reasonable to observe the patient on the medical unit at a lower level of care with CIWA protocol, IV fluids, thiamine and folate, and observation for the development of new symptoms such as changes in mental status. It is noted, however, that the patient remained alert and oriented throughout  hospitalization without ongoing nausea, vomiting, or inability to take oral medications. The maximum CIWA score was 15. Though ongoing observation was recommended on the last day, the patient wanted to leave and was deemed to have the capacity to leave against medical advice. It is unclear why this patient with concerns for mild alcohol withdrawal, CIWA scores of 9-15 with a normal mental status, no reports of ongoing nausea or vomiting, and without any other concurrent medical issue, required care at the inpatient level of care and could not have been safely treated at a lower level.", "id": "d5f1e521aff14f0e90118605ab860c73", "question": "What is the background context in this case summary?", "title": "d5f1e521aff14f0e90118605ab860c73", "sufficiency_score": 4}
+{"answers": {"text": ["This is the case of a child who presented to the emergency department (ED) with a 2 day history of abdominal pain. The location of pain was right lower quadrant (RLQ), and additional symptoms included anorexia. There was no fever, cough, sore throat, or vomiting. The patient was seen by the primary care physician (or provider) (PCP) who gave Zofran and sent her to the ED for further evaluation. ", "Diagnosis: Abdominal Pain.", "Treatment: Inpatient stay.", "The insurer denied the inpatient stay.", "This patient was brought to the ED for evaluation of abdominal pain. There was initial concern for appendicitis", "The patient's condition improved while in the ED and vital signs remained stable. He was admitted to the inpatient unit for overnight observation and re-evaluation. He was discharged home the following day."], "answer_start": [199, 58, 86, 115, 658, 810]}, "context": "Digestive System/Gastrointestinal. \nInpatient Hospital. \n\nDiagnosis: Abdominal Pain. \nTreatment: Inpatient stay. \n\nThe insurer denied the inpatient stay. The health plan's determination is upheld. \n\nThis is the case of a child who presented to the emergency department (ED) with a 2 day history of abdominal pain. The location of pain was right lower quadrant (RLQ), and additional symptoms included anorexia. There was no fever, cough, sore throat, or vomiting. The patient was seen by the primary care physician (or provider) (PCP) who gave Zofran and sent her to the ED for further evaluation. \n\nThe inpatient hospitalization was not medically necessary. This patient was brought to the ED for evaluation of abdominal pain. There was initial concern for appendicitis, but the ED work-up was non diagnostic. The patient's condition improved while in the ED and vital signs remained stable. He was admitted to the inpatient unit for overnight observation and re-evaluation. He was discharged home the following day. His care was appropriate for a lower level. The inpatient level of care was not medically necessary.", "id": "0568b517ac54448a821717fd02aa4605", "question": "What is the background context in this case summary?", "title": "0568b517ac54448a821717fd02aa4605", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Deep Vein Thrombosis", "Treatment: Inpatient admission", "The insurer is denied coverage for inpatient admission.", "This patient with a history of CAD, prior MI, CVA was found to have a pulmonary embolus with lower extremity thrombus.", "This is a male patient with a medical history of coronary artery disease (CAD), hyperlipidemia, hypertension, prior myocardial infarction (MI) and cardiovascular accident (CVA), depression, pneumonia, and bilateral lower extremity weakness. The patient presented to the Emergency Department (ED) with complaints of chest pain and leg pain. The patient described the chest pain as left-sided, sharp, stabbing, worse with smoking cigarettes, worse with cough and worse with exertion. These episodes were reported to be intermittent and last several hours at a time. The patient denied shortness of breath, lightheadedness, dizziness, headache and abdominal pain. The patient's echocardiogram was done that showed normal left ventricular ejection fraction (LVEF). The patient reported previous neuropathic leg pain; he ran out of gabapentin last week. The patient's presenting vital signs were: blood pressure (BP) 152/87, pulse 51, temperature 97.8, respirations 20, oxygen saturation 99% and BMI 34.99. The patient's physical exam noted bilateral lower extremity swelling the left being greater than the right. The patient's laboratory results included sodium 140, potassium 5.0, BUN 10, and creatinine 0.8, an initial troponin was less than 0.012. The patient's electrocardiogram (EKG) revealed sinus bradycardia at a heart rate of 49 bpm. There was left anterior fascicular block and there was asymmetrical T-wave inversion in leads III, AVF, V3-V6. These were non-specific repolarization changes. The patient's chest x-ray showed fibrosis at both lung bases. There was no acute pulmonary disease and no change when compared with imaging done. The patient was found to have an acute venous thrombosis of the left bilateral lower extremities. At the time of discharge, the patient was advised to make outpatient appointments with his primary care provider, cardiology and hematology."], "answer_start": [0, 32, 63, 2031, 146]}, "context": "Diagnosis: Deep Vein Thrombosis\nTreatment: Inpatient admission\nThe insurer is denied coverage for inpatient admission.\nThe denial is overturned. \nThis is a male patient with a medical history of coronary artery disease (CAD), hyperlipidemia, hypertension, prior myocardial infarction (MI) and cardiovascular accident (CVA), depression, pneumonia, and bilateral lower extremity weakness. The patient presented to the Emergency Department (ED) with complaints of chest pain and leg pain. The patient described the chest pain as left-sided, sharp, stabbing, worse with smoking cigarettes, worse with cough and worse with exertion. These episodes were reported to be intermittent and last several hours at a time. The patient denied shortness of breath, lightheadedness, dizziness, headache and abdominal pain. The patient's echocardiogram was done that showed normal left ventricular ejection fraction (LVEF). The patient reported previous neuropathic leg pain; he ran out of gabapentin last week. The patient's presenting vital signs were: blood pressure (BP) 152/87, pulse 51, temperature 97.8, respirations 20, oxygen saturation 99% and BMI 34.99. The patient's physical exam noted bilateral lower extremity swelling the left being greater than the right. The patient's laboratory results included sodium 140, potassium 5.0, BUN 10, and creatinine 0.8, an initial troponin was less than 0.012. The patient's electrocardiogram (EKG) revealed sinus bradycardia at a heart rate of 49 bpm. There was left anterior fascicular block and there was asymmetrical T-wave inversion in leads III, AVF, V3-V6. These were non-specific repolarization changes. The patient's chest x-ray showed fibrosis at both lung bases. There was no acute pulmonary disease and no change when compared with imaging done. The patient was found to have an acute venous thrombosis of the left bilateral lower extremities. At the time of discharge, the patient was advised to make outpatient appointments with his primary care provider, cardiology and hematology.\n\nThis patient with a history of CAD, prior MI, CVA was found to have a pulmonary embolus with lower extremity thrombus. The multiple comorbid conditions along with the presence of PE and lower extremity thrombus argue against outpatient management. Thus, as discussed in Up to Date, while out patient anticoagulation can be used for PE, this assumes carefully selected patients. Most patients are still initially admitted as an inpatient for several days followed by long term outpatient anticoagulation.\n\nThe health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.\n\nBased on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.\n\n", "id": "68623a1e96bb45b29549fb882baf83fb", "question": "What is the background context in this case summary?", "title": "68623a1e96bb45b29549fb882baf83fb", "sufficiency_score": 4}
+{"answers": {"text": ["This patient is a female with a past medical history of asthma, diabetes mellitus, hypertension, and noncompliance with medication for seizure disorder.  The patient was brought to the Emergency Department by the Emergency Medical Services (EMS) with subjective complaints of severe headache, vomiting times approximately 1 hour, and the patient was noted to have left-sided facial droop on EMS arrival.  On arrival at the Emergency Department, the patient was awake and alert and continues to complain of a headache.  The patient stated she had urinated on herself and did not have neck pain or back pain.  The patient denied a fever.  The patient's blood pressure was 167/81 and her heart rate was 95.  The patient underwent imaging studies, which showed no acute pathology.  The patient had an active seizure in the Emergency Department and was treated with Ativan for the seizure.  She also received Keppra while in the Emergency Department.  A stroke was ruled out.  The patient was admitted to the general medical floor with a diagnosis of a breakthrough seizure.  The patient underwent a neurology consultation.  The patient was given a scheduled dose of Keppra and intravenous fluids, along with proton pump inhibitors and antiemetics.  The patient requested and was discharged in stable condition.", "Diagnosis: Breakthrough seizure", "Treatment: Inpatient admission", "The insurer denied coverage for inpatient admission."], "answer_start": [144, 0, 34, 66]}, "context": "Diagnosis: Breakthrough seizure\n \nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission.  The denial is upheld. \n\nThis patient is a female with a past medical history of asthma, diabetes mellitus, hypertension, and noncompliance with medication for seizure disorder.  The patient was brought to the Emergency Department by the Emergency Medical Services (EMS) with subjective complaints of severe headache, vomiting times approximately 1 hour, and the patient was noted to have left-sided facial droop on EMS arrival.  On arrival at the Emergency Department, the patient was awake and alert and continues to complain of a headache.  The patient stated she had urinated on herself and did not have neck pain or back pain.  The patient denied a fever.  The patient's blood pressure was 167/81 and her heart rate was 95.  The patient underwent imaging studies, which showed no acute pathology.  The patient had an active seizure in the Emergency Department and was treated with Ativan for the seizure.  She also received Keppra while in the Emergency Department.  A stroke was ruled out.  The patient was admitted to the general medical floor with a diagnosis of a breakthrough seizure.  The patient underwent a neurology consultation.  The patient was given a scheduled dose of Keppra and intravenous fluids, along with proton pump inhibitors and antiemetics.  The patient requested and was discharged in stable condition.\n\nBased on MCG guidelines for Seizure, patient meets the criteria for observation care. Patient has an elevated lactate level of 2.3 and requires medication initiation.  Due to the patient's poor social condition (i.e. living in the shelter), medication should be monitored and adjusted with closing monitoring.  While the patient meets the criteria for observation status, patient does not meet the MCG guideline clinical criteria for inpatient admission.  The patient did not have hemodynamic instability or status epilepticus. Whether the patient's focal neurologic deficit (i.e. left facial droop) is new or not is questionable since the patient reported having residual left sided weakness from a stroke several years ago.  The patient's CT of the head and neck ruled out brain disorder or intracranial pathology. \n\nThe patient was discharged within 24 hours of being started on scheduled doses of Keppra, which could have been done at the observation setting.  Thus, based on the medical records provided and MCG guideline review, inpatient admission was not medically necessary to treat this patient's medical condition. \n\nThe health care plan acted reasonably and with sound medical judgment, and in the best interest of the patient.\n\nThe carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.\n", "id": "f6d419b64c524af29e99c409f7c80ea5", "question": "What is the background context in this case summary?", "title": "f6d419b64c524af29e99c409f7c80ea5", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Hyperkalemia", "Treatment: Inpatient hospital admission", "The insurer denied coverage for inpatient hospital admission.", "This patient is a woman who had a history of Addison's disease, hyperprolactinemia, pituitary adenoma, anti-phospholipid antibody syndrome with a history of deep vein thrombosis (DVT) and pulmonary embolus, diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease with stent several years ago and depression. She was sent to the Emergency Department (ED) by her Hematologist for a potassium level of 6.2 on laboratory testing; the patient was asymptomatic. Initial vital signs including a blood pressure of 98/69, a heart rate of 77, a temperature 97.4F, a respiratory rate of 18, and an oxygen saturation on room air of 98%. An EKG revealed peaked T waves, but was otherwise unremarkable. Laboratory test results included a white blood cell (WBC) count of 8.0, a hemoglobin of 10.9, a creatinine of 1.2, a glucose of 213, a sodium of 136, a potassium of 6.2, a chloride of 110, a bicarbonate of 16, and a troponin <0.012. She was treated with Kayexalate, intravenous fluids, calcium gluconate, and insulin and had an episode of nausea and vomiting while taking the Kayexalate.", "She was seen by a Hematologist who raised the issue of possible type 4 renal tubular acidosis and by an Endocrinology consultant who felt that medication compliance may have played a role. Psychiatry did not feel that she was actively depressed. She was discharged on stress doses of steroids tapered back to her maintenance doses of Florinef and hydrocortisone over a week, as well as on her other medications, which included aspirin, atorvastatin Linzess, Trulicity, bupropion, Cabergoline, Lexapro, Lantis, Novolog, metformin, metoprolol, Protonix and rivaroxaban."], "answer_start": [0, 26, 67, 153, 1250]}, "context": "Diagnosis: Hyperkalemia\n \nTreatment: Inpatient hospital admission\n\nThe insurer denied coverage for inpatient hospital admission. The denial is upheld. \n\nThis patient is a woman who had a history of Addison's disease, hyperprolactinemia, pituitary adenoma, anti-phospholipid antibody syndrome with a history of deep vein thrombosis (DVT) and pulmonary embolus, diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease with stent several years ago and depression. She was sent to the Emergency Department (ED) by her Hematologist for a potassium level of 6.2 on laboratory testing; the patient was asymptomatic. Initial vital signs including a blood pressure of 98/69, a heart rate of 77, a temperature 97.4F, a respiratory rate of 18, and an oxygen saturation on room air of 98%. An EKG revealed peaked T waves, but was otherwise unremarkable. Laboratory test results included a white blood cell (WBC) count of 8.0, a hemoglobin of 10.9, a creatinine of 1.2, a glucose of 213, a sodium of 136, a potassium of 6.2, a chloride of 110, a bicarbonate of 16, and a troponin <0.012. She was treated with Kayexalate, intravenous fluids, calcium gluconate, and insulin and had an episode of nausea and vomiting while taking the Kayexalate.  \n\nShe was seen by a Hematologist who raised the issue of possible type 4 renal tubular acidosis and by an Endocrinology consultant who felt that medication compliance may have played a role. Psychiatry did not feel that she was actively depressed. She was discharged on stress doses of steroids tapered back to her maintenance doses of Florinef and hydrocortisone over a week, as well as on her other medications, which included aspirin, atorvastatin Linzess, Trulicity, bupropion, Cabergoline, Lexapro, Lantis, Novolog, metformin, metoprolol, Protonix and rivaroxaban.\n\nThere is no evidence that this patient required an acute inpatient level of care to evaluate or treat her newly noted potassium level of 6.2, which was asymptomatic, with no evidence for conduction abnormalities or arrhythmias. In addition, she did not have conditions that could contribute to a continued acute rise in potassium levels such as worsening renal function, rhabdomyolysis or significant gastrointestinal bleeding. The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.\n\nThe denial of the inpatient hospital admission is upheld because there is no evidence that this patient was at risk for short term adverse cardiovascular events, based on her clinical presentation and results of testing and treatment performed in the Emergency Department.\n\nThe carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.\n", "id": "bf3109a156b0487085e40a5df78db624", "question": "What is the background context in this case summary?", "title": "bf3109a156b0487085e40a5df78db624", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient with a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, moderate overbite and moderate overjet. The proposed treatment is braces."], "answer_start": [0]}, "context": "This is a patient with a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, moderate overbite and moderate overjet. The proposed treatment is braces.\n\nThe health plan's detrmination is upheld.\nThe malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. Thus, braces are not medically necessary for this case.", "id": "928f32e5719546678b07e1463dc82fcc", "question": "What is the background context in this case summary?", "title": "928f32e5719546678b07e1463dc82fcc", "sufficiency_score": 3}
+{"answers": {"text": ["This patient is a female who presented to emergency department.  The patient had a past medical history of congenital severe communicating hydrocephalus, orthostatic hypotension.  The patient had a history of recurrent falls usually without loss of consciousness.  The patient had a temperature 99.2 with a heart rate of 114, respirations 16, oxygen saturation 98% and blood pressure 120/78.  The patient complained of 4/10 pain to lower back and head.  The patient had a Glasgow coma scale score of 15.  The patient had a fall 1 hour prior to admission.  The patient denied any dizziness/lightheadedness prior to fall.  The patient stated that she woke up and was on the floor.  The patient complained of posterior head pain and lower back pain.  Examination showed right-sided temporal contusion.  There was bruising to left lower extremity.  The patient had a white blood cell count of 13, red blood cell count 4.14, hemoglobin 13, hematocrit 29.4, platelets 206.  CT the head revealed stable chronic severe communicate and hydrocephalus.  There was no shift of the midline structures, mass-effect, hemorrhage or other issues.  There was no evidence of acute infarction.  Chest x-ray was negative.  X-ray of the pelvis was negative.  An EEG showed no seizures.  The patient refused physical rehabilitation and was discharged.", "Diagnosis: Falls; congenital severe communicating hydrocephalus", "Treatment: Inpatient Admission", "The insurer denied coverage for Inpatient Admission.", "The documentation indicated that the patient did have a fall with a loss of consciousness.  There was no postictal state following the fall.  The patient had imaging studies that showed no evidence of significant findings.  A CAT scan showed no shift of midline structures, mass-effect or hemorrhage.  EEG showed no seizures."], "answer_start": [175, 0, 66, 98, 2324]}, "context": "Diagnosis: Falls; congenital severe communicating hydrocephalus\n \nTreatment: Inpatient Admission\n\nThe insurer denied coverage for Inpatient Admission. The denial was upheld.\n\nThis patient is a female who presented to emergency department.  The patient had a past medical history of congenital severe communicating hydrocephalus, orthostatic hypotension.  The patient had a history of recurrent falls usually without loss of consciousness.  The patient had a temperature 99.2 with a heart rate of 114, respirations 16, oxygen saturation 98% and blood pressure 120/78.  The patient complained of 4/10 pain to lower back and head.  The patient had a Glasgow coma scale score of 15.  The patient had a fall 1 hour prior to admission.  The patient denied any dizziness/lightheadedness prior to fall.  The patient stated that she woke up and was on the floor.  The patient complained of posterior head pain and lower back pain.  Examination showed right-sided temporal contusion.  There was bruising to left lower extremity.  The patient had a white blood cell count of 13, red blood cell count 4.14, hemoglobin 13, hematocrit 29.4, platelets 206.  CT the head revealed stable chronic severe communicate and hydrocephalus.  There was no shift of the midline structures, mass-effect, hemorrhage or other issues.  There was no evidence of acute infarction.  Chest x-ray was negative.  X-ray of the pelvis was negative.  An EEG showed no seizures.  The patient refused physical rehabilitation and was discharged.\nThe medical literature indicates that inpatient admission is indicated for patients with hemodynamic instability, altered mental status is severe persistent, diagnosis requiring inpatient admission, cardiac disease or finding that indicates necessity of immediate intervention, cardiac ischemia, sustained or symptomatic ventricular tachycardia, symptomatic conduction system disease, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response pacemaker malfunction, inheritable cardiovascular condition predisposing to arrhythmias diagnosed or suspected dehydration that is severe persistent, syncope causing injury requiring hospitalization or continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive or antiarrhythmic medication needed.  \nThe documentation indicated that the patient did have a fall with a loss of consciousness.  There was no postictal state following the fall.  The patient had imaging studies that showed no evidence of significant findings.  A CAT scan showed no shift of midline structures, mass-effect or hemorrhage.  EEG showed no seizures.  There was no evidence of hemodynamic instability, altered mental status that was severe persistent, diagnosis requiring inpatient admission, cardiac ischemia, sustained or symptom medic ventricular tachycardia, symptomatic conduction system disease, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response, pacemaker malfunction, dehydration that was severe persistent or syncope causing injury requiring hospitalization.  Therefore, the patient's condition was appropriate for level of observational care rather than inpatient level care.  As such, the inpatient admission was not medically necessary. \n\nBased on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.", "id": "93b4a906e8d44a939697646e055fe474", "question": "What is the background context in this case summary?", "title": "93b4a906e8d44a939697646e055fe474", "sufficiency_score": 4}
+{"answers": {"text": ["This is a patient who experienced a burn to the right thigh. 11 days after the initial burn, patient was found to have worsening superinfection after failure of outpatient antibiotic therapy. It was determined that the patient had a 2% total body surface area (TBSA) third degree burn. The patient was admitted for intravenous (IV) antibiotics, pain control, wound care, and plans for surgical debridement and likely skin grafting. Patient underwent tangential excision and split thickness skin graft to the thigh.", "The patient had a 3rd degree burn to 2% of his TBSA. This is a burn that started as partial thickness but progressed as an outpatient."], "answer_start": [31, 684]}, "context": "Burns\nInpatient hospital stay\n\nThis is a patient who experienced a burn to the right thigh. 11 days after the initial burn, patient was found to have worsening superinfection after failure of outpatient antibiotic therapy. It was determined that the patient had a 2% total body surface area (TBSA) third degree burn. The patient was admitted for intravenous (IV) antibiotics, pain control, wound care, and plans for surgical debridement and likely skin grafting. Patient underwent tangential excision and split thickness skin graft to the thigh. The health plan's determination of medical necessity is overturned in whole. The best interest of this patient is an inpatient admission. The patient had a 3rd degree burn to 2% of his TBSA. This is a burn that started as partial thickness but progressed as an outpatient. According to the International Society for Burn Injury guidelines, any third degree burn necessitates a transfer to a burn center. Besides meeting standard practices for medical necessity, this case also meets McKesson InterQual criteria for acute adult: burns. This case qualifies with 3rd degree burns with 2-5% TBSA and need for complex burn care.", "id": "0afd78a5227d4e5ba371b6e02dda4427", "question": "What is the background context in this case summary?", "title": "0afd78a5227d4e5ba371b6e02dda4427", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Muscle weakness, Normal pressure hydrocephalus, Peripheral arterial occlusive disease", "Treatment: Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week", "The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week.", "This is a female with a medical history of uncontrolled Type ll diabetes mellitus, aortic valve disorder, peripheral arterial occlusive disease, muscle weakness, congestive heart failure, sepsis, diabetic polyneuropathy, chronic obstructive lung disease, chronic kidney disease stage 3, cerebrovascular accident, anemia, migraine and normal pressure hydrocephalus. She has been receiving Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week. The patient requested an increase of CDPAS to 84 hours per week, which was denied by the insurer.", "Uniform Assessment System (UAS) documentation indicates that the patient is totally dependent for housekeeping tasks; needs maximal assistance for meal preparation and shopping; extensive assistance for stairs and medications. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing and limited assistance for all other ADLs, except bed mobility (setup help). The UAS indicates the patient's decision making for daily tasks is modified independence (some difficulty in new situations). The patient needs extensive assistance with finances and medications", "This patient has an extensive medical history associated with various symptoms causing decreased functional ability with daily activities", "The patient's daughter was able to provide assistance; however, the daughter is currently working and unable to continue providing informal care. The UAS identified a second informal caregiver. There is no current information on the availability of the other caregiver."], "answer_start": [0, 98, 219, 390, 951, 1879, 2258]}, "context": "Diagnosis: Muscle weakness, Normal pressure hydrocephalus, Peripheral arterial occlusive disease\n\nTreatment: Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week\n\nThe insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week.\n\nThe denial is overturned. \n\nThis is a female with a medical history of uncontrolled Type ll diabetes mellitus, aortic valve disorder, peripheral arterial occlusive disease, muscle weakness, congestive heart failure, sepsis, diabetic polyneuropathy, chronic obstructive lung disease, chronic kidney disease stage 3, cerebrovascular accident, anemia, migraine and normal pressure hydrocephalus. She has been receiving Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week. The patient requested an increase of CDPAS to 84 hours per week, which was denied by the insurer. \n\nUniform Assessment System (UAS) documentation indicates that the patient is totally dependent for housekeeping tasks; needs maximal assistance for meal preparation and shopping; extensive assistance for stairs and medications. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing and limited assistance for all other ADLs, except bed mobility (setup help). The UAS indicates the patient's decision making for daily tasks is modified independence (some difficulty in new situations). The patient needs extensive assistance with finances and medications, which can suggest some cognitive deficits. Overall, it does not appear that cognitive impairment is a major contributing factor to the patient's functional impairment with most daily tasks. The patient's physical limitations are most likely the primary cause of the patient's need for assistance with most daily activities.\n\nThis patient has an extensive medical history associated with various symptoms causing decreased functional ability with daily activities Considering the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance with household related tasks and ADLs. The patient's daughter was able to provide assistance; however, the daughter is currently working and unable to continue providing informal care. The UAS identified a second informal caregiver. There is no current information on the availability of the other caregiver. Considering the request for additional service is for 84 CDPAS hours per week, it is reasonable to conclude that there are no informal caregivers who can provide care for that amount of hours per week. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unavailable for personal care assistance on a regular basis, then personal care services are indicated to provide necessary assistance with daily activities as needed throughout the day. \n\nCDPAS 12 hours per day can adequately accommodate all instrumental activities of daily living (IADLs) and ADLs that are done on a routine basis each day.  However, the patient needs assistance with toileting, incontinence care and mobility around her home (transfers, walking). It is unclear how the patient will have assistance for these unscheduled activities when they occur at times when the aide is not present. It is not known whether there is a plan for informal caregivers to provide assistance when the aide is not present. Re-assessment will determine if further modification of the plan is needed to meet the patient's personal care needs.\n\nThe health plan did not act reasonably with sound medical judgement in the best interest of the patient.\n\nBased on the above, the medical necessity for CDPAS, 7 days per week, 12 hours per day; 84 hours per week is substantiated. The insurer's denial is overturned.", "id": "508e78df71804f2abbbb20f7f4d70335", "question": "What is the background context in this case summary?", "title": "508e78df71804f2abbbb20f7f4d70335", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is with a past medical history of hypertension, memory impairment, tremor, metastatic gastrointestinal stromal tumor with multiple recent hospitalizations for complications, hepatocellular carcinoma, hepatitis C, cirrhosis and biliary stricture. \n", "The patient has a complicated past medical history.", "The patient does not have an informal helper. The patient has had worsening memory as documented by MMSE assessment with increased weakness related to underlying medical issues with an increased need for assistance with ADL's and Instrumental Activities of Daily Living (IADLs) as documented in multiple provider letters and in the assessment tool as compared to previous assessment. The patient lives in an apartment on the 6th floor with no elevator and the bathroom is not in the apartment", "Multiple providers who care for the patient documented medical necessity to increase PCW service hours.", "Diagnosis: Gastrointestinal and Liver Cancer.", "Treatment: Home Health Care.", "The insurer denied the requested health service/treatment of Increase in Personal Care Worker hours."], "answer_start": [227, 637, 804, 1518, 0, 47, 77]}, "context": "Diagnosis: Gastrointestinal and Liver Cancer. \nTreatment: Home Health Care. \nThe insurer denied the requested health service/treatment of Increase in Personal Care Worker hours. \n\nThe health plan determination is overturned. \n\nThe patient is with a past medical history of hypertension, memory impairment, tremor, metastatic gastrointestinal stromal tumor with multiple recent hospitalizations for complications, hepatocellular carcinoma, hepatitis C, cirrhosis and biliary stricture. \n\nThe increase in personal care worker (PCW) service to 7 days per week, 12 hours per day, 84 hours per week is medically necessary for this patient. \n\nThe patient has a complicated past medical history. The PCW is medically necessary for helping the patient to transport and attend the medical appointments and tests. The patient does not have an informal helper. The patient has had worsening memory as documented by MMSE assessment with increased weakness related to underlying medical issues with an increased need for assistance with ADL's and Instrumental Activities of Daily Living (IADLs) as documented in multiple provider letters and in the assessment tool as compared to previous assessment. The patient lives in an apartment on the 6th floor with no elevator and the bathroom is not in the apartment, making her assistance needs for tasks of stairs, walking, locomotion, and toilet use higher than assessed. PCW service hours are not solely for supervision and safety but for assisting the patient with ADL's and IADL's. Multiple providers who care for the patient documented medical necessity to increase PCW service hours. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in the home, which is the case for this patient. \n", "id": "0b23b6ac89eb4a1892ee848eaa6957f4", "question": "What is the background context in this case summary?", "title": "0b23b6ac89eb4a1892ee848eaa6957f4", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with neck pain and migraine headaches that has previously\nhad cooled radiofrequency ablation (c-RFA) with near 100% relief for almost one\nyear.", "the patient has previously undergone this procedure with near 100% relief for about a year.", "Diagnosis:  Neck pain and migraines.", "Treatment:  Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.", "The insurer denied the Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.", "This patient has chronic low back pain with facet arthropathy.  The patient has had\ntwo diagnostic medial branch blocks and previously had radiofrequency ablation (RFA) with excellent results."], "answer_start": [270, 2524, 0, 37, 134, 2048]}, "context": "Diagnosis:  Neck pain and migraines.\nTreatment:  Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.\n\nThe insurer denied the Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.  The denial is overturned. \n\nThe patient is a female with neck pain and migraine headaches that has previously\nhad cooled radiofrequency ablation (c-RFA) with near 100% relief for almost one\nyear.\n\nYes, the proposed cooled radiofrequency neuroablation (64633-RT and 64634-RT) is medically necessary.\n\nThe requested cooled radiofrequency ablation (c-RFA) is medically necessary.  The procedure uses the same code as thermal radiofrequency ablation (t-RFA), often referred to as conventional radiofrequency ablation (RFA).  The temperature for cooled radiofrequency ablation (c-RFA) is above 60 degrees Celsius, which is often the temperature used in a thermal radiofrequency ablation (t-RFA).  Many of\nthe original articles on radiofrequency ablation (RFA) cite 60 degrees for ablation.  In addition, the tissue temperature has been shown to be 80 degrees.  Cooled radiofrequency ablation (c-RFA) is not to be confused with pulsed radiofrequency\nablation (RFA), where the temperature is below 42 degrees.  Neural ablation has\nbeen shown to occur at 42 degrees Celsius.  Therefore, any temperature about 42 is\na thermal lesion.  Studies have shown conventional radiofrequency ablation (c-RFA) to be as effective as thermal radiofrequency ablation (t-RFA).\n\nStudies have shown conventional radiofrequency ablation (c-RFA) to as effective as t-RFA.  It poses no increased risk and is an alternative to thermal radiofrequency ablation (t-RFA).  The distinction between the two is primarily due to proprietary technology.  No study has shown it to be inferior to  thermal radiofrequency ablation (t-RFA), and its\nindications are same for thermal radiofrequency ablation (t-RFA).  In essence, there is no distinction, and it can be used in all settings that  thermal radiofrequency ablation (t-RFA) can be used. \n\nThis patient has chronic low back pain with facet arthropathy.  The patient has had\ntwo diagnostic medial branch blocks and previously had radiofrequency ablation (RFA) with excellent results.  Therefore, the criteria according to the Spine Intervention Society has been met, and this is medically necessary and standard of care.  In essence, there is no distinction, and it can be used in all settings that  thermal radiofrequency ablation (t-RFA) can be used.  In addition, the patient has previously undergone this procedure with near 100% relief for about a year.  Given the above, the requested conventional radiofrequency ablation (c-RFA) is medically necessary.", "id": "6db743877eb544da8b68a82d9b7b9648", "question": "What is the background context in this case summary?", "title": "6db743877eb544da8b68a82d9b7b9648", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with neuropathic pain who has been prescribed Lidocaine 5% patch.", "The patient is a female with low back pain and lumbar radiculopathy, a neuropathic type pain, who has been prescribed lidocaine patches. This is a continuation of therapy. The patient has been on this in the past. She has tried and failed multiple options. She cannot take NSAIDs (nonsteroidal antiinflammatory drugs) due to anti-coagulation. She has failed Gabapentin and Cymbalta. She cannot take Tylenol due to liver issues.", "She has used this medication in the past with good results.", "Diagnosis: Neuropathic pain\nTreatment: Lidocaine Patch", "The insurer denied the Lidocaine Patch."], "answer_start": [123, 282, 757, 0, 55]}, "context": "Diagnosis: Neuropathic pain\nTreatment: Lidocaine Patch\nThe insurer denied the Lidocaine Patch.\nThe denial is overturned. \n\nThe patient is a female with neuropathic pain who has been prescribed Lidocaine 5% patch.\n\nYes, the treatment with Lidocaine 5% patch is medically necessary.\n\nThe patient is a female with low back pain and lumbar radiculopathy, a neuropathic type pain, who has been prescribed lidocaine patches. This is a continuation of therapy. The patient has been on this in the past. She has tried and failed multiple options. She cannot take NSAIDs (nonsteroidal antiinflammatory drugs) due to anti-coagulation. She has failed Gabapentin and Cymbalta. She cannot take Tylenol due to liver issues. Chronic opiates are generally not recommended. She has used this medication in the past with good results. Lidocaine patches have been shown to be effective in the treatment of chronic low back pain in the literature. It is the least invasive option, and it tends to have low side effects.  She has tried lidocaine jelly, but she develops a rash. The options are limited. Given the above, the requested lidocaine patches are medically necessary,  \n\nThe risks of the alternatives far outweigh the benefits. The patient has failed most conventional and common modalities. \n\nLidocaine patches have been used for numerous pain complaints outside of PHN (postherpetic neuralgia), including low back pain. This has been shown in the literature, and is considered standard of care in the treatment of many pain complaints aside from PHN.\n", "id": "2f9755ffd3314310afb5e0d681865b96", "question": "What is the background context in this case summary?", "title": "2f9755ffd3314310afb5e0d681865b96", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient with a history of chronic iritis in the right eye.  The patient's visual acuities are 20/40 in the right eye (OD) and 20/20 in the left eye (OS).  The patient has diagnoses of posterior capsular opacification OD, dry eye and status post retinal detachment repair OD.  The patient's treating physician noted that BromSite is used to treat chronic iritis in the right eye, and BromSite will be used to stabilize and alleviate the patient's symptoms due to iritis.  The physician also noted that the patient has used Ketorolac 0.5% in the past with no success and is currently using Bromfenac, but the patient states this does not seem to be as effective as BromSite.  It was noted that the patient has used BromSite in the past with great success.", "Diagnosis:  Iritis.", "Treatment:  BromSite 0.075% Ophthalmic Solution.", "The insurer denied coverage for BromSite 0.075% Ophthalmic Solution."], "answer_start": [164, 0, 20, 70]}, "context": "Diagnosis:  Iritis.\nTreatment:  BromSite 0.075% Ophthalmic Solution.\n\nThe insurer denied coverage for BromSite 0.075% Ophthalmic Solution.  The denial is upheld. \n\nThis is a male patient with a history of chronic iritis in the right eye.  The patient's visual acuities are 20/40 in the right eye (OD) and 20/20 in the left eye (OS).  The patient has diagnoses of posterior capsular opacification OD, dry eye and status post retinal detachment repair OD.  The patient's treating physician noted that BromSite is used to treat chronic iritis in the right eye, and BromSite will be used to stabilize and alleviate the patient's symptoms due to iritis.  The physician also noted that the patient has used Ketorolac 0.5% in the past with no success and is currently using Bromfenac, but the patient states this does not seem to be as effective as BromSite.  It was noted that the patient has used BromSite in the past with great success.\n\nBased on the review of the patient's medical record and literature, the requested medication, BromSite (bromfenac) 0.075% ophthalmic solution is not considered medically necessary for this patient.  The patient has not tried available formulary alternatives (i.e., flurbiprofen), or has not demonstrated contraindications to use of alternatives.  The literature does not support that BromSite is superior in efficacy or tolerability compared to other topical nonsteroidal anti-inflammatory drug (NSAID)-based ophthalmic drops.\n\nThe health plan acted reasonably with sound medical judgment, and in the best interest of the patient.\n\nBased on the above, the medical necessity for BromSite 0.075% Ophthalmic Solution is not substantiated.  The insurer's denial should be upheld.", "id": "a46afac6fbe64c3b9b30e2f92b22d16d", "question": "What is the background context in this case summary?", "title": "a46afac6fbe64c3b9b30e2f92b22d16d", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient who was admitted with hypertensive emergency which is indicated by a systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage. The patient's blood pressure was 261/147, and he presented with signs of myocardial infarction including elevated troponin and electrocardiogram (EKG) changes. The patient also had acute kidney injury (AKI) noted with elevated creatinine from a baseline of 2.2 up to 4.7. The patient's condition required close cardiac monitoring in the Coronary Care Unit (CCU) and required intravenous (IV) Cardene drip and adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure.", "Diagnosis: Hypertensive emergency.", "Treatment: Full hospital admission.", "The insurer denied coverage for the full hospital admission."], "answer_start": [162, 0, 36, 73]}, "context": "Diagnosis: Hypertensive emergency.\n\nTreatment: Full hospital admission.\n\nThe insurer denied coverage for the full hospital admission.\n\nThe denial is overturned.\n\nThis is a male patient who was admitted with hypertensive emergency which is indicated by a systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage. The patient's blood pressure was 261/147, and he presented with signs of myocardial infarction including elevated troponin and electrocardiogram (EKG) changes. The patient also had acute kidney injury (AKI) noted with elevated creatinine from a baseline of 2.2 up to 4.7. The patient's condition required close cardiac monitoring in the Coronary Care Unit (CCU) and required intravenous (IV) Cardene drip and adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure.\n\nBased on the review of the medical record and literature, the full hospital admission was medically necessary for this patient. The patient's medical condition required an extended stay after blood pressure control due to his worsening kidney function and possible need for renal replacement therapy. Thus, the inpatient admission was appropriate and consistent with the standard of care.\n\nThe health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.\n\nBased on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial should be overturned.", "id": "a22158724a634effab94e415bb1f2f2f", "question": "What is the background context in this case summary?", "title": "a22158724a634effab94e415bb1f2f2f", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a diagnosis of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  Available records include a letter of medical necessity a letter from her physical therapist (PT), a fax, a letter detailing accessories, Durable Medical Equipment Order, progress note (telehealth office visit), and appeal from physical therapy for Rifton Dynamic Pacer.  At issue is the medical necessity of the requested gait trainer.", "The patient has diagnoses of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently. ", "The PT Letter documents that patient had a Kid Walk Gait trainer but has grown out of the device.  The patient was stable with the dynamic pacer and was able to perform assisted stepping approximately 30 feet at a time.", "Diagnosis:  Spastic quadriplegic cerebral palsy.", "Treatment:  Gait Trainer.", "The health plan denied the Gait Trainer. "], "answer_start": [148, 751, 2243, 0, 49, 76]}, "context": "Diagnosis:  Spastic quadriplegic cerebral palsy.\nTreatment:  Gait Trainer.\n\nThe health plan denied the Gait Trainer.  The determination is upheld.\n\nThe patient has a diagnosis of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  Available records include a letter of medical necessity a letter from her physical therapist (PT), a fax, a letter detailing accessories, Durable Medical Equipment Order, progress note (telehealth office visit), and appeal from physical therapy for Rifton Dynamic Pacer.  At issue is the medical necessity of the requested gait trainer.\n\nThe requested gait trainer is not medically necessary for this patient.  The patient has diagnoses of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  There are not sufficient benefits of the use of a gait trainer in patients with cerebral palsy supported by medical literature to warrant it as a medically necessary device.  A Cochrane Review of Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy found that there was a lack of evidence to support significant benefits.  In this review, comparison with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support).  However this was not definite.  Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function.  The lack of supportive medical evidence of significant benefit and outcomes for gait trainer in patients with cerebral palsy means this device cannot be considered medically necessary, even if it is useful for the patient.  The PT Letter documents that patient had a Kid Walk Gait trainer but has grown out of the device.  The patient was stable with the dynamic pacer and was able to perform assisted stepping approximately 30 feet at a time.  Gait trainer devices can be usable by patients and yet not be medically necessary.  The patient's possession of and ability to use a gait trainer in the past does not alter the lack of evidence that such a device is medically necessary", "id": "a0f00d8ba7744803bdd265a2de80bdc6", "question": "What is the background context in this case summary?", "title": "a0f00d8ba7744803bdd265a2de80bdc6", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Shortness of breath, lower abdominal pain, vaginal bleeding", "Treatment: Inpatient admission", "The insurer denied the inpatient admission.", "The patient is a female with a history of iron deficiency anemia and uterine fibroids who presented to the Emergency Department (ED) for an emergency evaluation due to shortness of breath, palpitations for a day, chills and fever, lower abdominal cramping, rash, and vaginal bleeding for two to three days. The patient reported a recent history (one week ago) of uterine fibroid embolization. The patient reported that she was discharged after the procedure with Toradol, gabapentin, Tylenol, tramadol, levofloxacin, Zofran, Prilosec and senna.", "On initial presentation, the patient was febrile (temperature of 100.6 degrees Fahrenheit), blood pressure (BP) was 124/88, pulse was 82 beats per minute (she was later tachycardic at 104), and respirations were 20 breaths per minute. On examination, the patient looked ill, with tachycardia, suprapubic tenderness to palpation, erythema/bleeding of vagina, enlarged uterus, submandibular lymphadenopathy, and bilateral upper and lower extremity morbilliform urticarial rash. Laboratory studies were remarkable for leukocytosis, microcytic anemia, thrombocytosis, eosinophilia, transaminitis (aspartate aminotransferase [AST] / alanine aminotransferase [ALT] 353/335), and proteinuria.", "In the emergency department, the patient was administered Benadryl and steroids.  The treating physician's clinical impression was emergently concerned for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome secondary to gabapentin, levofloxacin or Toradol.  For management of DRESS syndrome, the patient was kept on intravenous (IV) Benadryl and intravenous (IV) Prednisone.  Although patient was advised to stay in the hospital, the patient decided to leave the hospital against medical advice. The patient was sent home (against medical advice) with prednisone, Augmentin and recommendations to follow up with gynecology (GYN) and her primary care physician (PCP).", "This patient presented with elevated temperature, lymphadenopathy, elevated liver enzymes, and eosinophilia a week after a uterine artery embolization.", "the patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome."], "answer_start": [0, 71, 102, 174, 722, 1410, 2154, 2632]}, "context": "Diagnosis: Shortness of breath, lower abdominal pain, vaginal bleeding\nTreatment: Inpatient admission\nThe insurer denied the inpatient admission.\nThe denial is overturned. \n\nThe patient is a female with a history of iron deficiency anemia and uterine fibroids who presented to the Emergency Department (ED) for an emergency evaluation due to shortness of breath, palpitations for a day, chills and fever, lower abdominal cramping, rash, and vaginal bleeding for two to three days. The patient reported a recent history (one week ago) of uterine fibroid embolization. The patient reported that she was discharged after the procedure with Toradol, gabapentin, Tylenol, tramadol, levofloxacin, Zofran, Prilosec and senna.  \n\nOn initial presentation, the patient was febrile (temperature of 100.6 degrees Fahrenheit), blood pressure (BP) was 124/88, pulse was 82 beats per minute (she was later tachycardic at 104), and respirations were 20 breaths per minute. On examination, the patient looked ill, with tachycardia, suprapubic tenderness to palpation, erythema/bleeding of vagina, enlarged uterus, submandibular lymphadenopathy, and bilateral upper and lower extremity morbilliform urticarial rash. Laboratory studies were remarkable for leukocytosis, microcytic anemia, thrombocytosis, eosinophilia, transaminitis (aspartate aminotransferase [AST] / alanine aminotransferase [ALT] 353/335), and proteinuria. \n\nIn the emergency department, the patient was administered Benadryl and steroids.  The treating physician's clinical impression was emergently concerned for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome secondary to gabapentin, levofloxacin or Toradol.  For management of DRESS syndrome, the patient was kept on intravenous (IV) Benadryl and intravenous (IV) Prednisone.  Although patient was advised to stay in the hospital, the patient decided to leave the hospital against medical advice. The patient was sent home (against medical advice) with prednisone, Augmentin and recommendations to follow up with gynecology (GYN) and her primary care physician (PCP). \n\nYes, the inpatient admission was medically necessary.\n\nThis patient presented with elevated temperature, lymphadenopathy, elevated liver enzymes, and eosinophilia a week after a uterine artery embolization.  Common complications of uterine artery embolization include pelvic pain, fever, and vaginal discharge, but these are self-limiting in most patients.  The most serious potential complications are introduction of embolic agents into inadvertent vessels, necrosis of the gluteus maximus or limb, or pulmonary embolism. However, the patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.\n\nDrug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, potentially life-threatening drug-induced hypersensitivity reaction that includes skin eruption, hematologic abnormalities (eosinophilia, atypical lymphocytosis), lymphadenopathy, and/or internal organ involvement (liver, kidney, lung). The diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) is based upon the combination of clinical features (history of drug exposure, cutaneous findings, systemic findings, such as fever, lymphadenopathy, and visceral involvement) and laboratory findings. Identification and prompt withdrawal of the offending drug is the mainstay of treatment for patients with drug reaction with eosinophilia and systemic symptoms (DRESS). Serial biochemical measurements should be performed to monitor liver function. Severe hepatocellular injury may evolve to acute liver failure and the only effective therapy may be liver transplantation.  It is obvious from the above that drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a very serious condition. \n\nIt is obvious from the above, that drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious condition and quick and adequate management is medically necessary. In this patient's case, admission for intravenous (IV) steroids was medically necessary to monitor for any possible worsening of her situation, to investigate which drug was the offending one and to rule out any other possible etiology for her symptoms.", "id": "fcc5b921a8484228afd10ed3e793ec20", "question": "What is the background context in this case summary?", "title": "fcc5b921a8484228afd10ed3e793ec20", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with past medical history of hypertension, hypothyroidism, osteoarthritis, urinary incontinence, chronic kidney disease, and chronic constipation who had been assigned 4 hours of PCA (personal care assistant) services per day, 7 days/week. There was a request to increase PCA service hours and the patient had an assessment tool performed telephonically and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating.", "Diagnosis: osteoarthritis", "Treatment: Personal Care Worker (PCW) Service", "The insurer denied Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day.", "The patient's previous informal caregiver moved out of state leaving the patient with no informal caregiver", "The patient has activities of daily living (ADL) and Instrumental activities of daily living (IADL) care needs outside of the PCA service hours currently provided, specifically with needed help with meal preparation, eating, dressing, toileting, toilet transfer, walking, and locomotion."], "answer_start": [299, 78, 104, 151, 1255, 1455]}, "context": "Orthopedic/Musculoskeletal\nNursing Services (including Private Duty Nursing)\n\nDiagnosis: osteoarthritis\nTreatment: Personal Care Worker (PCW) Service \nThe insurer denied Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day. The health plan's determination is overturned.\n\nThe patient is a female with past medical history of hypertension, hypothyroidism, osteoarthritis, urinary incontinence, chronic kidney disease, and chronic constipation who had been assigned 4 hours of PCA (personal care assistant) services per day, 7 days/week. There was a request to increase PCA service hours and the patient had an assessment tool performed telephonically and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating.\n\nThe Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day is medically necessary for this patient. \nThe patient's previous informal caregiver moved out of state leaving the patient with no informal caregiver, although the insurer incorrectly assumed the patient continued to have informal caregiver. The patient has activities of daily living (ADL) and Instrumental activities of daily living (IADL) care needs outside of the PCA service hours currently provided, specifically with needed help with meal preparation, eating, dressing, toileting, toilet transfer, walking, and locomotion. The assessment tool performed over the phone also underestimated the patient's ADL and IADL assistance needs for tasks of meal preparation, personal hygiene, dressing upper/lower body, walking, locomotion, toileting, transfer toilet, and eating. The PCA service hours are not solely for safety and supervision but to assist the patient with successful completion of ADL and IADL tasks. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. The requested PCA services 8 hours/day, 7 days/week are medically necessary for this patient.", "id": "f0d7f69656ed4c20bd384315654e68c4", "question": "What is the background context in this case summary?", "title": "f0d7f69656ed4c20bd384315654e68c4", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has maxillary and mandibular crowding and many unerupted permanent teeth.  The orthodontist noted in the diagnosis that tooth number (#) 22 is impacted.  The patient is treatment planned for 36-42 months of comprehensive orthodontics with canine exposure and ligation.  At issue is the medical necessity of braces and monthly visits.", "He is in the process of losing his remaining primary teeth, as they are replaced with permanent teeth.", "Diagnosis:  Dental Disorder.", "Treatment:  Braces and Monthly Visits.", "The insurer denied Braces and Monthly Visits.", "The patient does have maxillary and mandibular crowding"], "answer_start": [146, 573, 0, 29, 69, 1833]}, "context": "Diagnosis:  Dental Disorder.\nTreatment:  Braces and Monthly Visits.\n\nThe insurer denied Braces and Monthly Visits.  The determination is upheld.\n\nThe patient has maxillary and mandibular crowding and many unerupted permanent teeth.  The orthodontist noted in the diagnosis that tooth number (#) 22 is impacted.  The patient is treatment planned for 36-42 months of comprehensive orthodontics with canine exposure and ligation.  At issue is the medical necessity of braces and monthly visits.\n\nOrthodontic treatment is not medically necessary for the patient at this time.  He is in the process of losing his remaining primary teeth, as they are replaced with permanent teeth.  Research indicates the following risk factors for impacted canines in patients over 10 years of age (2):  1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side (The patient does not have this, as shown in the panoramic radiograph), 2) The canines cannot be palpated, and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption), 3) The lateral incisor is proclined and tipped distally (Photographic evidence does not indicate proclined lateral incisors), and 4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided).\n\nWhile that study shows risk factors for impacted maxillary canines, there is nothing in this panoramic radiograph to suggest that tooth #22 will be unable to erupt.  Studies show that impacted mandibular canines are rare (3), and none of the records support a diagnosis requiring treatment at this time.  The patient does have maxillary and mandibular crowding; however, the patient does not exhibit any of the criteria to suspect that the canine is impacted.  Therefore, orthodontic treatment is not medically necessary.", "id": "430775773b93449294748d9d85baf439", "question": "What is the background context in this case summary?", "title": "430775773b93449294748d9d85baf439", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Spinal Muscular Atrophy", "Treatment: Evrysdi SGM", "The health plan denied the requested prescription drug.", "A review of the prior authorization request indicated a diagnosis of spinal muscular atrophy type 2. The patient was not dependent on any invasive ventilation or noninvasive ventilation (though other notes indicate that he was using bi-level positive airway pressure (BiPAP)). The medication was prescribed by or in consultation with a physician specializing in the treatment of spinal muscular atrophy. The patient is not currently undergoing treatment with Evrysdi. The diagnosis of spinal muscular atrophy was confirmed with genetic testing. The patient has three copies of (genetic proteins= survival motor neuron (SMN) SMN2 and 0 copies of SMN1.", "An office note indicates that the patient did have BiPAP dependence. He is using BiPAP at night with classicist daily. He was undergoing a home physical and occupational therapy. He required a G-tube (gastrostomy tube) for feeding. He was receiving Spinraza. It was noted that the patient had spinal muscular atrophy type 2 and had a stable motor assessment despite complaints of weakness in the arm that was attributed to a delay in Spinraza dosing. A change to Evrysdi was planned.", "The reason for denial on prior review as per communications from CVS Caremark is that the patient did not undergo a Hammersmith infant neurologic exam, part two (HIN2), Hammersmith functional motor scale expanded, Children's Hospital of Philadelphia infant test of neuromuscular disorders (CHOP-INTEND or MFM32).\nA letter of medical necessity dated indicated that he had been treated with Spinraza but had a decline in function. His physician recommended Evrysdi. He indicated that the HIN2 and CHOP-INTEND would not be appropriate, that HFMSC could not be performed, and that the MFM 32 was not routinely used in clinical practice."], "answer_start": [0, 35, 58, 159, 1128, 1612]}, "context": "Diagnosis: Spinal Muscular Atrophy\nTreatment: Evrysdi SGM\nThe health plan denied the requested prescription drug. \nThe health plan's determination is upheld.\n\nA review of the prior authorization request indicated a diagnosis of spinal muscular atrophy type 2. The patient was not dependent on any invasive ventilation or noninvasive ventilation (though other notes indicate that he was using bi-level positive airway pressure (BiPAP)). The medication was prescribed by or in consultation with a physician specializing in the treatment of spinal muscular atrophy. The patient is not currently undergoing treatment with Evrysdi. The diagnosis of spinal muscular atrophy was confirmed with genetic testing. The patient has three copies of (genetic proteins= survival motor neuron (SMN) SMN2 and 0 copies of SMN1.\nThe patient did not undergo a Hammersmith Infant Neurological Exam, Part 2, Hammersmith Functional Motor Scale Expanded (HFMSE), Children's Hospital of Philadelphia infant test of neuromuscular disorders or Motor Function Measure - 32 items (MFM-32). The patient's age and initiation of the request is not documented.\nAn office note indicates that the patient did have BiPAP dependence. He is using BiPAP at night with classicist daily. He was undergoing a home physical and occupational therapy. He required a G-tube (gastrostomy tube) for feeding. He was receiving Spinraza. It was noted that the patient had spinal muscular atrophy type 2 and had a stable motor assessment despite complaints of weakness in the arm that was attributed to a delay in Spinraza dosing. A change to Evrysdi was planned.\nThe reason for denial on prior review as per communications from CVS Caremark is that the patient did not undergo a Hammersmith infant neurologic exam, part two (HIN2), Hammersmith functional motor scale expanded, Children's Hospital of Philadelphia infant test of neuromuscular disorders (CHOP-INTEND or MFM32).\nA letter of medical necessity dated indicated that he had been treated with Spinraza but had a decline in function. His physician recommended Evrysdi. He indicated that the HIN2 and CHOP-INTEND would not be appropriate, that HFMSC could not be performed, and that the MFM 32 was not routinely used in clinical practice.\n\nThe health plan's determination of medical necessity is upheld, in whole.\n\nNo. Evrysdi SGM is an oral medication used to treat spinal muscular atrophy type I. Evrysdi is not medically necessary. In order to determine whether accuracy is effective for the patient, there must be a reproducible documentation of examination findings. It is possible that the physician may not see the patient at every visit. The HFMSC and MFM 32 would be appropriate for these patients. The risk of physical injury with the HFMSC is low. There is no rationale why the physician cannot perform these simple tests or derive a score from his existing examination. The patient would be most properly monitored with the use of these of one of the scales, and, in its absence, response or lack of response cannot be monitored and the requested medication would therefore not be considered medically necessary.\n", "id": "4a053028f7d0447c9a080b995d5d0933", "question": "What is the background context in this case summary?", "title": "4a053028f7d0447c9a080b995d5d0933", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient with past medical history of hypertension (HTN). He presented to the emergency department (ED) with complaints of abdominal/epigastric pain, fever and nausea and vomiting for a couple of days. The pain radiated to the right upper quadrant (RUQ). The patient had a sonogram at an urgent care center with findings of gallstones. Exam revealed the abdomen to be soft with RUQ tenderness and Murphy's sign. No guarding or rebound was noted. The patient was afebrile. His white blood cell count was 15.88.  An abdominal ultrasound was performed that showed distended gall bladder containing a calculus. The wall was mildly thickened with a small amount of pericholecystic fluid. There was also a positive sonographic Murphy's sign with the findings compatible with acute cholecystitis. The plan was to admit to surgery and underwent an uneventful laparoscopic cholecystectomy. He was treated with intravenous antibiotics and his diet was advanced as tolerated. He was medically stable and discharged home. ", "Diagnosis: Acute Cholecystitis", "Treatment: Inpatient hospital admission", "The insurer denied the inpatient hospital admission."], "answer_start": [155, 0, 32, 74]}, "context": "Diagnosis: Acute Cholecystitis\n\nTreatment: Inpatient hospital admission \n\nThe insurer denied the inpatient hospital admission. \n\nThe denial was upheld.  \n\nThis is a male patient with past medical history of hypertension (HTN). He presented to the emergency department (ED) with complaints of abdominal/epigastric pain, fever and nausea and vomiting for a couple of days. The pain radiated to the right upper quadrant (RUQ). The patient had a sonogram at an urgent care center with findings of gallstones. Exam revealed the abdomen to be soft with RUQ tenderness and Murphy's sign. No guarding or rebound was noted. The patient was afebrile. His white blood cell count was 15.88.  An abdominal ultrasound was performed that showed distended gall bladder containing a calculus. The wall was mildly thickened with a small amount of pericholecystic fluid. There was also a positive sonographic Murphy's sign with the findings compatible with acute cholecystitis. The plan was to admit to surgery and underwent an uneventful laparoscopic cholecystectomy. He was treated with intravenous antibiotics and his diet was advanced as tolerated. He was medically stable and discharged home. \n\nAccording to MCG Health Inpatient and Surgical care- 24th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) clinical indications for admission to inpatient care may include patients with 1 or more of the following: 1) Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (34 micromoles/L), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); or  2) Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); Cholecystectomy not anticipated (i.e., within subsequent few days) due to 1 or more of the following: Finally, MCG Health - Inpatient and Surgical care 24th edition. Cholecystectomy by laparoscopy ORG: S-365 (ISC) noted that  Procedure is indicated for 1 or more of the following: Symptomatic gallstone disease as indicated by ALL of the following: Evidence of gallstone disease as indicated by 1 or more of the following: Stones demonstrated on cholecystography, ultrasound, CT, or MRI, Non-visualizing gallbladder with double-dose cholecystography or HIDA scan, Symptoms of gallstone disease as indicated by 1 or more of the following: Biliary colic; Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness, Systemic signs of inflammation as indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L).  \n\nThe health plan acted reasonably with sound medical judgment in the best interest of the patient.\n\nBased on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.\n", "id": "f3352079176b428eb40ba76a30b89925", "question": "What is the background context in this case summary?", "title": "f3352079176b428eb40ba76a30b89925", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Seizures", "Treatment: Inpatient Hospital", "The health plan denied the inpatient stay.", "The patient is a male who presented to the emergency department after a staring episode.", "He was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.", "He was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable,  he was felt to be stable for discharge to home with follow up as an outpatient.\nThe hospitalization is under review for medical necessity.", "This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office.", "His evaluation included video EEG monitoring", "as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study."], "answer_start": [0, 20, 50, 142, 231, 889, 1679, 1957, 2051]}, "context": "Diagnosis: Seizures\nTreatment: Inpatient Hospital\nThe health plan denied the inpatient stay. \nThe health plan's determination is overturned.\n\nThe patient is a male who presented to the emergency department after a staring episode.\nHe was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.\nHe was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable,  he was felt to be stable for discharge to home with follow up as an outpatient.\nThe hospitalization is under review for medical necessity.\n\nI overturn, in whole, the health plan's determination of medical necessity.\n\nYes, the requested health service of the inpatient stay was medically necessary for this patient. This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office. He required prompt evaluation for possible seizures or other causes of paroxysmal behavior. His evaluation included video EEG monitoring, which needs to be done in an inpatient setting, as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study. While typical absence seizures cause staring episodes and are often benign, they typically present at an older age (mean age 6 years). Staring episodes in a can be a sign of a much more serious disorder, including seizures or sepsis, and require prompt evaluation with close monitoring for potential deterioration of clinical status.", "id": "1a9b5994a4ab45bead7c3c310f498a28", "question": "What is the background context in this case summary?", "title": "1a9b5994a4ab45bead7c3c310f498a28", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Cardiac/Circulatory.", "Treatment: Inpatient Hospital.", "The insurer denied inpatient stay.", "The patient is a male with a history of non-ischemic cardiomyopathy, atrial fibrillation, chronic kidney disease and morbid obesity presented to the emergency department complaining of dyspnea, edema and a 50 pound weight gain over the prior two weeks. He had a left ventricular ejection fraction of 20% and an implanted left ventricular assist device (LVAD). He was on chronic antibiotics for a driveline infection.", "In the emergency department, his mean arterial blood pressure (MAP) was 80 millimeters of mercury (mmHg). His heart rate was 70 beats/minute. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for abdominal distension and lower extremity edema. The cardiology consultant later noted bibasilar pulmonary rales. Chest x-ray showed mild vascular congestion. The patient was admitted to the hospital with decompensated heart failure. He noted persistent dyspnea. His physical exam showed bibasilar rales and edema. He was treated with high dose intravenous furosemide twice daily. The next day, his dyspnea had improved but he had persistent rales, jugular venous distension and peripheral edema. High dose twice daily intravenous furosemide was continued until it was held after hypotension the night prior; the patient's MAP had fallen to 40 mmHg. His blood pressure was improved and oral diuretics were started. He was discharged. His discharge weight was 50 pounds less than his admission weight. Medical necessity for an inpatient admission is the subject under review.", "This patient, with severe left ventricular systolic dysfunction and a left ventricular assist device, presented to the hospital with massive volume overload due to acute decompensated heart failure. He remained volume overloaded despite six days of aggressive intravenous diuresis, which was then complicated by hypotension."], "answer_start": [0, 33, 65, 128, 547, 1738]}, "context": "Diagnosis: Cardiac/Circulatory. \nTreatment: Inpatient Hospital. \nThe insurer denied inpatient stay. \nThe denial is overturned.\n\nThe patient is a male with a history of non-ischemic cardiomyopathy, atrial fibrillation, chronic kidney disease and morbid obesity presented to the emergency department complaining of dyspnea, edema and a 50 pound weight gain over the prior two weeks. He had a left ventricular ejection fraction of 20% and an implanted left ventricular assist device (LVAD). He was on chronic antibiotics for a driveline infection. \n\nIn the emergency department, his mean arterial blood pressure (MAP) was 80 millimeters of mercury (mmHg). His heart rate was 70 beats/minute. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for abdominal distension and lower extremity edema. The cardiology consultant later noted bibasilar pulmonary rales. Chest x-ray showed mild vascular congestion. The patient was admitted to the hospital with decompensated heart failure. He noted persistent dyspnea. His physical exam showed bibasilar rales and edema. He was treated with high dose intravenous furosemide twice daily. The next day, his dyspnea had improved but he had persistent rales, jugular venous distension and peripheral edema. High dose twice daily intravenous furosemide was continued until it was held after hypotension the night prior; the patient's MAP had fallen to 40 mmHg. His blood pressure was improved and oral diuretics were started. He was discharged. His discharge weight was 50 pounds less than his admission weight. Medical necessity for an inpatient admission is the subject under review.\n\nAn inpatient stay was medically necessary for this patient. This patient, with severe left ventricular systolic dysfunction and a left ventricular assist device, presented to the hospital with massive volume overload due to acute decompensated heart failure. He remained volume overloaded despite six days of aggressive intravenous diuresis, which was then complicated by hypotension. He required careful and continuous monitoring of his clinical status, LVAD parameters and laboratory values, along with adjustment of his pharmacologic regimen. This warranted an inpatient level of care.", "id": "6abaeaf5f204414e8191ac81949138c1", "question": "What is the background context in this case summary?", "title": "6abaeaf5f204414e8191ac81949138c1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient in question is a female with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. Braces and monthly visit (x 12) were denied as not medically necessary. ", "Diagnosis: Class I malocclusion.", "Treatment: Braces/monthly visits.", "The insurer denied braces/monthly visits.", "The patient has an", "overbite and overjet.", "there is mild crowding", "The diagnosis states the patient has a skeletal Class I relationship"], "answer_start": [154, 0, 33, 67, 554, 585, 612, 1003]}, "context": "Diagnosis: Class I malocclusion.\nTreatment: Braces/monthly visits.\nThe insurer denied braces/monthly visits.\nThe health plan's determination is upheld. \n\nThe patient in question is a female with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. Braces and monthly visit (x 12) were denied as not medically necessary. \n\nBraces and monthly visit (x 12) are not medically necessary at this time.\n\nThe patient has an appropriate overbite and overjet. Yes, there is mild crowding, but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 27 with tooth 6, and the gingival margin of 27 appears to be the same as tooth 22. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.", "id": "9a3d8cde9bb14296be843cc500969499", "question": "What is the background context in this case summary?", "title": "9a3d8cde9bb14296be843cc500969499", "sufficiency_score": 4}
+{"answers": {"text": ["The patient had past efficacy and no past reported seizures after TMS therapy and is being treated for seizures and has not had one for many years.", "Diagnosis: Major Depressive Disorder.", "Treatment: Transcranial Magnetic Stimulation.", "The insurer denied coverage for Transcranial Magnetic Stimulation.", "This is a male patient who reportedly had depressive symptoms including depressed mood, anhedonia, low energy with difficulty getting out of bed, hopelessness, concentration problems, decreased libido, and he had a diagnosis of Major Depressive Disorder in addition to Generalized Anxiety Disorder. He also had a past reported suicide attempt. The patient had multiple past antidepressant trials without sustained efficacy or with side effects including Fluoxetine, Sertraline, Venlafaxine, Desvenlafaxine, Duloxetine, Fetzima, Viibryd, Trintellix, and Amitriptyline, as well as augmenting medications of Aripiprazole, Rexulti, Quetiapine, Olanzapine, Vraylar, and Lamotrigine. He reportedly had successful transcranial magnetic stimulation (TMS) therapy in the past. He had a history of seizures and takes anti-seizure medications Depakote and Vimpat. The request was for TMS again.", "The insurer denied the request for TMS stating that having a history of seizures is a contraindication for TMS."], "answer_start": [3222, 0, 38, 84, 179, 1064]}, "context": "Diagnosis: Major Depressive Disorder.\nTreatment: Transcranial Magnetic Stimulation.\nThe insurer denied coverage for Transcranial Magnetic Stimulation.\nThe denial is overturned. \n\nThis is a male patient who reportedly had depressive symptoms including depressed mood, anhedonia, low energy with difficulty getting out of bed, hopelessness, concentration problems, decreased libido, and he had a diagnosis of Major Depressive Disorder in addition to Generalized Anxiety Disorder. He also had a past reported suicide attempt. The patient had multiple past antidepressant trials without sustained efficacy or with side effects including Fluoxetine, Sertraline, Venlafaxine, Desvenlafaxine, Duloxetine, Fetzima, Viibryd, Trintellix, and Amitriptyline, as well as augmenting medications of Aripiprazole, Rexulti, Quetiapine, Olanzapine, Vraylar, and Lamotrigine. He reportedly had successful transcranial magnetic stimulation (TMS) therapy in the past. He had a history of seizures and takes anti-seizure medications Depakote and Vimpat. The request was for TMS again.\n\nThe insurer denied the request for TMS stating that having a history of seizures is a contraindication for TMS. This reviewer disagrees with the decision to deny the request for TMS therapy. \n\nTMS therapy has been cleared by the Food and Drug Administration (FDA) and is indicated for the treatment of Major Depressive Disorder in patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode. In this case this patient had another major depressive episode after reported remission from major depression after past TMS therapy so TMS was considered appropriate and medically necessary treatment again. He reportedly tried and failed multiple classes of antidepressant medication. He reportedly responded to past TMS therapy and had no reported adverse effects and had not reported a seizure for many years as he was being treated with anti-seizure medications. \n\nStultz and Osburn, state seizures if present are usually self-limiting and that they are rare. They noted that most treatment recommendations are supportive in nature and that the risk of TMS related seizures is less than 1% and that TMS therapy has successfully been used in patients with epilepsy/seizures, traumatic brain injury (TBI), and prior TMS related seizures. They stated that the rate of TMS related seizures was comparable to most psychotropic medications; and they also stated that while having a seizure is a rare adverse effect of TMS, the benefits of treating refractory depression with TMS may outweigh risks of possible adverse effects. The only reported absolute contraindication of TMS is a ferromagnetic metal in the head or neck as epilepsy is considered a relative contraindication and not an absolute contraindication. It was reported that the FDA stated that patients with seizures should be closely monitored when having TMS therapy. \n\nAlthough the health care plan acted reasonably and with sound clinical judgment, it did not appear that denying TMS was in the best interests of the patient considering the risks of worsened depression and suicide risk. The patient had past efficacy and no past reported seizures after TMS therapy and is being treated for seizures and has not had one for many years. The risk of treatment refractory depression in a patient with current major depressive episodes with a history of a past suicide attempt is higher than the medical risks of potential seizures in a patient being treated for seizures who did not have a past TMS related seizure from his past TMS treatment.\n\nThe carrier's denial of coverage for Transcranial Magnetic Stimulation is overturned. The medical necessity is substantiated.", "id": "d0fbb2c287944557b550cfbfb4a62e45", "question": "What is the background context in this case summary?", "title": "d0fbb2c287944557b550cfbfb4a62e45", "sufficiency_score": 4}
+{"answers": {"text": ["This male patient has bilateral below elbow amputations of the arms. A request for bilateral myoelectric prostheses has since been approved. However, the request for prosthetic arm additions (extra socket for artificial arms), that was separately coded as L7499, has been denied.  ", "Diagnosis: Bilateral below the elbow amputations.", "Treatment: Prosthetic Arm Additions (extra socket for left artificial arm).", "The insurer denied coverage for Prosthetic Arm Additions (extra socket for left artificial arm)."], "answer_start": [250, 0, 51, 128]}, "context": "Diagnosis: Bilateral below the elbow amputations.\n\nTreatment: Prosthetic Arm Additions (extra socket for left artificial arm).\n\nThe insurer denied coverage for Prosthetic Arm Additions (extra socket for left artificial arm).\n\nThe denial is upheld. \n\nThis male patient has bilateral below elbow amputations of the arms. A request for bilateral myoelectric prostheses has since been approved. However, the request for prosthetic arm additions (extra socket for artificial arms), that was separately coded as L7499, has been denied.  \n\nThe insurer appropriately approved base code L6883 -Replacement socket, below elbow/wrist disarticulation, molded to patient mode, for use with or without external power.  However, the requested L7499 code- Skeletal contoured and dynamic below elbow socket- is an inappropriate unbundling code that should be incorporated into the base code of the replacement sockets (L6833).  Such unbundling of codes from the base code are inappropriate and have been previously adjudicated in case law.\n\nThe health plan acted reasonably, with sound medical judgement and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidenced based.\n\nThe medical necessity is not substantiated. The carrier's denial of coverage for prosthetic arm additions (extra socket for artificial arms), should be upheld.  \n", "id": "8a9366f637234b839ae78da916560698", "question": "What is the background context in this case summary?", "title": "8a9366f637234b839ae78da916560698", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Orthopedic/Musculoskeletal.", "Treatment: Physical Therapy.", "The insurer denied Physical Therapy Services for medical necessity.", "This is a male patient that initially began receiving physical therapy service from a nonparticipating provider for impairments and functional deficits related to a knee surgery (anterior cruciate ligament (ACL) reconstruction). The patient had previously been participating in physical therapy for functional deficits related to the knee surgery. Documentation submitted indicated the patient had reached maximum therapeutic benefit with the care plan. It was noted the patient had completed 36 visits over several months.", "The progress note demonstrated very good clinical status with range of motion 0-125 and strength was \"good to good plus.\" ", "There is a letter of medical necessity from the provider stating that the patient underwent left knee surgery. The patient was placed in a long brace locked an extension for 4 weeks after surgery and required the use of crutches. He was enrolled in formal physical therapy to gradually restore his range of motion, strength, and ability to perform activities of daily living (ADL)s without limitation or pain. It was noted the patient was seen several times postoperatively and presented with disuse atrophy of the quadriceps muscles with his nerve supply intact. He had limited range of motion due to pain and swelling and was not strong enough to return to activity. It was felt the patient needed to undergo formal physical therapy for months to fully resolve these underlying issues and that it was the provider's standard protocol for all ACL reconstruction patients without any other type of setbacks after surgery to undergo a minimum of 6 months of formal physical therapy in order to make a full recovery.", "the patient underwent left knee surgery for right knee anterior cruciate ligament reconstruction. The patient was being treated for the same medical condition, postoperative knee rehabilitation following surgery and had been participating in physical therapy. The patient had 36 therapy sessions and appeared to progress well. \nA progress note demonstrated very good clinical status with range of motion 0-125 and strength was \"good to good plus.\" The patient was actively performing exercises on the treadmill at 10 mph(miles per hour) and doing multiple exercises such as single leg hops, and squats holding for 10 seconds. The patient had been instructed in an independent home exercise program"], "answer_start": [0, 40, 71, 165, 690, 813, 2045]}, "context": "Diagnosis: Orthopedic/Musculoskeletal. \nTreatment: Physical Therapy. \n\nThe insurer denied Physical Therapy Services for medical necessity. \nThe denial was upheld. \n\nThis is a male patient that initially began receiving physical therapy service from a nonparticipating provider for impairments and functional deficits related to a knee surgery (anterior cruciate ligament (ACL) reconstruction). The patient had previously been participating in physical therapy for functional deficits related to the knee surgery. Documentation submitted indicated the patient had reached maximum therapeutic benefit with the care plan. It was noted the patient had completed 36 visits over several months. \nThe progress note demonstrated very good clinical status with range of motion 0-125 and strength was \"good to good plus.\" \nThere is a letter of medical necessity from the provider stating that the patient underwent left knee surgery. The patient was placed in a long brace locked an extension for 4 weeks after surgery and required the use of crutches. He was enrolled in formal physical therapy to gradually restore his range of motion, strength, and ability to perform activities of daily living (ADL)s without limitation or pain. It was noted the patient was seen several times postoperatively and presented with disuse atrophy of the quadriceps muscles with his nerve supply intact. He had limited range of motion due to pain and swelling and was not strong enough to return to activity. It was felt the patient needed to undergo formal physical therapy for months to fully resolve these underlying issues and that it was the provider's standard protocol for all ACL reconstruction patients without any other type of setbacks after surgery to undergo a minimum of 6 months of formal physical therapy in order to make a full recovery. \n\nThe health plan's determination of medical necessity is upheld in whole. \nThe requested health service/treatment of Physical Therapy Services was not medically necessary for this patient. \nRecords provided indicate the patient underwent left knee surgery for right knee anterior cruciate ligament reconstruction. The patient was being treated for the same medical condition, postoperative knee rehabilitation following surgery and had been participating in physical therapy. The patient had 36 therapy sessions and appeared to progress well. \nA progress note demonstrated very good clinical status with range of motion 0-125 and strength was \"good to good plus.\" The patient was actively performing exercises on the treadmill at 10 mph(miles per hour) and doing multiple exercises such as single leg hops, and squats holding for 10 seconds. The patient had been instructed in an independent home exercise program and there was no indication that this patient would continue to require supervised therapy sessions rather than transitioning to a self-directed independent home exercise program as is the standard of care following the standard 24 visits of postoperative rehabilitation for this condition. There is no documentation to suggest that therapy performed in the skilled setting was required or that equivalent results could not be achieved while performing these exercises independently at home, which is the generally accepted standard of care. \n\nTherefore, the Physical Therapy Services are not medically necessary. ", "id": "81375d5230ea45f8a909a6c349214ea3", "question": "What is the background context in this case summary?", "title": "81375d5230ea45f8a909a6c349214ea3", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Dental Problems", "Treatment: Dental/Orthodontic procedure", "Diagnosis: Dental Problems-teeth spacing problem", "Treatment: Dental/Orthodontic procedure-Braces and monthly visits", "The health plan denied the treatment of Braces and monthly visits as not medically necessary.", "The patient has maxillary and mandibular crowding. The orthodontist mentioned in the diagnosis that #27 is impacted. Tooth #11 is blocked out to the labial. The patient is treatment planned for 36 months of comprehensive orthodontics with extraction of first premolars to create room with possible canine exposure and ligation."], "answer_start": [0, 27, 68, 117, 183, 347]}, "context": "Diagnosis: Dental Problems\nTreatment: Dental/Orthodontic procedure\n\nDiagnosis: Dental Problems-teeth spacing problem\nTreatment: Dental/Orthodontic procedure-Braces and monthly visits\nThe health plan denied the treatment of Braces and monthly visits as not medically necessary. \nThe reviewer has overturned in whole the health plan\ndetermination.\n\nThe patient has maxillary and mandibular crowding. The orthodontist mentioned in the diagnosis that #27 is impacted. Tooth #11 is blocked out to the labial. The patient is treatment planned for 36 months of comprehensive orthodontics with extraction of first premolars to create room with possible canine exposure and ligation. \n\nIt is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered.1 Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.2 The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth.2 If left untreated the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason the treatment of braces and follow up visits is deemed medically necessary.", "id": "db80f3faf09f4712a22dcd64becac7da", "question": "What is the background context in this case summary?", "title": "db80f3faf09f4712a22dcd64becac7da", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Intractable back pain.", "Treatment: Hospital admission.", "The insurer denied coverage for the hospital admission.", "This is a male patient with no significant past medical history who presented to the Emergency Department (ED) with intractable back pain. The patient also endorsed difficult ambulation and neck stiffness. In the ED, the patient received multiple pain medications including morphine without significant relief. The patient was unable to ambulate or sit up in the ED. Magnetic Resonance Imaging (MRI) of the lumbar spine was performed and the impression was: No acute fracture; no compression of the conus or cauda equine; annular bulge at L5-S1; transitional lumbosacral vertebra with lumbarization of S1; pseudoarthrosis of the transverse processes of the transitional vertebra with a sacral ala with bone marrow edema. It was noted that in the proper clinical setting, these findings could represent the initial presentation of Bertolotti syndrome. The patient was admitted to inpatient care for severe diffuse lower back pain bilaterally due to muscle spasm that resulted in the patient's inability to ambulate. Pain management was consulted and performed lumbar trigger point injection in the right lumbar paraspinal region, erector spinae and quadratus lumborum. The patient's pain improved but he experienced mild soreness in the lower back due to the injection. The patient was eventually able to ambulate on his own and was discharged with recommendations for outpatient Physical Therapy.", "The patient was unable to sit up or ambulate. He was unable to perform his activities of daily living (ADLs) and received opiate medications for pain."], "answer_start": [0, 35, 67, 152, 1550]}, "context": "Diagnosis: Intractable back pain.\n\nTreatment: Hospital admission.\n\nThe insurer denied coverage for the hospital admission.\n\nThe denial is overturned. \n\nThis is a male patient with no significant past medical history who presented to the Emergency Department (ED) with intractable back pain. The patient also endorsed difficult ambulation and neck stiffness. In the ED, the patient received multiple pain medications including morphine without significant relief. The patient was unable to ambulate or sit up in the ED. Magnetic Resonance Imaging (MRI) of the lumbar spine was performed and the impression was: No acute fracture; no compression of the conus or cauda equine; annular bulge at L5-S1; transitional lumbosacral vertebra with lumbarization of S1; pseudoarthrosis of the transverse processes of the transitional vertebra with a sacral ala with bone marrow edema. It was noted that in the proper clinical setting, these findings could represent the initial presentation of Bertolotti syndrome. The patient was admitted to inpatient care for severe diffuse lower back pain bilaterally due to muscle spasm that resulted in the patient's inability to ambulate. Pain management was consulted and performed lumbar trigger point injection in the right lumbar paraspinal region, erector spinae and quadratus lumborum. The patient's pain improved but he experienced mild soreness in the lower back due to the injection. The patient was eventually able to ambulate on his own and was discharged with recommendations for outpatient Physical Therapy.\n\nThe patient was unable to sit up or ambulate. He was unable to perform his activities of daily living (ADLs) and received opiate medications for pain. These two factors are explicitly mentioned in the Milliman Care Guidelines (MCG) 24th Edition: Back Pain as criteria for admission.\n\nFurther, Joint Commission standards (2) require:\n\"The hospital reassesses and responds to the patient's pain though the following: ...\nProgress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control.\"\n\nThe admission was required by the standard of care and was medically reasonable and necessary.\n\nThe healthcare plan did not act with sound medical judgment and in the best interest of the patient.\n\nThe insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.", "id": "e4a875becca54384b3d527dcf04cc774", "question": "What is the background context in this case summary?", "title": "e4a875becca54384b3d527dcf04cc774", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with a past medical history notable for eczema and recent rhino/enterovirus upper respiratory tract infection with dehydration that presented to the Emergency Department for assessment and management of 1 day of watery, non-bloody stools and non-bloody, non-bilious vomiting.  Her mother notes irritability, fatigue and poor intake of solids but was drinking.  There was no associated fever, rashes, distention, low urine output or weight loss.  Of note the patient had been discharged after a 2-day admission the day prior to this presentation. ", "Diagnosis: Acute Viral Gastroenteritis", "Treatment: Inpatient Admission", "The insurer denied coverage for inpatient admission", "This child appears to have had viral gastroenteritis with loose stools, self-limited vomiting and minimal dehydration that responded to modest intravenous fluid repletion while in the Emergency Department.  The decision to admit her came after she demonstrated a successful oral challenge after a single normal saline bolus and one dose of Zofran, but refused to take additional volume.", "her vomiting never recurred during the admission and no additional anti-emetics were required.", "Her hypoglycemia resolved with supplementation.", "she was able to tolerate fluids in the Emergency Department and a regular diet after admission."], "answer_start": [147, 0, 40, 72, 721, 1988, 2463, 2705]}, "context": "Diagnosis: Acute Viral Gastroenteritis\n\nTreatment: Inpatient Admission\n\nThe insurer denied coverage for inpatient admission\n\nThe denial is upheld\n\nThe patient is a female with a past medical history notable for eczema and recent rhino/enterovirus upper respiratory tract infection with dehydration that presented to the Emergency Department for assessment and management of 1 day of watery, non-bloody stools and non-bloody, non-bilious vomiting.  Her mother notes irritability, fatigue and poor intake of solids but was drinking.  There was no associated fever, rashes, distention, low urine output or weight loss.  Of note the patient had been discharged after a 2-day admission the day prior to this presentation. \n  \nThis child appears to have had viral gastroenteritis with loose stools, self-limited vomiting and minimal dehydration that responded to modest intravenous fluid repletion while in the Emergency Department.  The decision to admit her came after she demonstrated a successful oral challenge after a single normal saline bolus and one dose of Zofran, but refused to take additional volume.  In accordance with a review of the approach to acute viral gastroenteritis in children in resource-rich countries from UpToDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction.   She did not meet any of these criteria to merit the inpatient setting. Her vomiting and loose stool at home prior to anti-emetics that never recurred clearly does not equate to intractable vomiting as stated in the appeal.  In fact, her vomiting never recurred during the admission and no additional anti-emetics were required.\n \nIn regards to her volume status a second review of dehydration in children discusses the elements to assess the degree of dehydration. Uptodate.\n\nThe documentation of this child's appearance and vitals would indicate minimal dehydration that resolved by the time of the decision to admit to the hospital.  A venous lactate of 2.2 is insufficient to estimate her volume status.  Her hypoglycemia resolved with supplementation. After bolus fluid resuscitation in the Emergency Department, anti-emetics and observation the child could have avoided an unnecessary acute care admission.  Clearly the Zofran was sufficient as she was able to tolerate fluids in the Emergency Department and a regular diet after admission.  After a brief period of observation this patient could have been safely discharged with outpatient follow-up.  She actually received no acute care after admission to merit reimbursement at that level except for continued intravenous fluids despite tolerating feeds without issue once permitted. In regards to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the reviews from Uptodate summarizing the approach to nausea/vomiting and dehydration in children in cited above.\n\nUphold denial of coverage for acute inpatient admission. The health plan acted reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for the inpatient admission is upheld.  Medical necessity is not substantiated.\n", "id": "847ee31bf65d4f8d907267c6e631f8a8", "question": "What is the background context in this case summary?", "title": "847ee31bf65d4f8d907267c6e631f8a8", "sufficiency_score": 4}
+{"answers": {"text": ["This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 13.10. Her genitourinary (GU) was at tanner 1. Her Insulin-like Growth Factor 1 (IGF1) was 184. Her height velocity is reported to be 3.4 centimeter (cm) /year.", "Diagnosis: idiopathic short stature", "Treatment: Nutropin", "The insurer denied Nutropin."], "answer_start": [160, 26, 63, 83]}, "context": "Endocrine\nGrowth Hormone\n\nDiagnosis: idiopathic short stature \nTreatment: Nutropin\nThe insurer denied Nutropin. The health plan's determination is overturned.\n\nThis is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 13.10. Her genitourinary (GU) was at tanner 1. Her Insulin-like Growth Factor 1 (IGF1) was 184. Her height velocity is reported to be 3.4 centimeter (cm) /year. \n\nNutropin is medically necessary for this patient. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for \"non-growth hormone-deficient short stature, defined by height SDS (standard deviation score) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means.\"\nThe patient had a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.", "id": "8bac09413f2e455ab6d7ffaba4a51f3c", "question": "What is the background context in this case summary?", "title": "8bac09413f2e455ab6d7ffaba4a51f3c", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Alzheimer's disease and a closed fracture of multiple ribs of the left side with routine healing.", "Treatment: Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.", "The insurer denied coverage for Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.", "This is a female patient with a past medical history of Alzheimer's disease, hyperlipidemia, chronic obstructive pulmonary disease, urinary incontinence, esophageal reflux disease, obesity, iron deficiency anemia, anxiety, diabetes mellitus, hypoxia, a closed fracture of multiple ribs of the left side with routine healing, nausea, interstitial lung disease, Rheumatoid factor positive, polycythemia and pain. She has significant functional impairment associated with various medical conditions. The patient lives with her daughter and grandchildren. She receives consumer directed personal assistance program services (CDPAP) services. The patient was approved for CDPAP 20 hours per week (4 hours per day, 5 days per week). The patient's daughter requested CDPAP 56 hours per week (8 hours per day, 7 days per week) which was denied, but the insurer increased CDPAP services to 5.5 hours per day, 7 days per week; total 38.5 hours per week. The patient's daughter requested an external appeal as designee for the patient.", "Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs); except phone use, stairs, transportation (limited assistance). For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet use. For all other ADLs, the patient needs limited assistance; except bed mobility (supervision)."], "answer_start": [0, 110, 247, 434, 1460]}, "context": "Diagnosis: Alzheimer's disease and a closed fracture of multiple ribs of the left side with routine healing. \nTreatment: Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.\n\nThe insurer denied coverage for Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.  \nThe denial is overturned. \n\nThis is a female patient with a past medical history of Alzheimer's disease, hyperlipidemia, chronic obstructive pulmonary disease, urinary incontinence, esophageal reflux disease, obesity, iron deficiency anemia, anxiety, diabetes mellitus, hypoxia, a closed fracture of multiple ribs of the left side with routine healing, nausea, interstitial lung disease, Rheumatoid factor positive, polycythemia and pain. She has significant functional impairment associated with various medical conditions. The patient lives with her daughter and grandchildren. She receives consumer directed personal assistance program services (CDPAP) services. The patient was approved for CDPAP 20 hours per week (4 hours per day, 5 days per week). The patient's daughter requested CDPAP 56 hours per week (8 hours per day, 7 days per week) which was denied, but the insurer increased CDPAP services to 5.5 hours per day, 7 days per week; total 38.5 hours per week. The patient's daughter requested an external appeal as designee for the patient.\n\nUniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs); except phone use, stairs, transportation (limited assistance). For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet use. For all other ADLs, the patient needs limited assistance; except bed mobility (supervision). \n\nConsidering the patient's medical history, and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present to provide assistance with ADLs and IADLs when needed, including ADLs that occur at unplanned times throughout the day and night, including: toileting, incontinence care, transfers and ambulation. Caregiver assistance is needed to help prevent adverse health and safety events.\n\nAssistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services (in this case CDPAP) are indicated to provide the patient with assistance for daily activities when necessary throughout the day and night. If the patient's care needs become more frequent and/or the family's ability to provide informal care decreases, re-assessment will be needed to determine if CDPAP 8 hours per day can adequately meet the patient's personal care needs.\n\nThe health plan did not act reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for the requested Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. Medical necessity is substantiated.", "id": "1b30e3150e6a40e1bf1253223b009fe5", "question": "What is the background context in this case summary?", "title": "1b30e3150e6a40e1bf1253223b009fe5", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Status Asthmaticus", "Treatment: Inpatient Hospital Admission", "The insurer denied coverage for inpatient hospital admission", "The patient is an obese male with a history of asthma and one previous admission for asthma. He had been sick for three days with upper respiratory infection (URI) symptoms. He then developed difficulty breathing and coughing and received 8 albuterol nebulizer treatments at home. When his respiratory symptoms did not improve with treatment for asthma at home his mother brought him to the Emergency Room (ER) for further treatment. His sister was also sick and had been admitted to the hospital with asthma.  In the ER, he was noted to have an increased work of breathing with tachycardia, shortness of breath, retractions and coarse breath sounds. He was treated with duoneb and albuterol every 2 hours. He required oxygen supplementation with 4 liters of oxygen at 28 percent. He was then switched to continuous albuterol when his breathing rate deteriorated and he became more short of breath. His mother agreed to treatment with intravenous (IV) dexamethasone and magnesium sulfate. His venous blood gas was 7.42 with a partial pressure of carbon dioxide (PCO2) of 42 indicating significant respiratory distress. He was transferred to the Pediatric Intensive Care Unit (PICU) for intensive asthma therapy.", "The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.", "He did require oxygen supplementation for ongoing hypoxemia. He had a history of previous asthma admission and had failed outpatient therapy for asthma exacerbation."], "answer_start": [0, 31, 72, 160, 1375, 3246]}, "context": "Diagnosis: Status Asthmaticus\n\nTreatment: Inpatient Hospital Admission\n\nThe insurer denied coverage for inpatient hospital admission\n\nThe denial is overturned\n\nThe patient is an obese male with a history of asthma and one previous admission for asthma. He had been sick for three days with upper respiratory infection (URI) symptoms. He then developed difficulty breathing and coughing and received 8 albuterol nebulizer treatments at home. When his respiratory symptoms did not improve with treatment for asthma at home his mother brought him to the Emergency Room (ER) for further treatment. His sister was also sick and had been admitted to the hospital with asthma.  In the ER, he was noted to have an increased work of breathing with tachycardia, shortness of breath, retractions and coarse breath sounds. He was treated with duoneb and albuterol every 2 hours. He required oxygen supplementation with 4 liters of oxygen at 28 percent. He was then switched to continuous albuterol when his breathing rate deteriorated and he became more short of breath. His mother agreed to treatment with intravenous (IV) dexamethasone and magnesium sulfate. His venous blood gas was 7.42 with a partial pressure of carbon dioxide (PCO2) of 42 indicating significant respiratory distress. He was transferred to the Pediatric Intensive Care Unit (PICU) for intensive asthma therapy.  \n\nThe insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.\n\nAccording to Sawicki and Haver, \"GENERAL APPROACH - Most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED. Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone, systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit.\"\n\nAccording to Scarfone, \"DISPOSITION - The decision regarding disposition (eg, discharge to home, continued observation, or hospitalization) is based upon both clinical and social factors. Discharge to home - Children who have marked improvement in clinical parameters within the first one to two hours of therapy may be discharged home. Marked improvement is manifested by diminished or absent wheezing and retracting and increased aeration that is sustained at least 60 minutes after the most recent albuterol dose. Hospitalization - Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation.\"\n\nThe patient was treated appropriately in the ER for status asthmaticus. He did require oxygen supplementation for ongoing hypoxemia. He had a history of previous asthma admission and had failed outpatient therapy for asthma exacerbation. His hypoxemia and respiratory distress with elevated venous pCO2 of 42 demonstrated that he was not stable enough to be discharged. The decision to admit him to the hospital for ongoing treatment was appropriate and consistent with the standard of care for status asthmaticus. \n\nThe health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.\n\nThe insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.\n\n", "id": "dada4f7b57f54a09ad8e36786957d94a", "question": "What is the background context in this case summary?", "title": "dada4f7b57f54a09ad8e36786957d94a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with psoriasis. He has tried and failed betamethasone for one year. He has been on Ilumya with great improvement; his body surface area affected is currently 0%. The subject under review is the medical necessity of the Ilumya 100 milligrams per milliliter (MG/ML).", "Diagnosis: Skin Disorders.", "Treatment: Pharmacy/Prescription Drugs.", "The insurer denied Ilumya 100 milligrams per milliliter (MG/ML)."], "answer_start": [159, 0, 28, 69]}, "context": "Diagnosis: Skin Disorders. \nTreatment: Pharmacy/Prescription Drugs. \nThe insurer denied Ilumya 100 milligrams per milliliter (MG/ML). \nThe denial is upheld. \n\nThe patient is a male with psoriasis. He has tried and failed betamethasone for one year. He has been on Ilumya with great improvement; his body surface area affected is currently 0%. The subject under review is the medical necessity of the Ilumya 100 milligrams per milliliter (MG/ML).\n\nThe health plan's determination is upheld in whole.\n\nThe requested health treatment of Ilumya 100MG/ML is not medically necessary for this patient. There is no documentation that the patient has tried and failed, has an intolerance to, or contraindication to the preferred therapies, making Ilumya medically necessary.\nThere is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Ilumya for this patient's condition as an accepted standard of practice in the U.S.\nThere are no comparative, controlled studies showing that Ilumya has a superior efficacy to the health plan's preferred alternatives, such as phototherapy and methotrexate.\nWithin the peer-reviewed literature, Racz et al. writes \"Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks\" (2). Mehta et al. writes \"Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>)10 % affected body surface area who have not responded to topical treatments...narrow band ultraviolet B (NB-UVB) ...effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile\" (3).\nAdditionally, West et al. 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (4).\nPer the medical and scientific literature and/or evidence based clinical practice guidelines, and the documentation provided, the request for Ilumya is not necessary. The patient has not tried and/or failed a preferred agent. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Ilumya medically more appropriate than the other options. Therefore, the administration of Ilumya is not strongly supported for this patient and is not medically necessary.", "id": "d3dd6e7d260a4f5ebd201e475198715c", "question": "What is the background context in this case summary?", "title": "d3dd6e7d260a4f5ebd201e475198715c", "sufficiency_score": 4}
+{"answers": {"text": ["This is a male patient who was admitted to the hospital for alcohol detoxification, as he had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis.  He reportedly was requesting detoxification from alcohol and cocaine.  He reportedly was drinking 1/2 bottle of whiskey and 5-6 beers daily as well as cocaine daily and cannabis daily.  He reportedly occasionally used ecstasy.  His chest x-ray reportedly revealed pleural effusion, left basilar lung infiltrate, and atelectasis.  He reportedly was put on a Librium taper and also had intravenous (IV) Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.", "He reportedly had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis, pleural effusion, left basilar lung infiltrate, and atelectasis and had a history of pulmonary embolism and deep vein thrombosis.  He was considered a medical risk and due to his multiple medical issues and he had reports of active alcohol moderate withdrawal symptoms including tremors, nausea, headache, and sensitivity to light.  He was put on a Librium taper and also had IV Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.", "Diagnosis: Alcohol withdrawal.", "Treatment: Inpatient hospital admission.", "The insurer denied coverage for the inpatient hospital admission."], "answer_start": [168, 2033, 0, 31, 73]}, "context": "Diagnosis: Alcohol withdrawal.\nTreatment: Inpatient hospital admission.\n\nThe insurer denied coverage for the inpatient hospital admission.  The denial is overturned. \n\nThis is a male patient who was admitted to the hospital for alcohol detoxification, as he had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis.  He reportedly was requesting detoxification from alcohol and cocaine.  He reportedly was drinking 1/2 bottle of whiskey and 5-6 beers daily as well as cocaine daily and cannabis daily.  He reportedly occasionally used ecstasy.  His chest x-ray reportedly revealed pleural effusion, left basilar lung infiltrate, and atelectasis.  He reportedly was put on a Librium taper and also had intravenous (IV) Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.  \n\nThe American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with co-morbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to large amounts of daily alcohol use, and also was using cocaine daily, and he reportedly had  co-morbid medical issues complicating the management of withdrawal.  He reportedly had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis, pleural effusion, left basilar lung infiltrate, and atelectasis and had a history of pulmonary embolism and deep vein thrombosis.  He was considered a medical risk and due to his multiple medical issues and he had reports of active alcohol moderate withdrawal symptoms including tremors, nausea, headache, and sensitivity to light.  He was put on a Librium taper and also had IV Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids. \n\nAccording to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting  as he continued to use large amounts of  alcohol and cocaine daily despite medical issues and he required and needed detoxification medication to modify withdrawal including a Librium taper and needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then, including severe and life threatening withdrawal symptoms.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues putting him at risk medically as well and required 24-hour hospital treatment. \n\nIt did not appear that the health care plan acted reasonably or in the best interests of the patient then.\n\nThe insurer's denial of coverage for the inpatient hospital admission is overturned.  Medical Necessity is substantiated.", "id": "2725200fee6b4f4fb008adb7f50a912f", "question": "What is the background context in this case summary?", "title": "2725200fee6b4f4fb008adb7f50a912f", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Overbite.", "Treatment: D8080 Comprehensive Orthodontic Treatment (Braces) and D8670 Periodic Orthodontic Treatment Visit, Pre-service.", "The insurer denied the D8080 Comprehensive Orthodontic Treatment and D8670 Periodic Orthodontic Treatment Visit, Pre-service.", "The patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and periodic orthodontic monthly visits.", "Patient presents with skeletal Class I relationship, Class II Canines, moderate maxillary and mandibular spacing, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.", "The health plan denied the treatment because it states that it is not medically necessary. The provider appealed based on the conditions and diagnoses with which the patient presented.", "The patient presents with a very deep overbite (greater than 50%). More than 50% of the anterior lower front teeth are covered by the upper teeth. In this case, the biting edge of the lower front teeth are biting into the gums of the upper front teeth when the patient closes their mouth."], "answer_start": [0, 21, 144, 297, 434, 635, 926]}, "context": "Diagnosis: Overbite.\nTreatment: D8080 Comprehensive Orthodontic Treatment (Braces) and D8670 Periodic Orthodontic Treatment Visit, Pre-service.\nThe insurer denied the D8080 Comprehensive Orthodontic Treatment and D8670 Periodic Orthodontic Treatment Visit, Pre-service.\nThe denial is overturned.\n\nThe patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and periodic orthodontic monthly visits.\n\nPatient presents with skeletal Class I relationship, Class II Canines, moderate maxillary and mandibular spacing, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.\n\nThe health plan denied the treatment because it states that it is not medically necessary. The provider appealed based on the conditions and diagnoses with which the patient presented.\n\nYes, the orthodontic therapy (Braces) and periodic orthodontic treatment visits are medically necessary.\nThe patient presents with a very deep overbite (greater than 50%). More than 50% of the anterior lower front teeth are covered by the upper teeth. In this case, the biting edge of the lower front teeth are biting into the gums of the upper front teeth when the patient closes their mouth. This is evident on the intra-oral photos of the upper anterior gum area.\n\nA severe overbite like this can result in gum recession, and eventually gum disease and possible tooth loss. Difficulty with speech and chewing are also a possible consequence of this condition.\n\nTherefore, given the above, the braces and visits are medically necessary.\n\nAs evidenced in the x-rays and the photos, the severity of the overbite and the other conditions of the patient's dentition warrants orthodontic treatment.\n\nThe long-term consequences of not treating these conditions would lead to more complications of the patient's dentition, and would thus affect the patient's overall health.", "id": "962eac8c50f4493580a05e074e9014c2", "question": "What is the background context in this case summary?", "title": "962eac8c50f4493580a05e074e9014c2", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Low Platelets", "Treatment: T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing", "The insurer denied the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing.", "The patient is a female.  She has a history of thrombocytopenia.  This had been present for one year.  She was noted to have positive antiphospholipid antibody titers.  It was noted that she had splenic lesions that felt consistent with splenic lymphangiomatosis.", "Bone marrow biopsy was done and revealed mild fibrosis and normal hematopoiesis.  Flow cytometry revealed mild T-cell immunophenotypic changes.", "The patient's CBC (complete blood count) was notable for normal white cell count, normal hemoglobin, and platelet count of 118.  CBC (complete blood count) testing prior was notable for mild leukopenia.", "No treatment was recommended, but the patient's physician ordered a blood T-cell clonality study.", "The patient had a bone marrow biopsy done that revealed", "T-cell immunophenotypic changes"], "answer_start": [0, 25, 112, 235, 500, 645, 849, 1131, 1194]}, "context": "Diagnosis: Low Platelets\nTreatment: T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing\nThe insurer denied the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing.\nThe denial is upheld.\n\nThe patient is a female.  She has a history of thrombocytopenia.  This had been present for one year.  She was noted to have positive antiphospholipid antibody titers.  It was noted that she had splenic lesions that felt consistent with splenic lymphangiomatosis.\n\nBone marrow biopsy was done and revealed mild fibrosis and normal hematopoiesis.  Flow cytometry revealed mild T-cell immunophenotypic changes.\n\nThe patient's CBC (complete blood count) was notable for normal white cell count, normal hemoglobin, and platelet count of 118.  CBC (complete blood count) testing prior was notable for mild leukopenia.\n\nNo treatment was recommended, but the patient's physician ordered a blood T-cell clonality study.\n\nNo, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.\n\nThere is no evidence supporting the medical necessity of this test.  The patient had a bone marrow biopsy done that revealed \"mild\" T-cell immunophenotypic changes, but did not reveal clear evidence suggesting presence of T-cell lymphoma.  There is no abnormal white cell population noted in peripheral blood.  There is no neutropenia.  Cytopenias are a presenting finding in patients with T-cell large granular lymphocytic leukemia, but there is also no indication that this patient has been found to have an abnormal population of LGL (large granular lymphocyte) cells.  Also, LGL (large granular lymphocyte) leukemia is commonly associated with neutropenia, and CBC (comprehensive blood count) testing in this case is not notable for neutropenia.\n\nTherefore, given the above, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.", "id": "0aa9fb670c7f4db7972b6324ae48ac2e", "question": "What is the background context in this case summary?", "title": "0aa9fb670c7f4db7972b6324ae48ac2e", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with gastroesophageal reflux disease (GERD) complicated by Barrett's esophagus, hiatal hernia status post Nissen's fundoplication, peptic ulcer disease with duodenal ulcer, and gastroparesis. He has had chronic dyspepsia and abdominal discomfort. He could not tolerate sucralfate tablets. Coverage is being requested for sucralfate suspension.", "The submitted documentation reports that the patient attempted and failed sucralfate tablets in the past.", "Diagnosis: Gastroesophageal reflux disease without esophagitis.", "Treatment: Sucralfate suspension.", "The insurer denied Sucralfate suspension."], "answer_start": [174, 590, 0, 64, 98]}, "context": "Diagnosis: Gastroesophageal reflux disease without esophagitis.\nTreatment: Sucralfate suspension.\nThe insurer denied Sucralfate suspension.\nThe determination is overturned.\n\nThe patient is a male with gastroesophageal reflux disease (GERD) complicated by Barrett's esophagus, hiatal hernia status post Nissen's fundoplication, peptic ulcer disease with duodenal ulcer, and gastroparesis. He has had chronic dyspepsia and abdominal discomfort. He could not tolerate sucralfate tablets. Coverage is being requested for sucralfate suspension.\n\nA formulary exception is indicated in this case. The submitted documentation reports that the patient attempted and failed sucralfate tablets in the past. Sucralfate (Carafate) is effective for the treatment of gastroesophageal reflux disease (GERD) symptoms. It is also effective for the treatment of peptic ulcer disease and dyspepsia associated with duodenogastric reflux. Sucralfate is available in tablet and liquid suspension forms, with similar reported efficacy and adverse effects, although the suspension has different physical characteristics which can result in easier traversion of the esophagus and different physical distribution in the stomach. As the patient has failed the tablet form, use of the suspension can be effective.", "id": "7d394ee71ebf48c796497807efc43660", "question": "What is the background context in this case summary?", "title": "7d394ee71ebf48c796497807efc43660", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Low Red Blood Cell Count (anemia).", "Treatment: Inpatient admission.", "The insurer denied the inpatient admission.", "The patient is a male with history of NSAID (nonsteroidal anti-inflammatory drug) use. He presented to the ER (emergency room) with anemia. As an outpatient, his Hgb (hemoglobin) was 7.3. He had recent black stool. He complained of some epigastric pain. He denied any NV (nausea and vomiting), hemetemesis, bright red blood per rectum or current melena.", "The patient was hemodynamically stable. His Hgb (hemoglobin) was 7.4. He was transfused 2 units of PRBCs (packed red blood cells).", "Day two, the patient's Hgb (hemoglobin) was 9.3. He was placed on PPIs (proton pump inhibitors) and seen by GI (gastroenterology). EGD (esophagogastroduodenoscopy) was scheduled.", "On day two, three and four, there was no hemetemesis, melena or bright red blood per rectum.", "On day five, Hgb (hemoglobin) was 10.7. EGD (esophagogastroduodenoscopy) revealed a duodenal ulcer, and the patient was discharged."], "answer_start": [0, 46, 78, 145, 500, 632, 812, 906]}, "context": "Diagnosis: Low Red Blood Cell Count (anemia).\nTreatment: Inpatient admission.\nThe insurer denied the inpatient admission.\nThe denial is upheld.\n\nThe patient is a male with history of NSAID (nonsteroidal anti-inflammatory drug) use. He presented to the ER (emergency room) with anemia. As an outpatient, his Hgb (hemoglobin) was 7.3. He had recent black stool. He complained of some epigastric pain. He denied any NV (nausea and vomiting), hemetemesis, bright red blood per rectum or current melena.\n\nThe patient was hemodynamically stable. His Hgb (hemoglobin) was 7.4. He was transfused 2 units of PRBCs (packed red blood cells).\n\nDay two, the patient's Hgb (hemoglobin) was 9.3. He was placed on PPIs (proton pump inhibitors) and seen by GI (gastroenterology). EGD (esophagogastroduodenoscopy) was scheduled.\n\nOn day two, three and four, there was no hemetemesis, melena or bright red blood per rectum.\n\nOn day five, Hgb (hemoglobin) was 10.7. EGD (esophagogastroduodenoscopy) revealed a duodenal ulcer, and the patient was discharged.\n\nNo, the Inpatient admission was not medically necessary.\nThe patient was hemodynamically stable, without evidence of active bleeding. He had no sepsis, coagulopathy, history of cirrhosis or any other significant co-morbidities. Therefore, treatment at a lower level care status was medically appropriate on day one. On day two, when his Hgb (hemoglobin) was up to 9.3, the patient was medically stable for discharge to outpatient care, or for EGD (esophagogastroduodenoscopy) at a lower level of care, and then discharged. Acute inpatient hospital stay was not medically necessary.\n\nYes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.\nAs above, as a lower level of care status was medically appropriate, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying the acute inpatient hospital stay.\n", "id": "48b1f32efbd44fd8a7a60afde158caed", "question": "What is the background context in this case summary?", "title": "48b1f32efbd44fd8a7a60afde158caed", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has been recommended to undergo bilateral sclerotherapy due to failure of conservative treatment.  The documentation indicated she has had a trial of conservative care.  This included over-the-counter medication in addition to elevation as well as compression without relief.  She continues to suffer from ongoing pain and has had treatment with the bilateral phlebectomy.  Later, she was seen with complaints of bilateral lower extremity symptomatic varicose veins.  The physical examination revealed there was mild edema bilaterally to the lower extremities.  Motor and sensation were intact.  Her bilateral leg incisions were well-healing and there were dense clusters of spider veins bilaterally.  The documentation indicated she had bilateral lower extremity symptomatic varicose veins despite compression in the absence of reflux and therefore it was recommended she undergo a bilateral sclerotherapy procedure.  A duplex revealed no evidence of venous reflux to the right lower extremity with evidence of focal venous reflux in the small saphenous vein to the left lower extremity.", "Diagnosis: Bilateral Lower Extremity Symptomatic Varicose Veins", "Treatment: Sclerotherapy", "The insurer denied coverage for sclerotherapy."], "answer_start": [162, 0, 65, 91]}, "context": "Diagnosis: Bilateral Lower Extremity Symptomatic Varicose Veins\n\nTreatment: Sclerotherapy\n\nThe insurer denied coverage for sclerotherapy.\n\nThe denial is upheld.\n\nThe patient has been recommended to undergo bilateral sclerotherapy due to failure of conservative treatment.  The documentation indicated she has had a trial of conservative care.  This included over-the-counter medication in addition to elevation as well as compression without relief.  She continues to suffer from ongoing pain and has had treatment with the bilateral phlebectomy.  Later, she was seen with complaints of bilateral lower extremity symptomatic varicose veins.  The physical examination revealed there was mild edema bilaterally to the lower extremities.  Motor and sensation were intact.  Her bilateral leg incisions were well-healing and there were dense clusters of spider veins bilaterally.  The documentation indicated she had bilateral lower extremity symptomatic varicose veins despite compression in the absence of reflux and therefore it was recommended she undergo a bilateral sclerotherapy procedure.  A duplex revealed no evidence of venous reflux to the right lower extremity with evidence of focal venous reflux in the small saphenous vein to the left lower extremity.\n\nThe proposed sclerotherapy treatments bilaterally are not medically necessary.  There is no evidence of reflux in the right lower extremity.  There is reflux in the left lower extremity, but the degree and severity of reflux in the left sapheno-popliteal junction is not quantified on the venous reflux report.\n\nThe health plan acted reasonably with sound medical judgment in the best interest of the patient.\n\nBased on the above, the medical necessity for the sclerotherapy is not substantiated. The insurer's denial is upheld.", "id": "2ecc1e84741d49ed83465d13e2ba8e33", "question": "What is the background context in this case summary?", "title": "2ecc1e84741d49ed83465d13e2ba8e33", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a large nodule that was previously shown to be benign. She has a large and enlarging nodule that is now 6 cm (centimeters).", "Diagnosis: Thyroid nodule.", "Treatment: Thyroid Radiofrequency Ablation.", "The insurer denied the Thyroid Radiofrequency Ablation.", "The patient is a female diagnosed with solitary right 6 cm (centimeter) thyroid nodule. This request is for Thyroid Radiofrequency Ablation.", "As reported, the patient has history of indeterminate thyroid biopsies. Her most recent ultrasound showed normal cervical lymph nodes and no evidence of left nodule. Her FNA (fine needle aspiration) showed right nodule 6 cm (centimeters) (Bethesda category 3). Thyroseq was negative. Her FNA (fine needle aspiration) approximately two years ago showed right nodule 4 cm (centimeters); suspicious for follicular Neoplasm; hurthle cell (Bethesda category 4); Thyroseq was negative."], "answer_start": [1206, 0, 27, 71, 154, 296]}, "context": "Diagnosis: Thyroid nodule.\nTreatment: Thyroid Radiofrequency Ablation.\nThe insurer denied the Thyroid Radiofrequency Ablation.\nThe denial is overturned.\n\nThe patient is a female diagnosed with solitary right 6 cm (centimeter) thyroid nodule. This request is for Thyroid Radiofrequency Ablation.\n\nAs reported, the patient has history of indeterminate thyroid biopsies. Her most recent ultrasound showed normal cervical lymph nodes and no evidence of left nodule. Her FNA (fine needle aspiration) showed right nodule 6 cm (centimeters) (Bethesda category 3). Thyroseq was negative. Her FNA (fine needle aspiration) approximately two years ago showed right nodule 4 cm (centimeters); suspicious for follicular Neoplasm; hurthle cell (Bethesda category 4); Thyroseq was negative.\n\nYes, the Thyroid Radiofrequency Ablation is medically necessary.\nThe American Association of clinical endocrinologists guidelines [1] recommend radiofrequency ablation of solid thyroid nodules if they are large or symptomatic. This is grade A evidence. The solid component of the nodules should be sampled prior to ablation to show the absence of malignancy. This is supported by multiple studies including a meta-analysis [2].\n\nThe patient has a large nodule that was previously shown to be benign. She has a large and enlarging nodule that is now 6 cm (centimeters).\n\nThe request is not for the convenience of the patient or provider. It is not part of a study. It is clinically appropriate. The request for radiofrequency ablation of the nodule is consistent with generally accepted standards of medical practice and is therefore medically necessary.\n\nNo, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, as the request is medically necessary as described above.", "id": "feaf9b9ea0c64348b018404739d89a22", "question": "What is the background context in this case summary?", "title": "feaf9b9ea0c64348b018404739d89a22", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has Crohn's disease status post total colectomy with ileoanal pouch anastomosis. The patient has failed prednisone, antibiotics, cyclosporine, and Remicade. The patient was started on Stelara. Due to only partial improvement, the dose was escalated to every 4 weeks with good control of disease. The coverage is requested to continue Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.", "In this case, the patient has failed Stelara every 8 weeks, and has had disease control on Stelara 90 mg every 4 weeks", "Diagnosis: Crohn's Disease", "Treatment: Stelara (90 mg every 4 weeks)", "The insurer denied Stelara (90 mg every 4 weeks)."], "answer_start": [167, 1908, 0, 27, 68]}, "context": "Diagnosis: Crohn's Disease\nTreatment: Stelara (90 mg every 4 weeks)\nThe insurer denied Stelara (90 mg every 4 weeks). \nThe health plan's determination is overturned.\n\nThe patient has Crohn's disease status post total colectomy with ileoanal pouch anastomosis. The patient has failed prednisone, antibiotics, cyclosporine, and Remicade. The patient was started on Stelara. Due to only partial improvement, the dose was escalated to every 4 weeks with good control of disease. The coverage is requested to continue Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.\n\nThe request for Stelara to 90 mg every 4 weeks is supported as medically necessary by current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease and pouchitis [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. In this case, the patient has severe disease based on need for surgery. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% (percent) of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that \"Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy\" [4]. In this case, the patient has failed Stelara every 8 weeks, and has had disease control on Stelara 90 mg every 4 weeks; discontinuation of dosing every 4 weeks (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease. For all of these reasons, continuation of Stelara 90 mg every 4 weeks is supported to be more beneficial than any standard treatment or treatments in this case and is medically necessary by current medical literature.", "id": "922d57da9bb440af830f6e7cbcde92ac", "question": "What is the background context in this case summary?", "title": "922d57da9bb440af830f6e7cbcde92ac", "sufficiency_score": 4}
+{"answers": {"text": ["In this child's case, she was an infant at the time of her scald burn. She sustained second degree burns of her right-hand including fingers and joints. She was initially managed in the ED, but following initial wound care, was placed in observation status for the first wound care/dressing change. Upon evaluation, the burn was considerably deeper in some areas than previously thought. She was converted at that time to full inpatient status, and local wound care was continued.", "Diagnosis: Trauma/Injuries.", "Treatment: Inpatient Hospital.", "The insurer denied inpatient stay.", "The patient is a female who was taken to the emergency department (ED) following scald burn to the right hand. Hot tea spilled on her right hand from a tea kettle. She was treated with Tylenol and running under cool water at home with some symptomatic relief.", "Vital signs included temperature 98.6, heart rate 132, respiratory rate 28, and blood pressure 104/69. Examination was significant for no acute distress, mild tachycardia, moist mucous membranes, blistering on the first three digits crossing the metacarpal joint line with surrounding erythema, and blistering of the palm and radial aspect of the fourth digit. She was diagnosed with second-degree partial thickness burn of 0.5% body surface area involving the right hand. She was treated with ibuprofen and fentanyl. Laboratory evaluation was significant for leukocytosis (white blood cell [WBC] count 22.06 thousand [K]). The burn service was consulted with recommendation for admission for observation. Admission orders included physical therapy (PT)/occupational therapy (OT) evaluation, non-excisional debridement and cleansing with chlorhexidine, daily wound care with collagenase and gentamicin, attending wound check after 24 hours of collagenase and gentamicin, pain control as needed, and diet as tolerated.", "The following day, her pain was well-controlled, she was eating and drinking, and she was afebrile. However, during the wound check, the burns appeared to be significantly deeper than initially thought. At that point, her status was converted from observation level of care to acute inpatient level of care for continuing local wound care and ongoing re-evaluation of her wound status. There was some consideration for discharge, but upon wound evaluation during dressing change, the burns on the dorsum of the fingers were still quite deep. The palmar aspect of the hand was healing quite well. Local wound care was continued with collagenase and gentamicin using ibuprofen and morphine for pain management, and consideration was given for possible surgical intervention. During wound evaluation, there was still a small section on the dorsum of the index finger extending down into the first web space that was fairly deep, but the remainder of the wounds were healing well. Local wound care was recommended, and family teaching was initiated. She underwent dressing change, at which time the wounds were placed into Mepilex. She was discharged home for follow-up in Burn Clinic."], "answer_start": [2809, 0, 29, 61, 124, 384, 1402]}, "context": "Diagnosis: Trauma/Injuries. \nTreatment: Inpatient Hospital. \nThe insurer denied inpatient stay. \nThe denial is overturned.\n\nThe patient is a female who was taken to the emergency department (ED) following scald burn to the right hand. Hot tea spilled on her right hand from a tea kettle. She was treated with Tylenol and running under cool water at home with some symptomatic relief.\nVital signs included temperature 98.6, heart rate 132, respiratory rate 28, and blood pressure 104/69. Examination was significant for no acute distress, mild tachycardia, moist mucous membranes, blistering on the first three digits crossing the metacarpal joint line with surrounding erythema, and blistering of the palm and radial aspect of the fourth digit. She was diagnosed with second-degree partial thickness burn of 0.5% body surface area involving the right hand. She was treated with ibuprofen and fentanyl. Laboratory evaluation was significant for leukocytosis (white blood cell [WBC] count 22.06 thousand [K]). The burn service was consulted with recommendation for admission for observation. Admission orders included physical therapy (PT)/occupational therapy (OT) evaluation, non-excisional debridement and cleansing with chlorhexidine, daily wound care with collagenase and gentamicin, attending wound check after 24 hours of collagenase and gentamicin, pain control as needed, and diet as tolerated.\nThe following day, her pain was well-controlled, she was eating and drinking, and she was afebrile. However, during the wound check, the burns appeared to be significantly deeper than initially thought. At that point, her status was converted from observation level of care to acute inpatient level of care for continuing local wound care and ongoing re-evaluation of her wound status. There was some consideration for discharge, but upon wound evaluation during dressing change, the burns on the dorsum of the fingers were still quite deep. The palmar aspect of the hand was healing quite well. Local wound care was continued with collagenase and gentamicin using ibuprofen and morphine for pain management, and consideration was given for possible surgical intervention. During wound evaluation, there was still a small section on the dorsum of the index finger extending down into the first web space that was fairly deep, but the remainder of the wounds were healing well. Local wound care was recommended, and family teaching was initiated. She underwent dressing change, at which time the wounds were placed into Mepilex. She was discharged home for follow-up in Burn Clinic.\n\nAcute inpatient stay was medically necessary and appropriate for this infant. She had initially been admitted observation status but because of the severity of the burn was appropriately converted to acute inpatient status. In this child's case, she was an infant at the time of her scald burn. She sustained second degree burns of her right-hand including fingers and joints. She was initially managed in the ED, but following initial wound care, was placed in observation status for the first wound care/dressing change. Upon evaluation, the burn was considerably deeper in some areas than previously thought. She was converted at that time to full inpatient status, and local wound care was continued. As the burn injury continued to progress, there was even consideration for surgical intervention. Based on the current standard of care and the evolving damage that became evident over time during wound care, acute inpatient status was medically necessary and appropriate. Her medical needs exceeded what could be proved as observation status.", "id": "69ee8b9de81841b48a7bccb0e835ede5", "question": "What is the background context in this case summary?", "title": "69ee8b9de81841b48a7bccb0e835ede5", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a woman with relapsing remitting multiple sclerosis who is currently taking Tecfidera. She was previously on Copaxone and switched to Tecfidera due to breakthrough disease. She is currently stable on Tecfidera. The request for continued Tecfidera was previously denied as brand name Tecfidera is not in the plan formulary and it has not been documented that patient has tried and is intolerant of generic dimethyl fumarate.", "Diagnosis: Multiple Sclerosis.", "Treatment: Tecfidera DR 240mg.", "The insurer denied the Tecfidera DR 240mg."], "answer_start": [128, 0, 31, 62]}, "context": "Diagnosis: Multiple Sclerosis.\nTreatment: Tecfidera DR 240mg.\nThe insurer denied the Tecfidera DR 240mg.\nThe denial is upheld.\n\nThe patient is a woman with relapsing remitting multiple sclerosis who is currently taking Tecfidera. She was previously on Copaxone and switched to Tecfidera due to breakthrough disease. She is currently stable on Tecfidera. The request for continued Tecfidera was previously denied as brand name Tecfidera is not in the plan formulary and it has not been documented that patient has tried and is intolerant of generic dimethyl fumarate.\n\nNo, the Tecfidera is not medically necessary.\n\nThe Tecfidera is not medically necessary, as no justification or rationale is provided as to why there is a medical exception for continuation of Tecfidera without trying generic dimethyl fumarate, which has been approved by the FDA (United States Food and Drug Administration). There is no available data comparing Tecfidera and generic dimethyl fumarate in regards to efficacy and safety.\n\nTherefore, the Tecfidera is not medically necessary.\n\nYes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.\nDimethyl fumarate in the generic form is the same ingredient as Tecfidera, and there is no evidence in the medical literature that supports the use of Tecfidera over generic dimethyl fumarate.", "id": "49b172b594f74613ab80278b7ea7d06a", "question": "What is the background context in this case summary?", "title": "49b172b594f74613ab80278b7ea7d06a", "sufficiency_score": 4}
+{"answers": {"text": ["The patient in question is a male with a Class I occlusion with 5 millimeter (mm) overbite and 3mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics (braces) to correct his malocclusion. ", "Diagnosis: Class I Occlusion\nTreatment: Braces", "The insurer denied braces."], "answer_start": [121, 0, 48]}, "context": "Diagnosis: Class I Occlusion\nTreatment: Braces\n\nThe insurer denied braces. \nThe health plan's determination is upheld. \n\nThe patient in question is a male with a Class I occlusion with 5 millimeter (mm) overbite and 3mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics (braces) to correct his malocclusion. \n\nThere is no medical reason to correct this patient's malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6 mm. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.", "id": "6875caff2656468ea68b13c2b7896e01", "question": "What is the background context in this case summary?", "title": "6875caff2656468ea68b13c2b7896e01", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Status Post 2 Kidney Transplants.", "Treatment: Egg Retrieval with Fertilization of the Eggs.", "The patient is a gravida 1, para 0, elective abortion (EAB) 1 female with a history of focal glomerulosclerosis, which has resulted in kidney failure necessitating a kidney transplant. She has had two kidney transplants. She is currently on multiple immunosuppressive medications that would need to be reduced, stopped, or switched in order for the patient to attempt pregnancy, and doing so could endanger her transplant. An evaluation from her nephrologist and a maternal-fetal medicine physician all state that they discourage the patient from conceiving and attempting to carry a pregnancy on her own due to significant health risks. These risks include renal transplant rejection, pre-eclampsia, eclampsia, fetal growth retardation and further worsening of her renal function. She also is an insulin dependent diabetic and has hypertension. She has had loop electrosurgical excision procedure (LEEP) procedure for cervical dysplasia. There are no records or testing showing the patient's fertility potential or any studies detailing evidence of her fertility status. No semen analysis was given.", "The patient is requesting in vitro fertilization (IVF) which requires ovarian stimulation, egg retrieval, fertilization of oocytes to create embryos and freezing of embryos for future use. It is her intent to use a gestational surrogate to carry the pregnancy due to her multiple medical issues that make her carrying the pregnancy a significant potential risk to her health and well-being.", "The request for services have been denied as the patient does not meet criteria for the use of IVF treatment."], "answer_start": [0, 46, 194, 1296, 1688]}, "context": "Diagnosis: Status Post 2 Kidney Transplants. \nTreatment: Egg Retrieval with Fertilization of the Eggs. \n\nThe insurer denied Egg Retrieval with Fertilization of the Eggs.  The denial is upheld.\n\nThe patient is a gravida 1, para 0, elective abortion (EAB) 1 female with a history of focal glomerulosclerosis, which has resulted in kidney failure necessitating a kidney transplant. She has had two kidney transplants. She is currently on multiple immunosuppressive medications that would need to be reduced, stopped, or switched in order for the patient to attempt pregnancy, and doing so could endanger her transplant. An evaluation from her nephrologist and a maternal-fetal medicine physician all state that they discourage the patient from conceiving and attempting to carry a pregnancy on her own due to significant health risks. These risks include renal transplant rejection, pre-eclampsia, eclampsia, fetal growth retardation and further worsening of her renal function. She also is an insulin dependent diabetic and has hypertension. She has had loop electrosurgical excision procedure (LEEP) procedure for cervical dysplasia. There are no records or testing showing the patient's fertility potential or any studies detailing evidence of her fertility status. No semen analysis was given.\n\nThe patient is requesting in vitro fertilization (IVF) which requires ovarian stimulation, egg retrieval, fertilization of oocytes to create embryos and freezing of embryos for future use. It is her intent to use a gestational surrogate to carry the pregnancy due to her multiple medical issues that make her carrying the pregnancy a significant potential risk to her health and well-being.\n\nThe request for services have been denied as the patient does not meet criteria for the use of IVF treatment. \n\nThe health plan's determination is upheld.\n\nThe requested egg retrieval with fertilization of the eggs is not medically necessary for this patient.\n\nThere have been no studies to determine the patient's fertility status. Given her age, she may not meet criteria for starting fertility treatment. There is no evaluation of her partner to determine if there are any infertility issues. The patient does not meet standard criteria for IVF treatment.\n\nBased on the standard of care, it is reasonable to consider IVF for this patient due to her medical condition (chronic renal failure with renal transplant).  However, there was no evidence presented to show what her fertility potential is and/or any information on her reproductive history.  Without fully evaluating this patient to even see if she is a candidate for infertility treatment, one cannot approve aggressive treatment.  Standard of care requires that a patient and her partner have an initial work-up to look for all potential infertility issues.  None of this was done.  Therefore, this patient does not meet standard criteria for IVF. ", "id": "43086210da614ee69f6a8c48ce360244", "question": "What is the background context in this case summary?", "title": "43086210da614ee69f6a8c48ce360244", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male was admitted to this inpatient hospital for cellulitis of both legs, hematoma, and deep vein thrombosis (DVT) in his arm, and alcohol detoxification. He had a Clinical Institute Withdrawal Assessment Alcohol (CIWA) score of 9 and was very tremulous, agitated, nauseous, had anxiety, headache, and tactile hallucinations of bugs crawling on him. He was verbally abusive to staff. The patient was drinking 3 liters of alcohol per day. He reportedly was homeless. He had a diagnosis of schizophrenia, gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD). The patient was involved in an altercation prior to admission and fell and was hurt. He was given Ativan 2 mg (milligrams) and put on an Ativan CIWA protocol and taper which concluded. He reportedly was put on 2 intravenous (IV) antibiotics including Cefazolin and Clindamycin for cellulitis and fungal treatment, and also given Lovenox for his DVT. The patient was discharged when his IV antibiotics were completed, and he was given oral antibiotics including Keflex and Eliquis for his DVT. ", "Diagnosis: Alcohol Withdrawal.", "Treatment: Inpatient Admission.", "The insurer denied coverage for inpatient admission.", "He also had significant medical problems including cellulitis and DVT requiring IV antibiotics and Lovenox. He reportedly was homeless with a diagnosis of schizophrenia", "He was put on a CIWA protocol with an Ativan taper for alcohol detoxification", "He also was homeless and lacked supports and coping skills and the ability to care for his acute medical needs."], "answer_start": [149, 0, 32, 66, 2819, 3066, 3789]}, "context": "Diagnosis: Alcohol Withdrawal. \nTreatment: Inpatient Admission. \n\nThe insurer denied coverage for inpatient admission. \n\nThe denial is overturned. \n\nThe patient is a male was admitted to this inpatient hospital for cellulitis of both legs, hematoma, and deep vein thrombosis (DVT) in his arm, and alcohol detoxification. He had a Clinical Institute Withdrawal Assessment Alcohol (CIWA) score of 9 and was very tremulous, agitated, nauseous, had anxiety, headache, and tactile hallucinations of bugs crawling on him. He was verbally abusive to staff. The patient was drinking 3 liters of alcohol per day. He reportedly was homeless. He had a diagnosis of schizophrenia, gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD). The patient was involved in an altercation prior to admission and fell and was hurt. He was given Ativan 2 mg (milligrams) and put on an Ativan CIWA protocol and taper which concluded. He reportedly was put on 2 intravenous (IV) antibiotics including Cefazolin and Clindamycin for cellulitis and fungal treatment, and also given Lovenox for his DVT. The patient was discharged when his IV antibiotics were completed, and he was given oral antibiotics including Keflex and Eliquis for his DVT. \n    \nThe American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. \n\nAlso, the US (United States) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had several comorbid medical conditions complicating the management of withdrawal and he had past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment. \n\nHe also had significant medical problems including cellulitis and DVT requiring IV antibiotics and Lovenox. He reportedly was homeless with a diagnosis of schizophrenia and was unable to care for his medical needs if not in this 24-hour hospital. He was put on a CIWA protocol with an Ativan taper for alcohol detoxification which was complete but still required hospitalization for further IV antibiotic treatment of his cellulitis. He was at risk of sepsis if this were not treated and he likely would have been noncompliant as he was homeless and drinking 3 liters of alcohol daily and had a diagnosis of schizophrenia. \n\nHe did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting due to his acute medical issues requiring hospital treatment. He also was homeless and lacked supports and coping skills and the ability to care for his acute medical needs. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. \n\nThe health care plan did not act reasonably, with sound medical judgment, or in the best interests of the patient. \n\nThe insurer's denial of coverage for inpatient admission overturned. Medical Necessity is substantiated. ", "id": "88c5845d52ee45cab91c6294ae709ada", "question": "What is the background context in this case summary?", "title": "88c5845d52ee45cab91c6294ae709ada", "sufficiency_score": 4}
+{"answers": {"text": ["This is the case of a patient with a past medical history of gastroesophageal (GERD) and hypertension (HTN) who presented to the emergency department (ED) with the complaint of abdominal pain. He was afebrile with stable vital signs. As per the ED provider note, he complained of left flank pain since midnight. He reported no history of similar pain in the past. He had nausea but no vomiting. He denied fevers. He had a recent esophagogastroduodenoscopy (EGD) which showed acute gastritis. On exam, he had a soft abdomen, non-distended, tender to palpation in the epigastrium.  He had a HIDA (hepatobiliary iminodiacetic acid) scan which was positive by report for acute cholecystitis. Surgery was called to see the patient. He also had a computed tomography (CT) of the abdomen. He was made aware of renal cyst and instructed for this to have follow up with urology. As per the history and physical he presented with nausea and abdominal pain. His labs showed a white blood count (WBC) of 9.10 liver function test (AST [aspartate aminotransferase] 27, ALT [Alanine transaminase]24), Alkaline Phosphatase 59 and bilirubin total of 1. He was made NPO [nothing by mouth] and plan for OR [operating room] tomorrow for laparoscopic (lap) cholecystectomy.", "Diagnosis: Acute Cholecystitis", "Treatment acute inpatient admission", "The insurer denied coverage for acute inpatient admission", "the patient underwent an MRCP (Magnetic resonance cholangiopancreatography)", "He subsequently had the lap cholecystectomy.", "His HIDA scan was positive for acute cholecystitis"], "answer_start": [150, 0, 32, 69, 1501, 1621, 3636]}, "context": "Diagnosis: Acute Cholecystitis\n\nTreatment acute inpatient admission\n\nThe insurer denied coverage for acute inpatient admission\n\nThe denial is upheld\n\nThis is the case of a patient with a past medical history of gastroesophageal (GERD) and hypertension (HTN) who presented to the emergency department (ED) with the complaint of abdominal pain. He was afebrile with stable vital signs. As per the ED provider note, he complained of left flank pain since midnight. He reported no history of similar pain in the past. He had nausea but no vomiting. He denied fevers. He had a recent esophagogastroduodenoscopy (EGD) which showed acute gastritis. On exam, he had a soft abdomen, non-distended, tender to palpation in the epigastrium.  He had a HIDA (hepatobiliary iminodiacetic acid) scan which was positive by report for acute cholecystitis. Surgery was called to see the patient. He also had a computed tomography (CT) of the abdomen. He was made aware of renal cyst and instructed for this to have follow up with urology. As per the history and physical he presented with nausea and abdominal pain. His labs showed a white blood count (WBC) of 9.10 liver function test (AST [aspartate aminotransferase] 27, ALT [Alanine transaminase]24), Alkaline Phosphatase 59 and bilirubin total of 1. He was made NPO [nothing by mouth] and plan for OR [operating room] tomorrow for laparoscopic (lap) cholecystectomy.\n\nThere was no indication in the chart for the delay in surgery as the HIDA scan was positive, and the patient underwent an MRCP (Magnetic resonance cholangiopancreatography) despite having normal liver function tests. He subsequently had the lap cholecystectomy. This could have been done sooner and in an observation, status as noted by the insurer with the patient discharged within 48 hours of presentation if not sooner. \n\nAccording to the guidelines of Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone, patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The  clinical indications for admission to inpatient care may include patients with 1 or more of the following:  Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L (milligrams per liter), ...  Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (milligrams per deciliter) (34 micromoles/L (liter)), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), AST or ALT greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; ...Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Severe pain requiring acute inpatient management,  Bacteremia. \n\nThis patient did not need to be admitted as he could have been managed with an outpatient or ambulatory basis. He did not have any indication for acute inpatient admission given that he was afebrile, and the labs were normal with normal liver function tests, and normal bilirubin. His HIDA scan was positive for acute cholecystitis, but he did not need to be kept having an MRCP and could have had a lap cholecystectomy and sent home the same day. \n\nThe admission was not justified at the inpatient admission level as the patient should have been managed in an observation setting.  The health care plan did act reasonably and with sound medical judgment. \n\nThe insurer's denial of coverage for acute inpatient admission is upheld. Medical Necessity is not substantiated.\n", "id": "33bb468076764ca88998a23bf80785f3", "question": "What is the background context in this case summary?", "title": "33bb468076764ca88998a23bf80785f3", "sufficiency_score": 4}
+{"answers": {"text": ["The documentation indicates that the member has tried and failed antidepressants and antihypertensive agents.", "Diagnosis: Chronic Migraine. \nTreatment: Botox Injection.", "The patient has chronic migraine and has tried and failed antihypertensive drugs and antidepressant drugs. Botox was denied because there was not documentation of certain headache features. The provider appealed the determination.", "At issue is the medical necessity of a Botox injection."], "answer_start": [739, 0, 132, 364]}, "context": "Diagnosis: Chronic Migraine. \nTreatment: Botox Injection. \n\nThe insurer denied the Botox injection. \nThe determination is upheld. \n\nThe patient has chronic migraine and has tried and failed antihypertensive drugs and antidepressant drugs. Botox was denied because there was not documentation of certain headache features. The provider appealed the determination. \nAt issue is the medical necessity of a Botox injection. \n\nThe requested health service/treatment of Botox Injection is not medically necessary for this patient. While Botox is Food and Drug Administration (FDA) approved for the prevention of chronic migraine, the submitted documentation does not show that the patient has undergone an adequate trial of preventative agents. The documentation indicates that the member has tried and failed antidepressants and antihypertensive agents. Not all hypertensive agents or antidepressants are effective for prevention of migraine. There is no specification of what drugs were tried and failed or the duration of therapy. \n\nAdditionally, there is documentation that the patient has a headache on 15 days of the month. Chronic migraine is defined as 15 or more headache days per month with 8 or more of those days meeting migraine criteria for at least 3 months. There is inadequate documentation of chronic migraine. ", "id": "a43d4753a94d4584a0171917b3a2566e", "question": "What is the background context in this case summary?", "title": "a43d4753a94d4584a0171917b3a2566e", "sufficiency_score": 4}
+{"answers": {"text": ["The patient had a post-tonsillectomy bleed.", "Diagnosis: Post-tonsillectomy bleed", "Treatment: Inpatient Hospital Stay", "The insurer denied the Inpatient Hospital Stay.", "The patient has a history of a tonsil bleed. She had a tonsillectomy and adenoidectomy several days prior to presentation (unclear per the records provided). She presented to the emergency department (ED) with a tonsil bleed.", "She was noted to be hemodynamically stable and was tolerating oral intake well. She was admitted to the hospital. She had no recurrent bleeding. She was discharged the next day.\nAt issue is the medical necessity of an inpatient stay."], "answer_start": [673, 0, 36, 71, 149, 375]}, "context": "Diagnosis: Post-tonsillectomy bleed\nTreatment: Inpatient Hospital Stay\nThe insurer denied the Inpatient Hospital Stay.\nThe determination is upheld.\n\nThe patient has a history of a tonsil bleed. She had a tonsillectomy and adenoidectomy several days prior to presentation (unclear per the records provided). She presented to the emergency department (ED) with a tonsil bleed.\nShe was noted to be hemodynamically stable and was tolerating oral intake well. She was admitted to the hospital. She had no recurrent bleeding. She was discharged the next day.\nAt issue is the medical necessity of an inpatient stay.\nAn inpatient stay was not medically necessary for this patient.\nThe patient had a post-tonsillectomy bleed. It is considered standard of care to admit a young child for observation when there is evidence of bleeding because children have overall low blood volumes and excessive bleeding can lead to significant medical complications. Based on the clinical documents the child was not actively bleeding, had normal vital signs and was in no cardiopulmonary distress. It would be considered clinically appropriate and standard of care to observe the child overnight. However, the care could have been provided at a lower level than inpatient.", "id": "74a2d1e214ca4e73a386c15791e22888", "question": "What is the background context in this case summary?", "title": "74a2d1e214ca4e73a386c15791e22888", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Respiratory System. Treatment: Inpatient Hospital. The insurer denied Inpatient Stay.", "The patient is a girl with a past medical history significant for seasonal allergies who presented to the emergency department for evaluation of a sore throat. It was reported that the patient started to have a fever and sore throat. She presented to the emergency department, and at that time was noted to have right tonsillar hypertrophy and uvular deviation. Rapid Streptococcus test was positive. The ear, nose, and throat (ENT) service was consulted, and the patient was diagnosed with tonsillitis. The patient was discharged from the hospital with Augmentin. The patient's mother stated that she checked her tonsils regularly and was under the impression that the swelling became worse. The patient's mother stated that the patient had minimal relief of the throat pain despite using Tylenol, Motrin, and saltwater gargles. Because of the pain, the patient was unable to eat and only drank fluids. The patient was still able to swallow her secretions and had normal urinary output. The patient's mother denied difficulties breathing while awake. The patient's mother denied lethargy, syncope, seizure, cough, congestion, rhinorrhea, wheezing, vomiting, diarrhea, swelling in the extremities, or skin rash.", "At the time of the initial evaluation, the patient's temperature was 98.6 F, blood pressure was 106/74, pulse rate was 139 beats per minute (bpm), respiratory rate was 20 breaths/minute, and oxygen saturation was 100% on room air.", "The patient was sitting in an upright position in a chair, playing on a tablet. She looked nontoxic. On the head, eyes, ears, neck, throat (HEENT) exam, there was significant right tonsillar hypertrophy with exudate and uvular deviation to the right. There was tonsillar and right anterior cervical lymphadenopathy. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The rest of the exam was unremarkable. The patient was admitted to the hospital with tonsillar swelling.", "The patient was admitted to the hospital with a diagnosis of bacterial tonsillopharyngitis and a marked decrease in oral intake. In the hospital, the patient was managed with intravenous Unasyn, intravenous fluids, Tylenol, and Motrin. Within the first 24 hours of admission, her oral intake considerably improved, and she remained afebrile.\nAt issue is the medical necessity of Inpatient Stay.", "The patient presented to the hospital with tonsillopharyngitis.", "At the time of the presentation, the patient was afebrile, and had a normal blood pressure. She was initially tachycardic, but the tachycardia improved within a short period of time. At the time of the initial evaluation, the patient was not in any distress. She had a normal respiratory rate and normal oxygen saturation.", "During the hospitalization, the patient remained afebrile and hemodynamically stable", "she was discharged home on the second day after the day of admission."], "answer_start": [0, 121, 1334, 1566, 2060, 2632, 2973, 3468, 3572]}, "context": "Diagnosis: Respiratory System. Treatment: Inpatient Hospital. The insurer denied Inpatient Stay. The denial is upheld. \n\nThe patient is a girl with a past medical history significant for seasonal allergies who presented to the emergency department for evaluation of a sore throat. It was reported that the patient started to have a fever and sore throat. She presented to the emergency department, and at that time was noted to have right tonsillar hypertrophy and uvular deviation. Rapid Streptococcus test was positive. The ear, nose, and throat (ENT) service was consulted, and the patient was diagnosed with tonsillitis. The patient was discharged from the hospital with Augmentin. The patient's mother stated that she checked her tonsils regularly and was under the impression that the swelling became worse. The patient's mother stated that the patient had minimal relief of the throat pain despite using Tylenol, Motrin, and saltwater gargles. Because of the pain, the patient was unable to eat and only drank fluids. The patient was still able to swallow her secretions and had normal urinary output. The patient's mother denied difficulties breathing while awake. The patient's mother denied lethargy, syncope, seizure, cough, congestion, rhinorrhea, wheezing, vomiting, diarrhea, swelling in the extremities, or skin rash.\n\nAt the time of the initial evaluation, the patient's temperature was 98.6 F, blood pressure was 106/74, pulse rate was 139 beats per minute (bpm), respiratory rate was 20 breaths/minute, and oxygen saturation was 100% on room air.\n\nThe patient was sitting in an upright position in a chair, playing on a tablet. She looked nontoxic. On the head, eyes, ears, neck, throat (HEENT) exam, there was significant right tonsillar hypertrophy with exudate and uvular deviation to the right. There was tonsillar and right anterior cervical lymphadenopathy. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The rest of the exam was unremarkable. The patient was admitted to the hospital with tonsillar swelling.\nThe patient was admitted to the hospital with a diagnosis of bacterial tonsillopharyngitis and a marked decrease in oral intake. In the hospital, the patient was managed with intravenous Unasyn, intravenous fluids, Tylenol, and Motrin. Within the first 24 hours of admission, her oral intake considerably improved, and she remained afebrile.\nAt issue is the medical necessity of Inpatient Stay.\n\nThe health plan's determination of medical necessity is upheld in whole.\n\nThe requested health service/treatment of Inpatient Stay is not medically necessary for this patient.\nThe patient presented to the hospital with tonsillopharyngitis. Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus). In about 30% of patients, the cause is bacterial. Group A beta-hemolytic streptococcus (GABHS) is most common. At the time of the presentation, the patient was afebrile, and had a normal blood pressure. She was initially tachycardic, but the tachycardia improved within a short period of time. At the time of the initial evaluation, the patient was not in any distress. She had a normal respiratory rate and normal oxygen saturation. There was no strider or wheezing reported. It was indicated in the notes that the patient's oral intake considerably improved within the first 24 hours of hospitalization. During the hospitalization, the patient remained afebrile and hemodynamically stable, to the point that she was discharged home on the second day after the day of admission.\nOverall, this young patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.\nTherefore, the requested health service/treatment of Inpatient Stay is not medically necessary for this patient.", "id": "b96c5ceda7a846cea4c1f8201148e29f", "question": "What is the background context in this case summary?", "title": "b96c5ceda7a846cea4c1f8201148e29f", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a female with a Class I occlusion. She has severe mandibular crowding and moderate maxillary crowding, moderate overjet, and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits.", "Diagnosis: Dental Problems/Other/ Class I Occlusion", "Treatment: Dental/Orthodontic Procedure", "The health plan denied the requested dental treatment plan."], "answer_start": [197, 0, 52, 92]}, "context": "Diagnosis: Dental Problems/Other/ Class I Occlusion\nTreatment: Dental/Orthodontic Procedure\nThe health plan denied the requested dental treatment plan. \nThe health plan's determination is upheld.\n\nThe patient is a female with a Class I occlusion. She has severe mandibular crowding and moderate maxillary crowding, moderate overjet, and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits.\n\nThe health plan's determination of medical necessity is upheld, in whole.\n\nUsing the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces and monthly visits are not medically necessary for this case.", "id": "42cdc3bc893c4c22a8fba1b47ea0e2a0", "question": "What is the background context in this case summary?", "title": "42cdc3bc893c4c22a8fba1b47ea0e2a0", "sufficiency_score": 3}
+{"answers": {"text": ["This female presented to the ED with a various constellation of complaints, most prominently lower extremity weakness with a history of recent viral infection. There was initial concern about Guillain-Barre syndrome so she was admitted for monitoring. She was evaluated by a number of subspecialists during her hospitals stay, with no definitive answer found for her lower extremity weakness.", "Diagnosis: Leg weakness", "Treatment: Inpatient Hospital Stay", "The insurer denied the Inpatient Hospital Stay.", "The patient has a history significant for attention deficit hyperactivity disorder (ADHD) inattentive type, tic disorder, recent coronavirus 2019 (COVID 19) infection the month prior, and acute gastroenteritis a month prior, who presented to the ED with excessive clumsiness and bilateral leg weakness. She had fallen multiple times over the previous couple of days, and on the day of presentation experienced some dizziness and had a brief loss of consciousness but no loss of bowel or bladder control. In the ED, the evaluation was unremarkable, including a negative head computed tomography (CT) scan. On the pediatric floor, the vital signs included a temperature of 36.9 degrees Celsius, heart rate 96, respiratory rate 20, and blood pressure 98/72. The examination was significant for mild bilateral nystagmus, hypoactive reflexes, decreased power, bilateral extremity weakness. Laboratory evaluation was relatively unremarkable. Magnetic resonance imaging (MRI) of the spine was unremarkable, no significant abnormality.", "Admission orders included continuous telemetry, possible lumbar puncture, neurology consultation, regular diet, continuous cardiac monitoring, and possibly cardiology consultation. During her hospitalization, she recovered her strength and balance. She was evaluated by psychiatry (no acute inpatient needs), neurology (recommended outpatient electromyography (EMG) / nerve conduction velocity (NCV)), and cardiology (follow-up electrocardiogram (EKG) and benign murmur in the outpatient setting. She was ambulating independently, neurologic exam within normal limits, and was deemed stable for discharge.", "At issue is the medical necessity of an inpatient stay."], "answer_start": [2719, 0, 24, 59, 137, 1165, 1771]}, "context": "Diagnosis: Leg weakness\nTreatment: Inpatient Hospital Stay\nThe insurer denied the Inpatient Hospital Stay.\nThe determination is upheld.\n\nThe patient has a history significant for attention deficit hyperactivity disorder (ADHD) inattentive type, tic disorder, recent coronavirus 2019 (COVID 19) infection the month prior, and acute gastroenteritis a month prior, who presented to the ED with excessive clumsiness and bilateral leg weakness. She had fallen multiple times over the previous couple of days, and on the day of presentation experienced some dizziness and had a brief loss of consciousness but no loss of bowel or bladder control. In the ED, the evaluation was unremarkable, including a negative head computed tomography (CT) scan. On the pediatric floor, the vital signs included a temperature of 36.9 degrees Celsius, heart rate 96, respiratory rate 20, and blood pressure 98/72. The examination was significant for mild bilateral nystagmus, hypoactive reflexes, decreased power, bilateral extremity weakness. Laboratory evaluation was relatively unremarkable. Magnetic resonance imaging (MRI) of the spine was unremarkable, no significant abnormality.\nAdmission orders included continuous telemetry, possible lumbar puncture, neurology consultation, regular diet, continuous cardiac monitoring, and possibly cardiology consultation. During her hospitalization, she recovered her strength and balance. She was evaluated by psychiatry (no acute inpatient needs), neurology (recommended outpatient electromyography (EMG) / nerve conduction velocity (NCV)), and cardiology (follow-up electrocardiogram (EKG) and benign murmur in the outpatient setting. She was ambulating independently, neurologic exam within normal limits, and was deemed stable for discharge.\nAt issue is the medical necessity of an inpatient stay.\nThe requested inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care, including all consultations.\nGuillain-Barre syndrome is an immune-mediated disease typically triggered by infectious diseases. The clinical presentation is variable making diagnosis sometimes challenging. Patients typically report an ascending weakness and sensory deficit, beginning in the legs and progressing up to the arms and cranial muscles. Diagnosis is based on history, neurological exam, cerebrospinal fluid (CSF) findings, and electrophysiologic data. Peak disability typically occurs in two weeks. About 20% go on to develop respiratory failure and require intubation with mechanical ventilation. Cardiac arrhythmias may occur if the autonomic nervous system is involved. Treatment may involve intravenous immunoglobulin (IVIG) or plasma exchange.\nThis female presented to the ED with a various constellation of complaints, most prominently lower extremity weakness with a history of recent viral infection. There was initial concern about Guillain-Barre syndrome so she was admitted for monitoring. She was evaluated by a number of subspecialists during her hospitals stay, with no definitive answer found for her lower extremity weakness. While it was not unreasonable to monitor her for progression or regression of symptoms, she was overall hemodynamically stable with no evidence of impending respiratory failure and no reported suicidal ideation. She did not require acute inpatient admission and could have been safely managed at a lower level of care.", "id": "3b31625ca5ac477da2eab5fc68a876c1", "question": "What is the background context in this case summary?", "title": "3b31625ca5ac477da2eab5fc68a876c1", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with atopic dermatitis to the face, extremities and neck, treated with topical steroids, systemic steroids, Eucrisa, Opzelura, and tacrolimus. His provider is requesting Dupixent. The health plan denied coverage, as the patient is under the appropriate age.", "Diagnosis: Atopic Dermatitis.", "Treatment: Dupixent 300MG/2ML SOSY.", "The insurer denied the Dupixent 300MG/2ML SOSY."], "answer_start": [142, 0, 31, 69]}, "context": "Diagnosis: Atopic Dermatitis. \nTreatment: Dupixent 300MG/2ML SOSY. \n\nThe insurer denied the Dupixent 300MG/2ML SOSY. \nThe denial is upheld. \n\nThe patient is a male with atopic dermatitis to the face, extremities and neck, treated with topical steroids, systemic steroids, Eucrisa, Opzelura, and tacrolimus. His provider is requesting Dupixent. The health plan denied coverage, as the patient is under the appropriate age. \n\nNo, the requested Dupixent is not medically necessary. \n\nThis patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema. Systemics such as cyclosporine can also be used in atopic dermatitis. \n\nAccording to the recommendations provided by Simpson et al, steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. \n\nDupixent is not appropriate or medically necessary for this patient. \n\nYes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. \n", "id": "8a126882d3d54c2a9b6ff9340ba7f351", "question": "What is the background context in this case summary?", "title": "8a126882d3d54c2a9b6ff9340ba7f351", "sufficiency_score": 3}
+{"answers": {"text": ["This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services.", "the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion.", "Diagnosis: Trauma/Injuries/Spinal Cord Injury", "Treatment: Skilled Nursing Facility/Custodial Care", "The health plan denied the requested continued long term custodial care as not medically necessary.", "The patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy", "At issue is the medical necessity for continued long-term custodial services."], "answer_start": [1478, 1851, 0, 46, 97, 241, 1080]}, "context": "Diagnosis: Trauma/Injuries/Spinal Cord Injury\nTreatment: Skilled Nursing Facility/Custodial Care\nThe health plan denied the requested continued long term custodial care as not medically necessary.\nThe health plan's determination is upheld.\n\nThe patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy.\n\nAt issue is the medical necessity for continued long-term custodial services.\n\nI uphold, in whole, the health plan's determination of medical necessity.\n\nNo, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.\n\nThe long-term custodial services would not be medically necessary, based on the clinical documentation reviewed. This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition was via an oral diet, he did not have an active complex comorbidity that needed treatment, and he was participating in physical therapy. All of the above requirements did not require frequent nursing care > (greater than) 6.5 hours per day, daily physician assessments, or by themselves requiring facility-based treatment. The patient can undergo custodial care at home with physical therapy services as an outpatient. Therefore, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.", "id": "6f8fbe2d1c664a9882e8067561852a33", "question": "What is the background context in this case summary?", "title": "6f8fbe2d1c664a9882e8067561852a33", "sufficiency_score": 4}
+{"answers": {"text": ["This case of a woman with a history of aortic stenosis, coronary artery disease, stroke, hypertension, psoriasis, gout and hypercholesterolemia. She was prescribed Repatha after LDL (low-density lipoprotein) cholesterol remained elevated despite high intensity statin (rosuvastatin 40mg (milligrams) daily) and ezetimibe 10 mg daily therapies.  Lipid panel revealed LDL cholesterol of 90mg/dl (milligrams per deciliter).  The patient has documented coronary artery disease with significant coronary artery stenosis that required stent placement.  The patient's physician submitted documentation demonstrating that the patient has been treated with high intensity statin and ezetimibe.", "Diagnosis: Coronary Artery Disease", "Treatment: evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)", "The insurer denied coverage for evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)", "This patient is already treated with high intensity statin therapy and ezetimibe.  She suffers from atherosclerotic coronary artery and has a history of stroke."], "answer_start": [300, 0, 36, 144, 1094]}, "context": "Diagnosis: Coronary Artery Disease\n\nTreatment: evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)\n\nThe insurer denied coverage for evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)\n\nThe denial is overturned.\n\nThis case of a woman with a history of aortic stenosis, coronary artery disease, stroke, hypertension, psoriasis, gout and hypercholesterolemia. She was prescribed Repatha after LDL (low-density lipoprotein) cholesterol remained elevated despite high intensity statin (rosuvastatin 40mg (milligrams) daily) and ezetimibe 10 mg daily therapies.  Lipid panel revealed LDL cholesterol of 90mg/dl (milligrams per deciliter).  The patient has documented coronary artery disease with significant coronary artery stenosis that required stent placement.  The patient's physician submitted documentation demonstrating that the patient has been treated with high intensity statin and ezetimibe.\n\nThe health plan did not act reasonably with sound medical judgment and in the best interest of the patient. This patient is already treated with high intensity statin therapy and ezetimibe.  She suffers from atherosclerotic coronary artery and has a history of stroke.  Addition of a non-statin agent such Evolocumab in this setting has been associated with significant event rate reduction regardless of serum LDL level. (Reference 1, 2). Current American Heart Association and American College of Cardiology guidelines recommend addition of PCSK-9 (Proprotein convertase subtilisin/kexin type 9_ inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future ASCVD events including those with multivessel disease. (Reference 1,2,3).  Such patients are given a class I indication for treatment with non-statin therapy such as evolocumab when LDL-C levels are greater than 55mg/dl. (Reference 3) In conclusion, the proposed treatment (evolocumab) is medically necessary.\n\nThe insurer's denial of coverage for the evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick) is overturned. Medical Necessity is substantiated.", "id": "9813cff43cbb4d7aac825527c6c49b47", "question": "What is the background context in this case summary?", "title": "9813cff43cbb4d7aac825527c6c49b47", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Parkinson's disease; osteoarthritis.", "Treatment: Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).", "The insurer denied the Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).", "The patient is a male. His medical conditions include Parkinson's disease, dementia, diabetes, osteoarthritis, and heart disease. Denial of increase personal care aide (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan has approved PCA (personal care aide) live-in services.", "The patient's Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total assistance with housework and locomotion; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, walking, toileting, and bed mobility; extensive assistance with eating; and limited assistance with phone use. He has a Foley catheter due to urinary retention. He has infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating.", "There is an appeal letter from the patient's provider that notes that the patient has been admitted to hospice within the last several months. The patient is bedbound. He is noted to be more disoriented. He is not able to reposition himself, which places him at risk for skin breakdown. He requires full assistance with all ADLs (activities of daily living). He needs repositioning every two hours while in bed. He has unscheduled needs throughout the nighttime.", "The patient has advanced Parkinson's disease with dementia. He is in hospice care. UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with all ADLs (activities of daily living) and personal care. Compared to UAS (Uniform Assessment System) evaluation completed o previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating. The appeal letter notes the patient is bedbound and requires assistance with all ADLs (activities of daily living) and personal care as well as repositioning every 2 hours. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. He requires total care and frequent repositioning."], "answer_start": [0, 48, 151, 293, 609, 1282, 2702]}, "context": "Diagnosis: Parkinson's disease; osteoarthritis.\nTreatment: Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).\nThe insurer denied the Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).\nThe denial is overturned.\n\nThe patient is a male. His medical conditions include Parkinson's disease, dementia, diabetes, osteoarthritis, and heart disease. Denial of increase personal care aide (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan has approved PCA (personal care aide) live-in services.\n\nThe patient's Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total assistance with housework and locomotion; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, walking, toileting, and bed mobility; extensive assistance with eating; and limited assistance with phone use. He has a Foley catheter due to urinary retention. He has infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating.\n\nThere is an appeal letter from the patient's provider that notes that the patient has been admitted to hospice within the last several months. The patient is bedbound. He is noted to be more disoriented. He is not able to reposition himself, which places him at risk for skin breakdown. He requires full assistance with all ADLs (activities of daily living). He needs repositioning every two hours while in bed. He has unscheduled needs throughout the nighttime.\n\nYes, the requested increase in Personal Care Aide services to 24 hours/day, split shift, is medically necessary.\n\nNo, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.\nPersonal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. He is appealing denial of increase PCA (Personal Care Aide) services for a total of 168 hours per week, split shift. The plan has approved PCA (Personal Care Aide) live-in services.\n\nThe patient has advanced Parkinson's disease with dementia. He is in hospice care. UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with all ADLs (activities of daily living) and personal care. Compared to UAS (Uniform Assessment System) evaluation completed o previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating. The appeal letter notes the patient is bedbound and requires assistance with all ADLs (activities of daily living) and personal care as well as repositioning every 2 hours. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. He requires total care and frequent repositioning. These needs do not permit five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (Personal Care Aide), live-in, is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The requested increase in PCA (Personal Care Aide) for a total of 168 hours per week, split shift is medically necessary.", "id": "3ba984e00a544747938ca9865dfc8972", "question": "What is the background context in this case summary?", "title": "3ba984e00a544747938ca9865dfc8972", "sufficiency_score": 4}
+{"answers": {"text": ["this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD)  index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity.", "Diagnosis: Malocclusion.", "Treatment: Comprehensive Orthodontic Treatment.", "The insurer denied coverage for comprehensive orthodontic treatment", "the patient exhibits a malocclusion.", "In this case, the treating orthodontist claims an automatic qualifying condition of deep\nimpinging overbite with severe soft tissue damage."], "answer_start": [380, 0, 26, 76, 903, 1588]}, "context": "Diagnosis: Malocclusion. \nTreatment: Comprehensive Orthodontic Treatment. \n\nThe insurer denied coverage for comprehensive orthodontic treatment\n\nThe denial is upheld\n\nUpon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral. clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD)  index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. \n\nUpon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. \n\nIn this case, the treating orthodontist claims an automatic qualifying condition of deep\nimpinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer with a total of 10 points (4 points overjet, 4 points overbites, 2 points labiolingual spread). \n \nRegarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies referenced below. \n\nEach of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. \n\nUphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. \n\nThe insurer's denial of coverage for the comprehensive orthodontic treatment is upheld. Medical Necessity is not substantiated. ", "id": "83e8ec5bfcd24149a7ba7cb724422c09", "question": "What is the background context in this case summary?", "title": "83e8ec5bfcd24149a7ba7cb724422c09", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia.  She also has a history of 2 strokes.  The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week.  Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.", "Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes", "Treatment   Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week", "The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week", "Cognitive skills are described as \"severely impaired.\" She is oriented only to person and does not recognize caregivers or family members.  The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use.  She is incontinent of bowel and bladder.  The patient is also totally dependent for bed mobility and is non-ambulatory.  She is bed bound, unable to feed or reposition herself.   The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke"], "answer_start": [383, 0, 70, 203, 856]}, "context": "Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes\n\nTreatment   Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week  \n\nThe insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week  \n\nThe denial is overturned \n\nThe patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia.  She also has a history of 2 strokes.  The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week.  Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.\n\nAccording to the Uniform Assessment System (UAS) report , the patient has significant cognitive deficits.  Cognitive skills are described as \"severely impaired.\" She is oriented only to person and does not recognize caregivers or family members.  The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use.  She is incontinent of bowel and bladder.  The patient is also totally dependent for bed mobility and is non-ambulatory.  She is bed bound, unable to feed or reposition herself.   The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke, this supports the medical necessity of personal care assistance (PCA) 24hours per day, 7 days per week split shift, to allow her to resume living safely at home.  \n\nThe healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  \n\nThe requested increase Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is medically necessary for this patient.  \n\nThe health plan did not act reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.", "id": "314f655f82cc40f389517468b601dca3", "question": "What is the background context in this case summary?", "title": "314f655f82cc40f389517468b601dca3", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) a possible allergic reaction to peanut oil and tongue and lip swelling. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 99%. The physical exam was notable for no acute distress, angioedema of the tongue, no pulmonary retractions, labored breathing, or expiratory stridor, and able to speak in full sentences without difficulty and able to handle secretions. Lab work was unremarkable. The patient was diagnosed with anaphylaxis and treated with intravenous (IV) fluid, antihistamines, IV steroids, intramuscular (IM) epinephrine times (x) 2, and a nebulizer. Of note, the patient's symptoms improved upon arrival to the emergency department (ED), and improved after initial treatment in the ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.", "Diagnosis: Allergic reaction.", "Treatment: Inpatient Hospital Stay.", "The insurer denied the Inpatient Hospital Stay.", "This patient with a recent history of an urticarial rash presented to the ED with c/o possible allergic reaction to peanut oil and tongue and lip swelling."], "answer_start": [145, 0, 30, 66, 1163]}, "context": "Diagnosis: Allergic reaction.\nTreatment: Inpatient Hospital Stay.\nThe insurer denied the Inpatient Hospital Stay.\nThe determination is upheld.\n\n\nThe patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) a possible allergic reaction to peanut oil and tongue and lip swelling. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 99%. The physical exam was notable for no acute distress, angioedema of the tongue, no pulmonary retractions, labored breathing, or expiratory stridor, and able to speak in full sentences without difficulty and able to handle secretions. Lab work was unremarkable. The patient was diagnosed with anaphylaxis and treated with intravenous (IV) fluid, antihistamines, IV steroids, intramuscular (IM) epinephrine times (x) 2, and a nebulizer. Of note, the patient's symptoms improved upon arrival to the emergency department (ED), and improved after initial treatment in the ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.\nThe hospital stay was not medically necessary at an acute inpatient level of care. This patient with a recent history of an urticarial rash presented to the ED with c/o possible allergic reaction to peanut oil and tongue and lip swelling. There was no actual or impending airway compromise, unstable vital signs, hypoxia, respiratory distress or respiratory failure, progression of allergic reaction/angioedema while undergoing treatment, hypotension, acute coronary syndrome (ACS), hoarseness or need for IV vasopressors. Overall, this stable patient was treated with IV steroids, IM epinephrine, and antihistamines, and responded to the treatment in the ED, and these interventions could have been safely provided at a lower level of care than inpatient.", "id": "0733883f24ae4675ba41ca6ca8ec18d0", "question": "What is the background context in this case summary?", "title": "0733883f24ae4675ba41ca6ca8ec18d0", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Plantar fasciitis.", "Treatment: Custom Shoe Inserts (L3000 x2).", "The insurer denied coverage for Custom Shoe Inserts (L3000 x2).", "The patient is a female with long history of foot and ankle pain. There is a history of ankle sprain, metatarsalgia, painful calluses, bunions, and plantar fasciitis. The patient has tried good supportive shoes and compression socks to no avail, along with over-the-counter pain medications and continues to have arch pain.", "the notes outline that the deformity of the foot was such that even with the use of a prefabricated orthotic there was complete collapse of the arch.  As such, custom orthotics were recommended."], "answer_start": [0, 31, 76, 170, 507]}, "context": "Diagnosis: Plantar fasciitis. \nTreatment: Custom Shoe Inserts (L3000 x2). \n\nThe insurer denied coverage for Custom Shoe Inserts (L3000 x2). \n\nThe denial is overturned. \n\nThe patient is a female with long history of foot and ankle pain. There is a history of ankle sprain, metatarsalgia, painful calluses, bunions, and plantar fasciitis. The patient has tried good supportive shoes and compression socks to no avail, along with over-the-counter pain medications and continues to have arch pain. Furthermore, the notes outline that the deformity of the foot was such that even with the use of a prefabricated orthotic there was complete collapse of the arch.  As such, custom orthotics were recommended. \n \nA review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, there is no optimal answer when it comes to specific orthotic therapy for plantar fasciitis. While some patients may benefit from over-the-counter orthotics, others may get no better without the use of custom orthotics. In the case of this patient, it is clear from the medical records made available that the prefabricated orthotics made little difference and the patient needs a good custom orthotic to help with her plantar fasciitis by providing her more support. Given the available literature on this topic and this patients history, in this reviewer's expert opinion it is best that the orthotics are approved, so that the patient can get the treatment she needs to resolve her plantar fasciitis. \n\nThe health plan did not act reasonably with sound medical judgment in the best interest of the patient. \n\nThe insurer's denial of coverage for Custom Shoe Inserts (L3000 x2) is overturned. Medical Necessity is substantiated. ", "id": "cd754ecb776e4279bf12e2f7aa433b44", "question": "What is the background context in this case summary?", "title": "cd754ecb776e4279bf12e2f7aa433b44", "sufficiency_score": 4}
+{"answers": {"text": ["This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.\nAt issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.", "Diagnosis: Orthopedic/Musculoskeletal.", "Treatment: Durable Medical Equipment (DME).", "The insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories.", "the occupational therapist has provided a letter stating medical necessity"], "answer_start": [199, 0, 40, 85, 1247]}, "context": "Diagnosis: Orthopedic/Musculoskeletal. \nTreatment: Durable Medical Equipment (DME). \nThe insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories. \nThe denial is upheld. \n\nThis patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.\nAt issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.\n\nThe health plan's determination of medical necessity is upheld in whole.\n\nThe requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary for this patient.\nBased on the patient's diagnosis and documentation, it is not clear that the requested items are medically necessary, as patients with Down Syndrome can have varying degrees of hypotonia. Although the occupational therapist has provided a letter stating medical necessity, there is no documentation of current status or the degree of impairment. Based on the records provided, it is not clear that the Durable Medical Equipment - Pediatric tilt wheelchair with accessories is considered medically necessary.\nTherefore, the requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary.", "id": "172dd21c484642588d5cfb23d679b31e", "question": "What is the background context in this case summary?", "title": "172dd21c484642588d5cfb23d679b31e", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Autism\nTreatment: Occupational Therapy\nThe insurer denied the Occupational Therapy.", "The patient received occupational therapy with treatments focusing on improving regulation and decreasing internal distractions, improving attention/focus, and decreasing thumb sucking along with balance and coordination skills.   At issue is the medical necessity of the requested occupational therapy services.", "Per the documentation the patient's mother is continuously involved in exercises and the treatment plan including carryover at home."], "answer_start": [0, 125, 2112]}, "context": "Diagnosis: Autism\nTreatment: Occupational Therapy\nThe insurer denied the Occupational Therapy.\nThe determination is upheld.\n\nThe patient received occupational therapy with treatments focusing on improving regulation and decreasing internal distractions, improving attention/focus, and decreasing thumb sucking along with balance and coordination skills.   At issue is the medical necessity of the requested occupational therapy services.\n\nThe requested occupational therapy sessions were not medically necessary for this patient.\nThe patient's therapy progress note documentation does not support medical necessity for the standards of practice for occupational therapy. Occupational therapy (OT) is medically necessary when there is documentation that it is improving a patient's current condition or preventing or slowing further deterioration of the patient's condition or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.\nNo indication of objective measures of improvement are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment.\nActivities identified in the OT summary report which can be done by caregivers/parents include working with home exercise on the goals of : bear weight on upper extremities for 60 seconds, improving ball skills of throwing, catching, kicking with good force and gradation so he can participate with age appropriate ball activities, maintaining quadruped position.  Per the documentation the patient's mother is continuously involved in exercises and the treatment plan including carryover at home.  Therefore, the requested occupational therapy is not medically necessary.", "id": "6652daacd12748a494e57ce9df70dc07", "question": "What is the background context in this case summary?", "title": "6652daacd12748a494e57ce9df70dc07", "sufficiency_score": 4}
+{"answers": {"text": ["The member is a female with migraine headache disorder. She is currently treated with topiramate and Emgality for migraine prevention. The provider is requesting continuation of Emgality.\n", "Diagnosis: Migraine Headache", "Treatment: Emgality", "The insurer denied the Emgality.", "The patient has tried and failed a", "trial of topiramate for migraine prevention. She cannot be treated with divalproex sodium, as she is a female of childbearing age. She cannot be treated with amitriptyline or venlafaxine, as she is currently treated with escitalopram. She cannot be treated with a beta-blocker (Danesh and Gottschalk), as the medical records indicate relative bradycardia (heart rate 58 and 67 at two encounters)."], "answer_start": [109, 0, 29, 49, 351, 397]}, "context": "Diagnosis: Migraine Headache\nTreatment: Emgality\nThe insurer denied the Emgality.\nThe denial is overturned.\n\nThe member is a female with migraine headache disorder. She is currently treated with topiramate and Emgality for migraine prevention. The provider is requesting continuation of Emgality.\n\nYes, the requested Emgality is medically necessary.\n\nThe patient has tried and failed a reasonable trial of topiramate for migraine prevention. She cannot be treated with divalproex sodium, as she is a female of childbearing age. She cannot be treated with amitriptyline or venlafaxine, as she is currently treated with escitalopram. She cannot be treated with a beta-blocker (Danesh and Gottschalk), as the medical records indicate relative bradycardia (heart rate 58 and 67 at two encounters). Therefore, she has either tried and failed or has a contraindication to all of the preferred agents (Burch).\n\nTherefore, given the above, the requested Emgality is medically necessary.\n\nNo, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.", "id": "7b4a0c6ba8844bbf86bf8c8b613fed4d", "question": "What is the background context in this case summary?", "title": "7b4a0c6ba8844bbf86bf8c8b613fed4d", "sufficiency_score": 4}
+{"answers": {"text": ["This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol. ", "In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications.", "Diagnosis: Hypertension.", "Treatment: Bystolic 5 milligram (mg) tab.", "The insurer denied coverage for Bystolic 5 mg tab."], "answer_start": [146, 946, 0, 25, 68]}, "context": "Diagnosis: Hypertension.\nTreatment: Bystolic 5 milligram (mg) tab.\n\nThe insurer denied coverage for Bystolic 5 mg tab. The denial is overturned.\n\nThis patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol. \n\nBased on the information provided, the formulary medication (nebivolol) is likely to cause an adverse reaction. In addition, the other formulary drugs have been documented to be ineffective. The requested drug has successfully controlled blood pressure for approximately a year and a half. Studies have demonstrated that a small number of individuals require use of name brand medications following use of generic formulations. (2) In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications. \n\nThe requested drug is likely to be more effective than the formulary drugs.\n\nThe insurer's denial of coverage for Formulary Exception for Bystolic 5 milligram (mg) tab is overturned.   ", "id": "ab7c082a86214b68a67d265a49e175ce", "question": "What is the background context in this case summary?", "title": "ab7c082a86214b68a67d265a49e175ce", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.", "Diagnosis: Vision.", "Treatment: Pharmacy/Prescription Drugs.", "The insurer denied Acthar Gel.", "This patient has been on multiple medication including serum drops and punctual plugs without improvement.", "This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement."], "answer_start": [120, 0, 20, 61, 654, 1203]}, "context": "Diagnosis: Vision. \nTreatment: Pharmacy/Prescription Drugs. \nThe insurer denied Acthar Gel. \nThe denial is overturned.\n\nThe patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.\n\nThe health plan's determination is overturned.\n\nThis patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be medically necessary and appropriate as the next step in the treatment of this patient.\n\nAcathar gel has been Food and Drug Administration (FDA) approved for patients with severe acute and chronic allergic and inflammatory processes involving the eye and its adenoma. This includes keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation. This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be an appropriate as the next step in the treatment of this patient.", "id": "2ef0dd442cca43c7bfe7d465ef6aac5b", "question": "What is the background context in this case summary?", "title": "2ef0dd442cca43c7bfe7d465ef6aac5b", "sufficiency_score": 4}
+{"answers": {"text": ["This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol. ", "In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications.", "Diagnosis: Hypertension.", "Treatment: Bystolic 5 milligram (mg) tab."], "answer_start": [146, 946, 0, 25]}, "context": "Diagnosis: Hypertension.\nTreatment: Bystolic 5 milligram (mg) tab.\n\nThe insurer denied coverage for Bystolic 5 mg tab. The denial is overturned.\n\nThis patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol. \n\nBased on the information provided, the formulary medication (nebivolol) is likely to cause an adverse reaction. In addition, the other formulary drugs have been documented to be ineffective. The requested drug has successfully controlled blood pressure for approximately a year and a half. Studies have demonstrated that a small number of individuals require use of name brand medications following use of generic formulations. (2) In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications. \n\nThe requested drug is likely to be more effective than the formulary drugs.\n\nThe insurer's denial of coverage for Formulary Exception for Bystolic 5 milligram (mg) tab is overturned.   ", "id": "c32c283069a34daa836ce48be3c04581", "question": "What is the background context in this case summary?", "title": "c32c283069a34daa836ce48be3c04581", "sufficiency_score": 4}
+{"answers": {"text": ["The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.", "Diagnosis: Vision.", "Treatment: Pharmacy/Prescription Drugs.", "The insurer denied Acthar Gel.", "This patient has been on multiple medication including serum drops and punctual plugs without improvement.", "This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement."], "answer_start": [120, 0, 20, 61, 654, 1203]}, "context": "Diagnosis: Vision. \nTreatment: Pharmacy/Prescription Drugs. \nThe insurer denied Acthar Gel. \nThe denial is overturned.\n\nThe patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.\n\nThe health plan's determination is overturned.\n\nThis patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be medically necessary and appropriate as the next step in the treatment of this patient.\n\nAcathar gel has been Food and Drug Administration (FDA) approved for patients with severe acute and chronic allergic and inflammatory processes involving the eye and its adenoma. This includes keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation. This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be an appropriate as the next step in the treatment of this patient.", "id": "eda1d3de704a4a28ac0e54e0f0590bfb", "question": "What is the background context in this case summary?", "title": "eda1d3de704a4a28ac0e54e0f0590bfb", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Diabetic ketoacidosis (DKA).", "Treatment: Inpatient admission.", "The insurer denied coverage for an inpatient admission.", "The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.\n\nVital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.\n\nWhite blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.\n\nChest x-rays revealed (CXR) revealed B/L airspace disease.\n\nThe patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx). \n\nRepeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.\n\nThe patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.\n\nThis patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation."], "answer_start": [0, 40, 73, 157]}, "context": "Diagnosis: Diabetic ketoacidosis (DKA).\nTreatment: Inpatient admission.\n\nThe insurer denied coverage for an inpatient admission.  The denial is overturned.\n\nThe patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.\n\nVital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.\n\nWhite blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.\n\nChest x-rays revealed (CXR) revealed B/L airspace disease.\n\nThe patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx). \n\nRepeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.\n\nThe patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.\n\nThis patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation. Based on above, it was appropriate to admit this patient to the hospital for active treatment and very close monitoring. This patient was not stable to be treated in any other setting.\n\nThis patient decided to sign out against medical advice (AMA), which was not in any one's control. He was not stable at the time he absconded from the hospital.\n\nThe health plan did not act reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.", "id": "4db2088e530f44b2a5d2a86fe7f75a4c", "question": "What is the background context in this case summary?", "title": "4db2088e530f44b2a5d2a86fe7f75a4c", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Skin Disorders. \nTreatment: Inpatient Hospital. \nThe insurer denied Inpatient Admission.", "The patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.\nThe laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.\nThe patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.\nAt issue is the medical necessity of the Inpatient Admission.", "The patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis", "the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon."], "answer_start": [0, 129, 1910, 2086]}, "context": "Diagnosis: Skin Disorders. \nTreatment: Inpatient Hospital. \nThe insurer denied Inpatient Admission. \nThe denial is overturned. \n\nThe patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.\nThe laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.\nThe patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.\nAt issue is the medical necessity of the Inpatient Admission.\n\nThe health plan's determination of medical necessity is overturned in whole.\n\nThe requested health service/treatment of Inpatient Admission was medically necessary for this patient.\nThe patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis which are signs of systemic inflammatory process. Additionally, the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon. The documentation supports inpatient level of care for incision and drainage, IV antibiotics and pain medications.\nSimple infections are usually confined to the skin and underlying superficial soft tissues generally respond well to outpatient management. However, complicated infections typically extend into and involve the underlying deep tissues including deep abscesses, decubitus ulcers, necrotizing fasciitis, and Fournier gangrene. These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also represent complicated infections. In this case, the patient's infection extended deep into the subcutaneous tissue and was recurrent despite prior drainage. The inpatient level of care was necessary for repeat incision, drainage and IV antibiotics given the presence of purulence and systemic signs of infection.\nIt is widely accepted in the literature that diabetics have an increased propensity to develop infections. Hyperglycemia causes both micro- and macrovascular complications, which are known illustrated as possible mechanisms that prevent the ulcers from wound healing. Blood glucose management is therefore considered a basic component of the treatment of wound healing. In this case, the inpatient level of care is appropriate for aggressive blood glucose control and expedited wound drainage.\nTherefore, the requested health service/treatment of Inpatient Admission was medically necessary.", "id": "e50571523bf545a8b6f34a0324da51f2", "question": "What is the background context in this case summary?", "title": "e50571523bf545a8b6f34a0324da51f2", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Orthopedic/Musculoskeletal. \nTreatment: Durable Medical Equipment (DME). \nThe insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories. ", "This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.\nAt issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.", "the occupational therapist has provided a letter stating medical necessity"], "answer_start": [0, 199, 1247]}, "context": "Diagnosis: Orthopedic/Musculoskeletal. \nTreatment: Durable Medical Equipment (DME). \nThe insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories. \nThe denial is upheld. \n\nThis patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.\nAt issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.\n\nThe health plan's determination of medical necessity is upheld in whole.\n\nThe requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary for this patient.\nBased on the patient's diagnosis and documentation, it is not clear that the requested items are medically necessary, as patients with Down Syndrome can have varying degrees of hypotonia. Although the occupational therapist has provided a letter stating medical necessity, there is no documentation of current status or the degree of impairment. Based on the records provided, it is not clear that the Durable Medical Equipment - Pediatric tilt wheelchair with accessories is considered medically necessary.\nTherefore, the requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary.", "id": "eb1a1c7dc6df420cb65155225363ac48", "question": "What is the background context in this case summary?", "title": "eb1a1c7dc6df420cb65155225363ac48", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Skin Disorders. \nTreatment: Inpatient Hospital. \nThe insurer denied Inpatient Admission. ", "The patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.\nThe laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.\nThe patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.\nAt issue is the medical necessity of the Inpatient Admission.", "The patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis", "the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon."], "answer_start": [0, 129, 1910, 2086]}, "context": "Diagnosis: Skin Disorders. \nTreatment: Inpatient Hospital. \nThe insurer denied Inpatient Admission. \nThe denial is overturned. \n\nThe patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.\nThe laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.\nThe patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.\nAt issue is the medical necessity of the Inpatient Admission.\n\nThe health plan's determination of medical necessity is overturned in whole.\n\nThe requested health service/treatment of Inpatient Admission was medically necessary for this patient.\nThe patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis which are signs of systemic inflammatory process. Additionally, the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon. The documentation supports inpatient level of care for incision and drainage, IV antibiotics and pain medications.\nSimple infections are usually confined to the skin and underlying superficial soft tissues generally respond well to outpatient management. However, complicated infections typically extend into and involve the underlying deep tissues including deep abscesses, decubitus ulcers, necrotizing fasciitis, and Fournier gangrene. These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also represent complicated infections. In this case, the patient's infection extended deep into the subcutaneous tissue and was recurrent despite prior drainage. The inpatient level of care was necessary for repeat incision, drainage and IV antibiotics given the presence of purulence and systemic signs of infection.\nIt is widely accepted in the literature that diabetics have an increased propensity to develop infections. Hyperglycemia causes both micro- and macrovascular complications, which are known illustrated as possible mechanisms that prevent the ulcers from wound healing. Blood glucose management is therefore considered a basic component of the treatment of wound healing. In this case, the inpatient level of care is appropriate for aggressive blood glucose control and expedited wound drainage.\nTherefore, the requested health service/treatment of Inpatient Admission was medically necessary.", "id": "fc1a12514d794481824d0d32ae435940", "question": "What is the background context in this case summary?", "title": "fc1a12514d794481824d0d32ae435940", "sufficiency_score": 4}
+{"answers": {"text": ["The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.\n\nVital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.\n\nWhite blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.\n\nChest x-rays revealed (CXR) revealed B/L airspace disease.\n\nThe patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx). \n\nRepeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.\n\nThe patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.\n", "Diagnosis: Diabetic ketoacidosis (DKA).\nTreatment: Inpatient admission.\n\nThe insurer denied coverage for an inpatient admission.", "This patient decided to sign out against medical advice (AMA)"], "answer_start": [157, 0, 2286]}, "context": "Diagnosis: Diabetic ketoacidosis (DKA).\nTreatment: Inpatient admission.\n\nThe insurer denied coverage for an inpatient admission.  The denial is overturned.\n\nThe patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.\n\nVital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.\n\nWhite blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.\n\nChest x-rays revealed (CXR) revealed B/L airspace disease.\n\nThe patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx). \n\nRepeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.\n\nThe patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.\n\nThis patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation. Based on above, it was appropriate to admit this patient to the hospital for active treatment and very close monitoring. This patient was not stable to be treated in any other setting.\n\nThis patient decided to sign out against medical advice (AMA), which was not in any one's control. He was not stable at the time he absconded from the hospital.\n\nThe health plan did not act reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.", "id": "36ac14b5f7434b32bf6b042d5b01c2c6", "question": "What is the background context in this case summary?", "title": "36ac14b5f7434b32bf6b042d5b01c2c6", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Abdominal pain\nTreatment: CT (computed tomography) scan\nThe insurer denied Computed Tomography (CT) of Abdomen and Pelvis . ", "The patient is a female with history of recurrent diverticulitis and sigmoid colon resection, and lysis of adhesions. She has had constipation. She presented with significant tenderness and pain in the left lower quadrant of the abdomen. She had ongoing abdominal pain (persistent for a month)."], "answer_start": [0, 185]}, "context": "Diagnosis: Abdominal pain\nTreatment: CT (computed tomography) scan\nThe insurer denied Computed Tomography (CT) of Abdomen and Pelvis . \nThe health plan's determination is overturned. \n\nThe patient is a female with history of recurrent diverticulitis and sigmoid colon resection, and lysis of adhesions. She has had constipation. She presented with significant tenderness and pain in the left lower quadrant of the abdomen. She had ongoing abdominal pain (persistent for a month).\n\nComputed Tomography (CT) of Abdomen and Pelvis is medically necessary for this patient.\n\nGiven that a cause for ongoing abdominal pain has not been definitively determined in the patient, and CT scan has a high sensitivity for several serious etiologies for abdominal pain that cannot be discovered by physical examination or more limited imaging examinations, and given that the patient has a history of diverticulitis and may now have persistent diverticulitis or complications of diverticulitis such as abscess, the requested CT scan is medically necessary in this case.", "id": "fa0065ff3fa348cc851112f46c56a7ec", "question": "What is the background context in this case summary?", "title": "fa0065ff3fa348cc851112f46c56a7ec", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Asthma\nTreatment: Inpatient Hospital Stay\nThe insurer denied the inpatient hospital stay.", "This is a female child with a medical history significant for moderate persistent asthma, eosinophilic esophagitis, food allergies, allergic rhinitis, and eczema who presented to the emergency department (ED) with a one-day history of increased work of breathing. She had been seen in the ED earlier that day, treated with DuoNebs and steroids for an asthma exacerbation, and discharged home. She returned to the ED for persistent wheezing unresponsive to nebulized albuterol at home. \nThe examination was significant for non-toxic appearance, moist mucous membranes, tachycardia, decreased air movement, wheezing, and tachypnea. She was able to speak in full sentences, with non-focal neurologic exam. \nShe was treated with magnesium, two DuoNebs, and a normal saline bolus. She was subsequently admitted because she remained symptomatic. Admission orders included continuous cardiopulmonary monitoring, regular diet, maintenance intravenous (IV) fluids, albuterol 2.5 milligrams (mg) every three hours, continued home medications (cetirizine, Singular), continued oral steroids. \nShe remained hemodynamically stable throughout the hospital stay with no need for supplemental oxygen. Albuterol was gradually weaned to every four hours. She tolerated her other medications as well as her diet.  She was deemed stable for discharge to pursue allergy testing. At issue is the medical necessity of an inpatient stay.", "This female child with a complex and significant history including moderate persistent asthma presented to the ED for the second time in one day. She remained symptomatic despite aggressive care in the ED and was admitted for ongoing treatment."], "answer_start": [0, 133, 2552]}, "context": "Diagnosis: Asthma\nTreatment: Inpatient Hospital Stay\nThe insurer denied the inpatient hospital stay. \nThe determination is upheld. \n\nThis is a female child with a medical history significant for moderate persistent asthma, eosinophilic esophagitis, food allergies, allergic rhinitis, and eczema who presented to the emergency department (ED) with a one-day history of increased work of breathing. She had been seen in the ED earlier that day, treated with DuoNebs and steroids for an asthma exacerbation, and discharged home. She returned to the ED for persistent wheezing unresponsive to nebulized albuterol at home. \nThe examination was significant for non-toxic appearance, moist mucous membranes, tachycardia, decreased air movement, wheezing, and tachypnea. She was able to speak in full sentences, with non-focal neurologic exam. \nShe was treated with magnesium, two DuoNebs, and a normal saline bolus. She was subsequently admitted because she remained symptomatic. Admission orders included continuous cardiopulmonary monitoring, regular diet, maintenance intravenous (IV) fluids, albuterol 2.5 milligrams (mg) every three hours, continued home medications (cetirizine, Singular), continued oral steroids. \nShe remained hemodynamically stable throughout the hospital stay with no need for supplemental oxygen. Albuterol was gradually weaned to every four hours. She tolerated her other medications as well as her diet.  She was deemed stable for discharge to pursue allergy testing. At issue is the medical necessity of an inpatient stay. \n\nThe inpatient stay was not medically necessary. \n\nAsthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is said to occur when the patient fails to respond initially to bronchodilators and other medications administered in an emergency department (ED) setting. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. \nIn the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary. \nThis female child with a complex and significant history including moderate persistent asthma presented to the ED for the second time in one day. She remained symptomatic despite aggressive care in the ED and was admitted for ongoing treatment. While it was reasonable and appropriate to monitor this patient in the hospital to provide ongoing care, she was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at lower level of care.", "id": "f8aa759e16a241bbbcc0dd8482143cac", "question": "What is the background context in this case summary?", "title": "f8aa759e16a241bbbcc0dd8482143cac", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Shortness of breath\nTreatment: Hospital admission\nThe insurer denied coverage for an inpatient admission.", "This is a patient with a history of Asthma presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) with productive cough and wheezing. The patient had used her inhalers at home but did not feel better so came to the ED.\n\nVital signs at presentation included: Temperature 98.1 degrees F (Fahrenheit) , Heart Rate 99, Respiratory Rate 18, Blood Pressure 126/72, oxygen (O2) saturation 98 % on Room Air. White blood cell count (WBC) was 9.7 K (thousand) Hb (hemoglobin) 14.3, electrolytes were within normal limits (WNL), oxygen saturation was 92-93 % on room Air, chest x-ray was negative. COVID-19 (coronavirus disease 2019) and Influenza were negative.\n\nThe patient was noted to have bilateral (B/L) wheezing and was given Decadron intravenous (IV) 10 mg (milligrams), Magnesium sulfate, and DuoNebs. She did show improvement but as she was still wheezing, she was admitted to the hospital with acute exacerbation of asthma. Per the history and physical (H&P), the patient was in no acute distress (NAD), was afebrile, and hemodynamically stable. A lung exam showed a bilateral wheeze. The patient was switched to Solumedrol 60 mg and continued on nebulizers and Doxycycline. \n\nThe patient was in no distress with stable vital signs: Temperature 98 degrees F (Fahrenheit), Heart Rate 91, Respiratory Rate 17, Blood Pressure 113/65, oxygen (O2) saturation 98% on Room Air. No evidence of CO2 (carbon dioxide) retention.\n\nThe patient was not hypoxic, was hemodynamically stable, not using accessory muscles and was speaking in full sentences. No pneumonia (PNA) on the CXR (chest x-ray). The patient was stable to be switched to oral steroids and other medications."], "answer_start": [0, 140]}, "context": "Diagnosis: Shortness of breath\nTreatment: Hospital admission\nThe insurer denied coverage for an inpatient admission.\nThe denial is upheld.\n\nThis is a patient with a history of Asthma presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) with productive cough and wheezing. The patient had used her inhalers at home but did not feel better so came to the ED.\n\nVital signs at presentation included: Temperature 98.1 degrees F (Fahrenheit) , Heart Rate 99, Respiratory Rate 18, Blood Pressure 126/72, oxygen (O2) saturation 98 % on Room Air. White blood cell count (WBC) was 9.7 K (thousand) Hb (hemoglobin) 14.3, electrolytes were within normal limits (WNL), oxygen saturation was 92-93 % on room Air, chest x-ray was negative. COVID-19 (coronavirus disease 2019) and Influenza were negative.\n\nThe patient was noted to have bilateral (B/L) wheezing and was given Decadron intravenous (IV) 10 mg (milligrams), Magnesium sulfate, and DuoNebs. She did show improvement but as she was still wheezing, she was admitted to the hospital with acute exacerbation of asthma. Per the history and physical (H&P), the patient was in no acute distress (NAD), was afebrile, and hemodynamically stable. A lung exam showed a bilateral wheeze. The patient was switched to Solumedrol 60 mg and continued on nebulizers and Doxycycline. \n\nThe patient was in no distress with stable vital signs: Temperature 98 degrees F (Fahrenheit), Heart Rate 91, Respiratory Rate 17, Blood Pressure 113/65, oxygen (O2) saturation 98% on Room Air. No evidence of CO2 (carbon dioxide) retention.\n\nThe patient was not hypoxic, was hemodynamically stable, not using accessory muscles and was speaking in full sentences. No pneumonia (PNA) on the CXR (chest x-ray). The patient was stable to be switched to oral steroids and other medications. The patient could have been treated under observation status for up to 48 hours. She remained stable after admission and did not need acute inpatient hospitalization.\n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for the hospital admission is not substantiated.", "id": "a7cb9d904ce6463e925d76e2e643e903", "question": "What is the background context in this case summary?", "title": "a7cb9d904ce6463e925d76e2e643e903", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Nodular scleritis and recurrent bilateral anterior uveitis\nTreatment: Acthar Gel\nThe insurer denied the Acthar Gel.", "The patient is a female with a history of nodular scleritis and recurrent bilateral anterior uveitis for whom coverage of Acthar Gel is the subject of review. Coverage was previously denied coverage by the health plan, as current plan-approved criteria do not allow coverage of Acthar Gel unless the patient has a diagnosis of infantile spasms or multiple sclerosis. Alternatives on the plan's formulary are identified as dexamethasone, prednisolone, methylprednisolone, hydrocortisone, and prednisone. The plan requires a trial of 3 alternatives if there are 3 or more covered alternatives.\n\nThe patient is identified as having Ankylosing Spondylitis and Crohn's disease which have been causing severe eye inflammation with extreme flare-ups about every 3 months and/or scleritis for the past 14 years despite receiving systemic treatment for her rheumatologic disease. The patient is currently being treated with Humira (adalimumab) and has tried and failed samples of prednisolone, atropine, and Durezol. "], "answer_start": [0, 154]}, "context": "Diagnosis: Nodular scleritis and recurrent bilateral anterior uveitis\nTreatment: Acthar Gel\nThe insurer denied the Acthar Gel.\nThe denial is overturned.\n\nThe patient is a female with a history of nodular scleritis and recurrent bilateral anterior uveitis for whom coverage of Acthar Gel is the subject of review. Coverage was previously denied coverage by the health plan, as current plan-approved criteria do not allow coverage of Acthar Gel unless the patient has a diagnosis of infantile spasms or multiple sclerosis. Alternatives on the plan's formulary are identified as dexamethasone, prednisolone, methylprednisolone, hydrocortisone, and prednisone. The plan requires a trial of 3 alternatives if there are 3 or more covered alternatives.\n\nThe patient is identified as having Ankylosing Spondylitis and Crohn's disease which have been causing severe eye inflammation with extreme flare-ups about every 3 months and/or scleritis for the past 14 years despite receiving systemic treatment for her rheumatologic disease. The patient is currently being treated with Humira (adalimumab) and has tried and failed samples of prednisolone, atropine, and Durezol. \n\nThe health plan should cover the formulary exception for Acthar Gel.\n\nChronic use of formulary systemic steroids would place the patient at unnecessary risk and run counter to the standard of care, as the patient has already moved on to steroid-sparing agents. According to the package insert, H.P. (highly purified) Acthar Gel may be used for ophthalmic diseases. In this case, Acthar is proposed for the treatment of nodular scleritis and recurrent bilateral anterior uveitis that has been refractory to topical steroids (prednisolone, Durezol), immunosuppressive therapy (methotrexate), and biologics (Humira). \n\nSeveral case reports are identified in the peer-reviewed medical literature that supports the safety and efficacy of Acthar in the treatment of such non-infectious uveitis. Agarwal et al recently published a case report describing the potential role of subcutaneously administered ACTH (adrenocorticotropic hormone) gel in the management of a patient with non-infectious panuveitis with significant retinal vasculitis, macular edema, and optic nerve inflammation. Therapy with ACTH (adrenocorticotropic hormone) gel resulted in rapid and adequate control of retinal vascular leakage, macular edema, and optic nerve inflammation. \n\nIn a second case report by Ahmad et al, a 16-year-old female with recurrent uveitis associated with poorly controlled juvenile idiopathic arthritis reported remission of uveitis symptoms after receiving RCI (repository corticotropin injection) (80U [units] administered intramuscularly 2 times per week) as additive therapy. \n\nSharon et al. reported the clinical course of three patients with bilateral, non-infectious anterior, and intermediate uveitis, treated with ACTH (adrenocorticotropic hormone) gel for 12 months. The authors concluded that subcutaneous adrenocorticotropic hormone gel has shown to be a safe and effective therapy in the management of non-infectious uveitis. \n\nNelson et al performed a retrospective medical records review of patients who had a diagnosis of uveitis, received repository corticotropin injection (RCI) in the prior 12 months, and had completed or were receiving RCI (repository corticotropin injection) treatment at the time of data collection. The author concluded that physicians individualized RCI (repository corticotropin injection) therapy among patients who suffered uveitis for several years and when previous therapies were inadequate. Most patients improved after initiating RCI (repository corticotropin injection), most commonly in vision. As uveitis is usually treated with a stepwise approach using corticosteroids, immunosuppressive therapy, and biologics, and this patient has failed or been intolerant to each of these therapies, the medical necessity of Acthar is established in this case.", "id": "c876d9a635fd40318af44a24594cc62a", "question": "What is the background context in this case summary?", "title": "c876d9a635fd40318af44a24594cc62a", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Spasticity at the ankle\nTreatment: Durable Medical Equipment -flexion/extension device\nThe health plan denied the Durable Medical Equipment as not medically necessary.", "This is a male who is a partial spastic tetraplegic. He is status/post (s/p) C3-T1 decompression and fusion. He has spasticity and is requesting an Ankle Dorsiflexion Dynasplint for range of motion (ROM) and stretching."], "answer_start": [0, 225]}, "context": "Diagnosis: Spasticity at the ankle\nTreatment: Durable Medical Equipment -flexion/extension device\nThe health plan denied the Durable Medical Equipment as not medically necessary. \nThe health plan's determination is upheld. \n\nThis is a male who is a partial spastic tetraplegic. He is status/post (s/p) C3-T1 decompression and fusion. He has spasticity and is requesting an Ankle Dorsiflexion Dynasplint for range of motion (ROM) and stretching.\n\nThe ankle Dynasplint is not medically necessary for this patient with spasticity at the ankle. \n\nStandard of care for spasticity in the spinal cord population includes toxin injection with aggressive range of motion and splinting. Treatment for this condition includes a toxin injection and an ankle-foot orthosis (AFO)/multipodus boot.\n", "id": "48bcf1ed0fcf42d7883dfc625e30506c", "question": "What is the background context in this case summary?", "title": "48bcf1ed0fcf42d7883dfc625e30506c", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Gastroesophageal reflux disease (GERD)\nTreatment: Transoral incisionless fundoplication (TIF)\nThe insurer denied transoral incisionless fundoplication (TIF).", "The patient has gastroesophageal reflux disease (GERD). He has failed proton pump inhibitor therapy for multiple years, as well as pantoprazole 40 milligrams (mg) daily with famotidine 40 mg daily. An esophagogastroduodenoscopy showed unremarkable esophagus, a small hiatal hernia, patchy gastritis, gastric polyps, and unremarkable duodenum; gastroesophageal junction biopsies showed mild chronic inflammation. Esophageal manometry was normal. At issue is the medical necessity of transoral incisionless fundoplication (TIF) for the treatment of GERD."], "answer_start": [0, 203]}, "context": "Diagnosis: Gastroesophageal reflux disease (GERD)\nTreatment: Transoral incisionless fundoplication (TIF)\nThe insurer denied transoral incisionless fundoplication (TIF).\nThe determination is overturned.\n\nThe patient has gastroesophageal reflux disease (GERD). He has failed proton pump inhibitor therapy for multiple years, as well as pantoprazole 40 milligrams (mg) daily with famotidine 40 mg daily. An esophagogastroduodenoscopy showed unremarkable esophagus, a small hiatal hernia, patchy gastritis, gastric polyps, and unremarkable duodenum; gastroesophageal junction biopsies showed mild chronic inflammation. Esophageal manometry was normal. At issue is the medical necessity of transoral incisionless fundoplication (TIF) for the treatment of GERD.\n\nThe requested TIF is medically necessary. The efficacy of TIF using the EsophyX device has been studied in a meta-analysis including 3 randomized controlled trials (including 233 patients at 3 years), with findings of improved esophageal potential hydrogen (pH), decreased proton pump inhibitor utilization, and improved quality of life compared with proton pump inhibitor therapy of sham treatment [1-4]. The American College of Gastroenterology (ACG) guidelines for the treatment of GERD state that \"We suggest consideration of transoral incisionless fundoplication (TIF) for patients with troublesome regurgitation or heartburn who do not wish to undergo anti-reflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias greater than (>) 2 centimeters (cm).\" In this case, the patient does not have severe reflux esophagitis or hiatal hernia larger than 2 cm [5]. Additionally, the patient has attempted therapy with a proton pump inhibitor, as recommended by ACG guidelines, without improvement in symptoms and concurrent gastroesophageal junction inflammation on endoscopic biopsies. For these reasons, the use of transoral incisionless fundoplication is supported as medically necessary for the treatment of this patient's GERD.", "id": "ae57146bf3344e9e8bf7e053116902e2", "question": "What is the background context in this case summary?", "title": "ae57146bf3344e9e8bf7e053116902e2", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Coronary Artery Disease\nTreatment: Inpatient day\nThe insurer denied coverage for inpatient day", "This elderly woman presented to the hospital for elective cardiac catheterization due to worsening of dyspnea on exertion. Past medical history was significant for hypertension and diabetes mellitus. She was noted to have a positive stress test. Cardiac catheterization was performed and revealed a left anterior descending artery stenosis. A drug eluting stent was successfully deployed. There were no perioperative complications, and the patient was discharged the following day. \n\nThis patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the left anterior descending (LAD) artery. She was discharged the following day."], "answer_start": [0, 129]}, "context": "Diagnosis: Coronary Artery Disease\nTreatment: Inpatient day\nThe insurer denied coverage for inpatient day\nThe denial is upheld.\n\nThis elderly woman presented to the hospital for elective cardiac catheterization due to worsening of dyspnea on exertion. Past medical history was significant for hypertension and diabetes mellitus. She was noted to have a positive stress test. Cardiac catheterization was performed and revealed a left anterior descending artery stenosis. A drug eluting stent was successfully deployed. There were no perioperative complications, and the patient was discharged the following day. \n\nThis patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the left anterior descending (LAD) artery. She was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.\n\nThe health plan acted reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for the inpatient day is upheld. Medical Necessity is not substantiated.", "id": "8edadf5ab29045839ffbc1e79387a09a", "question": "What is the background context in this case summary?", "title": "8edadf5ab29045839ffbc1e79387a09a", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Gynecomastia.\nTreatment: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).\nThe insurer denied: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).", "This patient is a young adult male who presents with complaints of fullness behind both nipples since adolescence. The patient reports developing breast tissue just behind the nipples on both sides which caused projection. He has lost weight and has begun to work out in the gym frequently with a continued projection of the nipple. He reports that when he is cold and he has hardening of the nipples he has a normal profile. He would like to surgically correct the shape and fullness of his nipple. The patient denies taking prescription medications. He denies taking illicit drugs including marijuana. He denies testicular masses. Mastectomies and liposuction are planned.", "The patient has gynecomastia"], "answer_start": [0, 257, 1015]}, "context": "Diagnosis: Gynecomastia.\nTreatment: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).\nThe insurer denied: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).\nThe denial is upheld.\n\nThis patient is a young adult male who presents with complaints of fullness behind both nipples since adolescence. The patient reports developing breast tissue just behind the nipples on both sides which caused projection. He has lost weight and has begun to work out in the gym frequently with a continued projection of the nipple. He reports that when he is cold and he has hardening of the nipples he has a normal profile. He would like to surgically correct the shape and fullness of his nipple. The patient denies taking prescription medications. He denies taking illicit drugs including marijuana. He denies testicular masses. Mastectomies and liposuction are planned.\n\nThe proposed treatment is not medically necessary.\nThe mastectomies are cosmetic. The patient has gynecomastia, but the records do not document any health or functional problems caused by the enlarged breasts. There is no documentation of an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for a breast malignancy and there are no diagnostic studies provided. The records do not document a need for treatment with analgesics or problems with activities of daily living due to his enlarged breasts.  \n\nGynecomastia is a benign condition that does not cause health or functional problems.  According to a review article from the Mayo Clinic, \"Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces the symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended...Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction.\"  \n\nThe records do not provide any evidence of concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance, and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefits from the surgery, but his physiologic health will not be improved.\n", "id": "92468fc6dd38400d82cea54a25a010ad", "question": "What is the background context in this case summary?", "title": "92468fc6dd38400d82cea54a25a010ad", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Facial cellulitis\nTreatment: Inpatient admission\nThe insurer denied coverage for inpatient admission", "This is a patient with a past medical history significant for acne who presented to the emergency room with complaints of facial cellulitis, right jaw pain, and peri orbital inflammation. \n\nVitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 138/78, Pulse 84, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.5, hemoglobin 13.4, hematocrit 1.8, creatinine 0.7, glucose 120, lactic acid 0.7.\n \nPatient was admitted to hospital for a facial cellulitis and empirically started on antibiotics. Maxillofacial computed tomography (CT) scan showed left preseptal soft tissue edema consistent with cellulitis. No evidence of extension into the orbit. Xray panorex was grossly unremarkable. Infectious Diseases consulted and adjusted antibiotics accordingly. Patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient. \n\nAccording to documentation, patient presented with a localized left pre-septal cellulitis. Patient was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection, and no surgical intervention was required."], "answer_start": [0, 134]}, "context": "Diagnosis: Facial cellulitis\nTreatment: Inpatient admission\nThe insurer denied coverage for inpatient admission\nThe denial is upheld\n\nThis is a patient with a past medical history significant for acne who presented to the emergency room with complaints of facial cellulitis, right jaw pain, and peri orbital inflammation. \n\nVitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 138/78, Pulse 84, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.5, hemoglobin 13.4, hematocrit 1.8, creatinine 0.7, glucose 120, lactic acid 0.7.\n \nPatient was admitted to hospital for a facial cellulitis and empirically started on antibiotics. Maxillofacial computed tomography (CT) scan showed left preseptal soft tissue edema consistent with cellulitis. No evidence of extension into the orbit. Xray panorex was grossly unremarkable. Infectious Diseases consulted and adjusted antibiotics accordingly. Patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient. \n\nAccording to documentation, patient presented with a localized left pre-septal cellulitis. Patient was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection, and no surgical intervention was required. Based on above findings, patient did not meet criteria for acute inpatient admission. Patient met criteria for observation level of management. \n\nThe health plan acted reasonably with sound medical judgment in the best interest of the patient.\n\nThe insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated. \n", "id": "618d0b829e624b168df7eb1d5b101854", "question": "What is the background context in this case summary?", "title": "618d0b829e624b168df7eb1d5b101854", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Type 2 diabetes mellitus.\nTreatment: Afrezza\nThe insurer denied Afrezza. ", "This is a male diagnosed with Type 2 diabetes mellitus with hyperglycemia. This request is for Afreeza. As reported, he has a severe phobia of needles making it so that he has been unable to give rapid-acting insulin injections. He has previously prescribed Novolog for treatment but failed due to his inability to inject due to his phobia.", "The patient is unable to self-inject to due needle phobia."], "answer_start": [0, 133, 909]}, "context": "Diagnosis: Type 2 diabetes mellitus.\nTreatment: Afrezza\nThe insurer denied Afrezza. \nThe health plan's determination is overturned.\n\nThis is a male diagnosed with Type 2 diabetes mellitus with hyperglycemia. This request is for Afreeza. As reported, he has a severe phobia of needles making it so that he has been unable to give rapid-acting insulin injections. He has previously prescribed Novolog for treatment but failed due to his inability to inject due to his phobia.\n\nThe formulary alternative will be ineffective as the patient cannot self-inject insulin due to needle phobia.\nAfrezza is FDA (Food and Drug Administration) approved for the treatment of diabetes. It has been shown to be beneficial in patients with diabetes. Studies have demonstrated the safety and efficacy of the medication and treatment of diabetes. There are no studies showing the superiority of Afrezza over injectable insulin. The patient is unable to self-inject to due needle phobia. A formulary exception is indicated.", "id": "a0603ec50eed4293b41f05283eefb849", "question": "What is the background context in this case summary?", "title": "a0603ec50eed4293b41f05283eefb849", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Type 2 Diabetes\nTreatment: Freestyle Libre supplies\nThe insurer denied Freestyle Libre supplies.", "This is a male patient with type 2 diabetes with neuropathy treated with metformin and Ozempic. The patient's A1C is 5.8 percent (%). Freestyle Libre supplies were denied by the health plan and are under review for medical necessity."], "answer_start": [0, 138]}, "context": "Diagnosis: Type 2 Diabetes\nTreatment: Freestyle Libre supplies\nThe insurer denied Freestyle Libre supplies.\nThe determination is upheld.\n\nThis is a male patient with type 2 diabetes with neuropathy treated with metformin and Ozempic. The patient's A1C is 5.8 percent (%). Freestyle Libre supplies were denied by the health plan and are under review for medical necessity.\n\nThe requested Freestyle Libre supplies are not medically necessary for this patient. The requested service is for the management of type 2 diabetes for a patient who is not on insulin therapy. Long-term continuous glucose monitoring has been shown to be safe and effective for people with type 2 diabetes on multiple daily insulin injections and basal insulin therapy. The safety and efficacy of continuous glucose monitoring has not been sufficiently studied in people with type 2 diabetes in the absence of insulin therapy to determine safety and efficacy in this clinical situation. The use of continuous glucose monitoring in this clinical situation is not supported by the Endocrine Society guidelines [1] or the American Diabetes Association clinical guidelines [2]. Therefore, the requested Freestyle Libre supplies are not medically necessary for this patient.\n", "id": "5b01c8badba94900865c0b0f2426f5a4", "question": "What is the background context in this case summary?", "title": "5b01c8badba94900865c0b0f2426f5a4", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Osteomyelitis\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission", "Asked to review the case of an adult male that presented to the hospital with fever of 101.7 degrees F and symptoms of nausea and vomiting. Past medical history was significant for metastatic pancreatic cancer on chemotherapy, diabetes mellitus, hypertension, coronary artery disease status post right coronary artery (RCA) stent, and pulmonary embolus.  On arrival to the hospital blood pressure was 98/51 and pulse was 78. Physical examination was significant for poor distal pulses on lower extremities and  a second right toe amputation. Electrocardiogram demonstrated sinus rhythm with Q waves inferiorly and nonspecific T wave changes.  Serum blood testing demonstrated several abnormalities: White blood cells (WBC) 18,000 with bandemia, lactate of 2.0, troponin of 240, and B type natriuretic peptide of 3498.  Chest X ray revealed a right lower lung infiltrate. The patient was treated with intravenous antibiotics and admitted to the hospital for ischemia work up and sepsis work up.  Echocardiogram revealed an left ventricular ejection fraction (LVEF) of 55% with mild inferior \nwall hypokinesis and with moderate mitral regurgitation.  The patient was treated medically \nfor type II myocardial infarction.  He was ultimately diagnosed with infection due to \nosteomyelitis of the distal extremity and was discharged on antibiotic therapy.", "this patient had multiple medical problems including metastatic pancreatic cancer and possible sepsis.  The patient was ultimately diagnosed with osteomyelitis", "This patient presented with fever, nausea and vomiting and an elevated serum troponin level.  His pretest probability of coronary artery disease was high."], "answer_start": [0, 139, 2516, 1491]}, "context": "Diagnosis: Osteomyelitis\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission\n\nThe denial is overturned\n \n\nAsked to review the case of an adult male that presented to the hospital with fever of 101.7 degrees F and symptoms of nausea and vomiting. Past medical history was significant for metastatic pancreatic cancer on chemotherapy, diabetes mellitus, hypertension, coronary artery disease status post right coronary artery (RCA) stent, and pulmonary embolus.  On arrival to the hospital blood pressure was 98/51 and pulse was 78. Physical examination was significant for poor distal pulses on lower extremities and  a second right toe amputation. Electrocardiogram demonstrated sinus rhythm with Q waves inferiorly and nonspecific T wave changes.  Serum blood testing demonstrated several abnormalities: White blood cells (WBC) 18,000 with bandemia, lactate of 2.0, troponin of 240, and B type natriuretic peptide of 3498.  Chest X ray revealed a right lower lung infiltrate. The patient was treated with intravenous antibiotics and admitted to the hospital for ischemia work up and sepsis work up.  Echocardiogram revealed an left ventricular ejection fraction (LVEF) of 55% with mild inferior \nwall hypokinesis and with moderate mitral regurgitation.  The patient was treated medically \nfor type II myocardial infarction.  He was ultimately diagnosed with infection due to \nosteomyelitis of the distal extremity and was discharged on antibiotic therapy.\n\nThis patient presented with fever, nausea and vomiting and an elevated serum troponin level.  His pretest probability of coronary artery disease was high.(Reference 1)  Utilizing the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) he was considered intermediate risk. (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In addition to the issue of an acute coronary syndrome, this patient had multiple medical problems including metastatic pancreatic cancer and possible sepsis.  The patient was ultimately diagnosed with osteomyelitis that likely contributed to a type 2 myocardial infarction. (Reference 4).\n\nBased on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for full hospital admission is substantiated.\n", "id": "20a4ae8f941e4a89b4922396aefbca48", "question": "What is the background context in this case summary?", "title": "20a4ae8f941e4a89b4922396aefbca48", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis:  Dental Issues.\nTreatment:  Braces and Monthly Visits.\n\nThe insurer denied the braces and monthly visits.", "The patient is a male with a Class I malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is if the requested health service/treatment of braces and monthly visits are medically necessary."], "answer_start": [0, 162]}, "context": "Diagnosis:  Dental Issues.\nTreatment:  Braces and Monthly Visits.\n\nThe insurer denied the braces and monthly visits.  The health plan's determination is upheld.\n\nThe patient is a male with a Class I malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is if the requested health service/treatment of braces and monthly visits are medically necessary.\n\nThe health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.\n\nThe treatment for braces and monthly visits is not medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5 millimeter (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces are not medically necessary.\n\nThe health plan's determination is upheld in whole.", "id": "7bfac3d913204940bc41877d3642f781", "question": "What is the background context in this case summary?", "title": "7bfac3d913204940bc41877d3642f781", "sufficiency_score": 3}
+{"answers": {"text": ["Diagnosis: Cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder\nTreatment: Consumer Directed Personal Aide Services (CDPAS) for A total of 168 hours/week\nThe insurer denied the CDPAS for a total of 168 hours/week.", "This elderly female has medical conditions that include cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder, anxiety, osteoarthritis, diabetes, hypothyroidism, anemia, abnormal gait, and urinary incontinence. Denial of Consumer Directed Personal Aide Services (CDPAS) for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The patient needs assistance with ADLs (activities of daily living). She is frequently incontinent and cannot change or dress independently. A statement from her provider notes her condition is worsening. She has a history of multiple falls. She is unable to use her left arm after a shoulder injury. She uses the commode every 2-4 hours and cannot transfer without assistance. She needs to be cleaned and changed frequently during night due to incontinence. A statement from her children notes she lives alone. She has difficulty walking and cannot get to the bathroom or out of chair or bed when her aide leaves. She wakes up 5-6 times per night and needs assistance with going to the bathroom. ", "This patient has multiple chronic conditions. Denial of CDPAS for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The statement provided indicates that the patient's condition is deteriorating. She needs assistance with ADLs. She has urinary incontinence and requires assistance with transferring and toileting every 2-4 hours."], "answer_start": [0, 266, 1931]}, "context": "Diagnosis: Cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder\nTreatment: Consumer Directed Personal Aide Services (CDPAS) for A total of 168 hours/week\nThe insurer denied the CDPAS for a total of 168 hours/week.\nThe denial is overturned.\n\nThis elderly female has medical conditions that include cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder, anxiety, osteoarthritis, diabetes, hypothyroidism, anemia, abnormal gait, and urinary incontinence. Denial of Consumer Directed Personal Aide Services (CDPAS) for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The patient needs assistance with ADLs (activities of daily living). She is frequently incontinent and cannot change or dress independently. A statement from her provider notes her condition is worsening. She has a history of multiple falls. She is unable to use her left arm after a shoulder injury. She uses the commode every 2-4 hours and cannot transfer without assistance. She needs to be cleaned and changed frequently during night due to incontinence. A statement from her children notes she lives alone. She has difficulty walking and cannot get to the bathroom or out of chair or bed when her aide leaves. She wakes up 5-6 times per night and needs assistance with going to the bathroom. \n\nThe proposed treatment is medically necessary. \n\nPersonal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. Denial of CDPAS for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The statement provided indicates that the patient's condition is deteriorating. She needs assistance with ADLs. She has urinary incontinence and requires assistance with transferring and toileting every 2-4 hours. The information provided supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS for 70 hours/week is insufficient to support her continuous needs. The proposed CDPAS for a total of 168 hours/week, split shift is medically necessary.", "id": "b8d0bc6ba2014a4f87baed8f73718bc5", "question": "What is the background context in this case summary?", "title": "b8d0bc6ba2014a4f87baed8f73718bc5", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Shock from ICD (implantable cardiac defibrillator); lightheadedness\nTreatment: Inpatient Hospital Admission\nThe insurer denied: Inpatient Hospital Admission", "The patient is an adult male that presented to the hospital following three shocks from his implantable cardiac defibrillator. Accompanying symptoms included lightheadedness and dyspnea. The patient's past medical history was notable for \"septal defect repair\", mechanical aortic valve replacement (AVR), stoke, myocardial infarction status post revascularization and heart failure with a reduced left ventricular ejection fraction of 15% (percent). The patient also has a subcutaneous defibrillator that was implanted for primary prevention several months prior to presentation. On arrival to the hospital, the patient's vital signs were stable (blood pressure 130/91 millimeters of mercury [mmHg', pulse 85 beats per minute). Physical examination revealed clear lungs and mechanical heart valve sounds at the aortic position. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic changes. Serum blood testing revealed a potassium of 5.9 and an international normalized ratio (INR) that peaked at 4.69. Implantable cardioverter defibrillator interrogation revealed a single shock for supraventricular tachycardia and the patient was admitted to the telemetry ward for observation and treatment. The patient ultimately underwent diagnostic electrophysiologic testing and no ablation was performed. The patient was discharged on escalating doses of beta blocker therapy.\n", "This patient presented with an implantable cardioverter defibrillator shock as a result of a rapid heart rhythm. The patient has an extensive cardiac history including mechanical aortic valve replacement, myocardial infarction, stroke and heart failure with a severely reduced ejection fraction of 15%."], "answer_start": [0, 195, 1635]}, "context": "Diagnosis: Shock from ICD (implantable cardiac defibrillator); lightheadedness\nTreatment: Inpatient Hospital Admission\nThe insurer denied: Inpatient Hospital Admission\nThe denial is overturned.\n\nThe patient is an adult male that presented to the hospital following three shocks from his implantable cardiac defibrillator. Accompanying symptoms included lightheadedness and dyspnea. The patient's past medical history was notable for \"septal defect repair\", mechanical aortic valve replacement (AVR), stoke, myocardial infarction status post revascularization and heart failure with a reduced left ventricular ejection fraction of 15% (percent). The patient also has a subcutaneous defibrillator that was implanted for primary prevention several months prior to presentation. On arrival to the hospital, the patient's vital signs were stable (blood pressure 130/91 millimeters of mercury [mmHg', pulse 85 beats per minute). Physical examination revealed clear lungs and mechanical heart valve sounds at the aortic position. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic changes. Serum blood testing revealed a potassium of 5.9 and an international normalized ratio (INR) that peaked at 4.69. Implantable cardioverter defibrillator interrogation revealed a single shock for supraventricular tachycardia and the patient was admitted to the telemetry ward for observation and treatment. The patient ultimately underwent diagnostic electrophysiologic testing and no ablation was performed. The patient was discharged on escalating doses of beta blocker therapy.\n\nThe proposed treatment was medically necessary.\n\nThis patient presented with an implantable cardioverter defibrillator shock as a result of a rapid heart rhythm. The patient has an extensive cardiac history including mechanical aortic valve replacement, myocardial infarction, stroke and heart failure with a severely reduced ejection fraction of 15%. Hospitalization for diagnostic testing and treatment is clearly needed given the increased morbidity and mortality associated with both supraventricular and ventricular arrhythmias in this patient population. (Reference 1, 2) \nThis patient required additional work up to assess the nature of his arrhythmia and potentially eliminate recurrent arrhythmia that might result in additional future implantable cardioverter defibrillator therapies. The patent appropriately underwent diagnostic electrophysiologic testing and was ultimately treated with escalating doses of beta blocker therapy. This patient's comorbid conditions and presentation required a higher level of care. In conclusion, inpatient hospital admission was medically necessary. ", "id": "127cfeadaecb4743ba77d334d9dc7ffb", "question": "What is the background context in this case summary?", "title": "127cfeadaecb4743ba77d334d9dc7ffb", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Pressure ulcers\n\nTreatment: Topical Oxygen Wound Therapy (TOWT)\n\nThe insurer denied coverage for Topical Oxygen Wound Therapy (TOWT)", "According to the surgeon's note : \"This patient has a past medical history that is significant for Orthostatic hypertension, reflex disease, chronic obstructive pulmonary disease (COPD), respiratory failure, muscle weakness, generalized edema, history of ventilatory dependence, Failure to thrive, contractions of the hip, mass of the duodenum, cognitive dysfunction who has deteriorated over the past seven months. Patient has dementia which has progressed. Approximately several months ago he was walking but he lost the ability to walk. He was taken to ... hospital. He was noted to have some sort of liver failure/cholecystitis with elevated bilirubin and they placed a t-tube since he was not an operative candidate. He came back home and became fluid over-loaded and he was noted to have edema in his legs as well as lungs. He was then taken back to the hospital and was intubated and then this led to a tracheostomy. He was in the hospital as well as a care facility and developed multiple pressure ulcers.\"  The surgeon's note indicates that the patient continues to have inadequate nutrition and is not being turned and off-loaded adequately."], "answer_start": [0, 169]}, "context": "Diagnosis: Pressure ulcers\n\nTreatment: Topical Oxygen Wound Therapy (TOWT)\n\nThe insurer denied coverage for Topical Oxygen Wound Therapy (TOWT)\n\nThe denial is upheld\n\n \nAccording to the surgeon's note : \"This patient has a past medical history that is significant for Orthostatic hypertension, reflex disease, chronic obstructive pulmonary disease (COPD), respiratory failure, muscle weakness, generalized edema, history of ventilatory dependence, Failure to thrive, contractions of the hip, mass of the duodenum, cognitive dysfunction who has deteriorated over the past seven months. Patient has dementia which has progressed. Approximately several months ago he was walking but he lost the ability to walk. He was taken to ... hospital. He was noted to have some sort of liver failure/cholecystitis with elevated bilirubin and they placed a t-tube since he was not an operative candidate. He came back home and became fluid over-loaded and he was noted to have edema in his legs as well as lungs. He was then taken back to the hospital and was intubated and then this led to a tracheostomy. He was in the hospital as well as a care facility and developed multiple pressure ulcers.\"  The surgeon's note indicates that the patient continues to have inadequate nutrition and is not being turned and off-loaded adequately.  Multiple studies have been published showing efficacy for Topical Oxygen Wound Therapy (TOWT) for the management of diabetic ulcers.  There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.\n\nTopical Oxygen Wound Therapy (TOWT) is not considered medically necessary for this patient. There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.\n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for Topical Oxygen Wound Therapy (TOWT) is not substantiated.\n", "id": "d352efdd1fb940fd8f7d6db038f7ea1d", "question": "What is the background context in this case summary?", "title": "d352efdd1fb940fd8f7d6db038f7ea1d", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Type 2 Diabetes Mellitus\nTreatment: Formulary exception for Mounjaro 2.5 mg (milligrams)/0.5 ml (milliliters) Pen\nThe insurer denied the formulary exception for Mounjaro 2.5 mg/0.5 ml pen.", "The patient is an adult male with type 2 diabetes. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This denial is being appealed. The patient has tried Ozempic, which caused nausea. The patient is being treated with metformin. The patient's A1C (glycated hemoglobin) is 6.0% (percent).", "The patient's A1C was 6.0%. He is being treated with metformin.", "This request is for Mounjaro for the treatment of type 2 diabetes. The health plan's formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and was intolerant to Ozempic due to nausea."], "answer_start": [0, 223, 1176, 783]}, "context": "Diagnosis: Type 2 Diabetes Mellitus\nTreatment: Formulary exception for Mounjaro 2.5 mg (milligrams)/0.5 ml (milliliters) Pen\nThe insurer denied the formulary exception for Mounjaro 2.5 mg/0.5 ml pen.\nThe denial is upheld.\n\nThe patient is an adult male with type 2 diabetes. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This denial is being appealed. The patient has tried Ozempic, which caused nausea. The patient is being treated with metformin. The patient's A1C (glycated hemoglobin) is 6.0% (percent).\n\nThe health plan should not cover the formulary exception for Mounjaro.\n\nThis request is for Mounjaro for the treatment of type 2 diabetes. The health plan's formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and was intolerant to Ozempic due to nausea. The documentation does not indicate that the patient has tried and failed the remaining alternatives or that the patient has a contraindication to these alternatives. The patient's A1C was 6.0%. He is being treated with metformin. The patient does not have a prior documented A1C that was elevated to document a need for additional glucose lowering medication. The American Diabetes Association clinical guidelines do not support the use of Mounjaro in this clinical situation. Mounjaro has risks, including nausea and vomiting. Therefore, no, the health plan should not cover the formulary exception for Mounjaro. ", "id": "a68bd04d38ad4b6481ee2c480f4d90b6", "question": "What is the background context in this case summary?", "title": "a68bd04d38ad4b6481ee2c480f4d90b6", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Heart Failure\nTreatment: Entresto\nThe insurer denied Entresto.", "This is a male patient with a history of atrial fibrillation and nonischemic cardiomyopathy. An echocardiogram showed a dilated left ventricle with global hypokinesis and a left ventricular ejection fraction of 25-30 percent (%). There was severe mitral regurgitation. Per the physician's appeal letter the patient has New York Heart Association Functional Class II heart failure. The medical necessity for Entresto is at issue."], "answer_start": [0, 108]}, "context": "Diagnosis: Heart Failure\nTreatment: Entresto\nThe insurer denied Entresto.\nThe determination is overturned.\n\nThis is a male patient with a history of atrial fibrillation and nonischemic cardiomyopathy. An echocardiogram showed a dilated left ventricle with global hypokinesis and a left ventricular ejection fraction of 25-30 percent (%). There was severe mitral regurgitation. Per the physician's appeal letter the patient has New York Heart Association Functional Class II heart failure. The medical necessity for Entresto is at issue.\n\nBased on the information provided, Entresto is medically necessary.\n\nEntresto (sacubitril/valsartan) is a relatively new, first-in-class medication that combines an angiotensin receptor blocker with a neprilysin inhibitor. In the pivotal trial of Entresto, 4187 patients with New York Heart Association (NYHA) Class II-IV heart failure and reduced left ventricular ejection fractions (less than or equal to 40%) were randomly assigned to receive either Entresto or standard therapy with enalapril, an angiotensin converting enzyme (ACE) inhibitor. During a median follow-up time of 27 months, the combined endpoint of death from cardiovascular cause or heart failure hospitalization occurred in 21.8% of the Entresto group versus 26.5% of the enalapril group; this difference was highly significant and in favor of the Entresto group. The American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Failure Society of America (HFSA) guidelines for heart failure have given its use a Class I recommendation in this patient population.\n\nPer the policy provided Entresto is medically necessary when:\n1.\tThe individual is at least 18 years of age; (MET)\n2.\tThe individual is using the drug for NYHA class II, III or IV symptoms: (MET)\n3.\tAND\n4.\tThe individual has a left ventricular ejection fraction of 57% or less. (MET)", "id": "9e0c759eef9e471790fa47b91f9ef43a", "question": "What is the background context in this case summary?", "title": "9e0c759eef9e471790fa47b91f9ef43a", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Alzheimer's dementia\nTreatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week\nThe insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.", "This elderly female patient has conditions including Alzheimer's dementia. The denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. Uniform Assessment System evaluation completed 5 months ago showed severely impaired cognition and functional status: total dependence to maximal assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. There is no significant change compared to Uniform Assessment System evaluation completed 16 months ago. The patient's daughter reports that the patient has deteriorated since being diagnosed with COVID (coronavirus disease). A letter from the patient's physician notes the patient has rapidly deteriorating cognitive and physical health and functioning. She is confined to the bed and wheelchair. She has progressive dementia. She requires assistance multiple times per day with diaper changes. She requires continuous supervision and assistance with activities of daily living (ADLs).", "This patient has chronic conditions that include Alzheimer's dementia. Denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week for 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. The health plan denied the additional hours based on the Uniform Assessment System (UAS) evaluation and noted that hours could be adjusted to meet the patient's needs. Uniform Assessment System evaluation completed 5 months ago, shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed 16 months ago, the patient required maximal assistance to total dependence with all activities of daily living. The appeal statements note that the patient's cognitive and physical functioning are deteriorating. She is confined to the bed and wheelchair. The information provided shows that this patient has significant limitations in functioning."], "answer_start": [0, 452, 2224]}, "context": "Diagnosis: Alzheimer's dementia\nTreatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week\nThe insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.\nThe denial is partially overturned.\n\nThis elderly female patient has conditions including Alzheimer's dementia. The denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. Uniform Assessment System evaluation completed 5 months ago showed severely impaired cognition and functional status: total dependence to maximal assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. There is no significant change compared to Uniform Assessment System evaluation completed 16 months ago. The patient's daughter reports that the patient has deteriorated since being diagnosed with COVID (coronavirus disease). A letter from the patient's physician notes the patient has rapidly deteriorating cognitive and physical health and functioning. She is confined to the bed and wheelchair. She has progressive dementia. She requires assistance multiple times per day with diaper changes. She requires continuous supervision and assistance with activities of daily living (ADLs).\n\nAn increase in consumer directed personal assistance program (CDPAP) to 24 hours per day, 7 days per week, live in, is medically necessary for this patient. However, an increase in consumer directed personal assistance program (CDPAP) and:12 hours per day, 7 day(s) per week; 12 hours per day, 7 day(s) per week (split shift) - for a total of 168 hours per week is not medically necessary. \n\nPersonal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. This patient has chronic conditions that include Alzheimer's dementia. Denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week for 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. The health plan denied the additional hours based on the Uniform Assessment System (UAS) evaluation and noted that hours could be adjusted to meet the patient's needs. Uniform Assessment System evaluation completed 5 months ago, shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed 16 months ago, the patient required maximal assistance to total dependence with all activities of daily living. The appeal statements note that the patient's cognitive and physical functioning are deteriorating. She is confined to the bed and wheelchair. The information provided shows that this patient has significant limitations in functioning. The approved consumer directed personal assistance program (CDPAP) at 66.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The information does not support that the patient has continuous needs that will not allow an aide 5 hours of sleep. The proposed consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week and 12 hours per day - 7 days per week, split shift, is not medically necessary. However, an increase consumer directed personal assistance program to 24 hours per day, 7 days per week, live in, is medically necessary for this patient. ", "id": "7459358b8150414e83c3fc66caf4e91c", "question": "What is the background context in this case summary?", "title": "7459358b8150414e83c3fc66caf4e91c", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Knee pain.\nTreatment: Inpatient admission.\nThe health plan denied inpatient admission. ", "The patient is an adult male with knee pain. He has a history of severe morbid obesity, hypertension, and non-ischemic cardiomyopathy. He had undergone a left total knee replacement last year complicated by pain and decreased motion. He had undergone MUA (manipulation under anesthesia) x 2.\n\nThe patient was admitted to the hospital and discharged two days later. His surgery was arthrotomy, synovectomy and arthrolysis. He required PCA (patient-controlled analgesia), CVAC (Central Venous Access Catheter) and monitoring after the procedure.\n", "The anesthesia time was nearly 5 hours. The patient has COPD (chronic obstructive pulmonary disease) with reported need for CPAP (continuous positive airway pressure).", "The patient had a drain in place with continued output. A special VAC (vacuum-assisted closure) drain was placed. It was not removed until POD (post-operative day) #2.", "The patient was also found to have continued pain to require PCA (patient-controlled analgesia).", "BMI (body mass index) 45."], "answer_start": [0, 126, 973, 1197, 1432, 837]}, "context": "Diagnosis: Knee pain.\nTreatment: Inpatient admission.\nThe health plan denied inpatient admission. \nThe denial is overturned.\n\nThe patient is an adult male with knee pain. He has a history of severe morbid obesity, hypertension, and non-ischemic cardiomyopathy. He had undergone a left total knee replacement last year complicated by pain and decreased motion. He had undergone MUA (manipulation under anesthesia) x 2.\n\nThe patient was admitted to the hospital and discharged two days later. His surgery was arthrotomy, synovectomy and arthrolysis. He required PCA (patient-controlled analgesia), CVAC (Central Venous Access Catheter) and monitoring after the procedure.\n\nThe records show a complex and unique clinical condition to warrant the services provided. The important findings to substantiate inpatient admission are as follows:\nBMI (body mass index) 45. This is an outlier to ambulatory arthroplasty. The patient would be at extremely high risk for complications.\nThe anesthesia time was nearly 5 hours. The patient has COPD (chronic obstructive pulmonary disease) with reported need for CPAP (continuous positive airway pressure). There would be an increased risk of pulmonary problems.\nThe patient had a drain in place with continued output. A special VAC (vacuum-assisted closure) drain was placed. It was not removed until POD (post-operative day) #2. A patient would not be able to be discharged with active drainage.\nThe patient was also found to have continued pain to require PCA (patient-controlled analgesia).\n\nBased upon the described clinical condition, the inpatient admission and length of stay was warranted and medically necessary.\n", "id": "81cc98fd26f84f808b784b2dbf91b7a8", "question": "What is the background context in this case summary?", "title": "81cc98fd26f84f808b784b2dbf91b7a8", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Idiopathic short stature\nTreatment: Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN (subcutaneous solution pen injector)\nThe insurer denied coverage for Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN", "This is a teenager diagnosed with idiopathic short stature (ISS). This request is for Norditropin. His height velocity is reported to be 6.7 centimeters per year (cm/yr). He is at tanner 3. His insulin like growth factor 1 (IGF1) was 297 and insulin like growth factor binding protein 3 (IGFBP3) was 3.62.\n\nHis weight was 41.50 kilograms.\nHis height 150.5 cm (-2.24 standard deviation (SDS))\nHis mother's height is 160.02 cm and father's height is 162.56 cm and mid parental height is 167.8 cm (-1.26 SDS)\nHis predicted adult height is 171 cm, -0.81 SD.  "], "answer_start": [0, 270]}, "context": "Diagnosis: Idiopathic short stature\nTreatment: Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN (subcutaneous solution pen injector)\nThe insurer denied coverage for Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN\nThe denial is upheld\n\nThis is a teenager diagnosed with idiopathic short stature (ISS). This request is for Norditropin. His height velocity is reported to be 6.7 centimeters per year (cm/yr). He is at tanner 3. His insulin like growth factor 1 (IGF1) was 297 and insulin like growth factor binding protein 3 (IGFBP3) was 3.62.\n\nHis weight was 41.50 kilograms.\nHis height 150.5 cm (-2.24 standard deviation (SDS))\nHis mother's height is 160.02 cm and father's height is 162.56 cm and mid parental height is 167.8 cm (-1.26 SDS)\nHis predicted adult height is 171 cm, -0.81 SD.  \n\nThe peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:\n\nClassic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society[1], the Lawson Wilkins Pediatric Endocrinology Society[2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists[4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height; 3) height more than 2 SD below the mean and a height velocity over 1 yr more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10.\n\nThe patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported and growth factors are normal.\n\nGrowth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. Food and Drug Administration (FDA) approval for this indication is for \"non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means.\"[10-13]\n\nThe patient had a pretreatment height of -2.24 SD. The patient's height velocity and bone age would allow the patient to reach a normal adult height. The patient therefore does not meet idiopathic short stature criteria.\n\nThe request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.\n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN is not substantiated.", "id": "2b51736ee6e642fab5adf5ed25e6b35d", "question": "What is the background context in this case summary?", "title": "2b51736ee6e642fab5adf5ed25e6b35d", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI)\nTreatment: Inpatient admission\nThe insurer denied coverage for inpatient admission", "This is an adult with a past medical history which includes diabetes mellitus. She presented to the emergency department (ED) with 2 days of intermittent palpitations, dizziness, and fatigue. She denied chest pain or shortness of breath. She noted a cough ongoing for 6 weeks. There were various laboratory abnormalities noted, including hypokalemia, elevated blood glucose, and elevated troponin of 165.9. There were no ischemic electrocardiogram (EKG) changes but left ventricular hypertrophy (LVH) was noted. Her workup was normal, including stress testing and echocardiography, although troponin remained elevated. \n\nThe patient had an admission diagnosis of non-ST-elevation myocardial infarction (NSTEMI). Troponin was reported as elevated (and was, in fact high at 165.9). EKG showed LVH but no ischemic findings. Admission to telemetry was arranged."], "answer_start": [0, 169]}, "context": "Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI)\nTreatment: Inpatient admission\nThe insurer denied coverage for inpatient admission\nThe denial is overturned\n \nThis is an adult with a past medical history which includes diabetes mellitus. She presented to the emergency department (ED) with 2 days of intermittent palpitations, dizziness, and fatigue. She denied chest pain or shortness of breath. She noted a cough ongoing for 6 weeks. There were various laboratory abnormalities noted, including hypokalemia, elevated blood glucose, and elevated troponin of 165.9. There were no ischemic electrocardiogram (EKG) changes but left ventricular hypertrophy (LVH) was noted. Her workup was normal, including stress testing and echocardiography, although troponin remained elevated. \n\nThe patient had an admission diagnosis of non-ST-elevation myocardial infarction (NSTEMI). Troponin was reported as elevated (and was, in fact high at 165.9). EKG showed LVH but no ischemic findings. Admission to telemetry was arranged.\n\nA hospital admission was appropriate. When deciding on admission from the ED, the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) is commonly used. This score has been clinically validated and is described as \"an internationally accepted risk stratification tool.\" The patient had a HEART score of 4 (one point each for history, age, risk factors, and troponin). This score is considered moderate risk, and associated with a 12-17% likelihood of MACE (major adverse cardiac event) over the following six weeks, and would have led to a recommendation for \"the potential consideration of observation and further testing\" from the ED.\n\nFor type 1 Myocardial Infarction (MI), admission, and cardiac catheterization with revascularization as necessary are standard treatment. This was a reasonable likelihood in this case at the time of admission. Fortunately, the workup was reassuring.\n\nAlternatively, if type 2 MI was diagnosed, hospitalization still would have been warranted. The appropriate treatment for a type 2 MI is to treat the underlying condition. While the underlying condition in this case was never uncovered, initial concern for an underlying arrhythmia, particularly a ventricular tachyarrhythmia, was warranted. Her troponin was elevated, and she was having palpitations. The troponin itself was not explained, particularly its persistent elevation without suspected infarction. Common conditions to explain this finding include renal failure, heart failure, sepsis, pulmonary embolism, or other conditions such as advanced age - none of which were present in this case. \n\nInpatient admission was medically necessary. Troponin elevation with normal EKG was consistent with non ST elevation myocardial infarction (NSTEMI). The workup and intervention for this condition is typically intensive and prolonged. She was discharged to home immediately upon completion of a reasonable workup, minimizing her time in the hospital.\n\nBased on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for inpatient hospital admission is substantiated.", "id": "4d7af543df0d4ee2903903c21960dd55", "question": "What is the background context in this case summary?", "title": "4d7af543df0d4ee2903903c21960dd55", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Memory issues.\nTreatment: personal care aide level 2- 84 hours/week, 12 hours x 7 days.\nThe insurer denied personal care aide level 2- 84 hours/week, 12 hours x 7 days.", "This is a female patient with a medical history notable for memory loss. The patient is approved for 3.5 hours 4 days per week and 3.25 hours 1 day per week (17.25 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.\nThere were no letters of support or physician notes provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for dressing and toilet use. Other ADLs are independent. She is infrequently incontinent of urine. A task tool associated with the assessment recommended 15.76 hours per week to address her personal care needs. Compared to a prior assessment, she showed a modest decline in her functional status. At issue is the medical necessity of personal care aide level 2- 84 hours/week, 12 hours x 7 days."], "answer_start": [0, 211]}, "context": "Diagnosis: Memory issues.\nTreatment: personal care aide level 2- 84 hours/week, 12 hours x 7 days.\nThe insurer denied personal care aide level 2- 84 hours/week, 12 hours x 7 days.\nThe determination is upheld.\n\n\nThis is a female patient with a medical history notable for memory loss. The patient is approved for 3.5 hours 4 days per week and 3.25 hours 1 day per week (17.25 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.\nThere were no letters of support or physician notes provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for dressing and toilet use. Other ADLs are independent. She is infrequently incontinent of urine. A task tool associated with the assessment recommended 15.76 hours per week to address her personal care needs. Compared to a prior assessment, she showed a modest decline in her functional status. At issue is the medical necessity of personal care aide level 2- 84 hours/week, 12 hours x 7 days.\n\nThe requested health service/treatment of personal care aide level 2- 84 hours/week, 12 hours x 7 days has not been demonstrated to be medically necessary for this patient.\nThe patient's UAS demonstrates that she needs assistance primarily with her IADLs but also with bathing. The task tool recommended 15.76 hours per week to address her needs, and she is currently approved for 17.25 hours per week. There was no evidence provided that the patient has any unmet personal care needs at her current level of service. There is, therefore, insufficient evidence for medical necessity for the requested increase.\n", "id": "b211a6b63556433ab29ea06abe25f027", "question": "What is the background context in this case summary?", "title": "b211a6b63556433ab29ea06abe25f027", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Type 2 Diabetes Mellitus\nTreatment: Mounjaro\nThe insurer denied Mounjaro.", "This is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. She states that she started metformin and then tried Ozempic and with both, she suffered adverse side effects. She failed metformin due to stomach cramping and almost daily diarrhea. She paid a subscription for Weight Watchers. She is using Mounjaro and doing well; her glycated hemoglobin (A1C) was 4.7 percent (%). Her A1C was 7.9 %.  She has obesity, anxiety and depression. She has been on Ozempic and her sugars improved and her weight is down but she had terrible gastrointestinal (GI) side effects, nausea and an upset stomach. It was not reported in this visit note that she has T2DM. At issue is the medical necessity of Mounjaro."], "answer_start": [0, 115]}, "context": "Diagnosis: Type 2 Diabetes Mellitus\nTreatment: Mounjaro\nThe insurer denied Mounjaro.\nThe determination is upheld.\n\nThis is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. She states that she started metformin and then tried Ozempic and with both, she suffered adverse side effects. She failed metformin due to stomach cramping and almost daily diarrhea. She paid a subscription for Weight Watchers. She is using Mounjaro and doing well; her glycated hemoglobin (A1C) was 4.7 percent (%). Her A1C was 7.9 %.  She has obesity, anxiety and depression. She has been on Ozempic and her sugars improved and her weight is down but she had terrible gastrointestinal (GI) side effects, nausea and an upset stomach. It was not reported in this visit note that she has T2DM. At issue is the medical necessity of Mounjaro.\n\nThe requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).\nThere are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). The patient failed Ozempic. The patient can try one more formulary alternative. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.", "id": "8dab3004c5d74b48988623bc2896f1a6", "question": "What is the background context in this case summary?", "title": "8dab3004c5d74b48988623bc2896f1a6", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Unilateral leg pain and weakness\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission.", "This case involves a patient who presented to the hospital.  There was a history of obesity, diabetes mellitus, tobacco use, hypertension, prostate cancer, and cerebrovascular accident.  The patient presented with right-sided weakness that started 15 minutes prior.  The patient developed right-sided arm and leg weakness and associated numbness.  The symptoms had been intermittent for 2 days but became constant that day.  The patient reported severe back pain and multiple neurological symptoms in the past few weeks.  Vital signs of the patient were documented as blood pressure 157/117, temperature of 98.3 (degree) Fahrenheit, pulse of 80, respirations of 20, and oxygen saturation of 100% (percent) on room air.  The patient rated the pain 8 out of 10.  On exam, the patient appeared comfortable.  The patient was not ill or toxic appearing.  There was weakness present.  The patient had chronic left-sided facial droop.  The patient walked with a limp and dragged the right side.  The patient had decreased strength in the left upper extremity and left lower extremity with decreased sensation on the left side.  There was consideration for acute coronary syndrome, electrolyte disturbance, and transient ischemic attack versus cerebrovascular accident.  Neuroscience recommended admission for magnetic resonance imaging.  Imaging and laboratory work-up showed no acute findings.  The patient's white blood cell count was 7.1, hemoglobin was 12.6, hematocrit was 37.9, and creatinine was 1.07.  An electrocardiogram noted normal sinus rhythm and nonspecific T wave (interval on EKG [electrocardiogram]) abnormality.  The patient was given acetaminophen and ketorolac.  Magnetic resonance imaging of the brain did not show acute cerebrovascular accident.  Computed tomography angiography of the head and neck as well as computer tomography (CT) of the head did not show any large vessel occlusion.  \n\nIt was stated that the inpatient hospital admission was not considered medically necessary as per Milliman Care Guidelines (MCG) stroke guidelines.", "In this case, the patient presented to the hospital with acute right-sided arm and leg weakness.  The patient had a history of prior cerebrovascular accident with chronic left-sided weakness.  Initial diagnostic work-up had been unrevealing."], "answer_start": [0, 156, 3365]}, "context": "Diagnosis: Unilateral leg pain and weakness\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission.\n\nThe denial is upheld.\n\n \nThis case involves a patient who presented to the hospital.  There was a history of obesity, diabetes mellitus, tobacco use, hypertension, prostate cancer, and cerebrovascular accident.  The patient presented with right-sided weakness that started 15 minutes prior.  The patient developed right-sided arm and leg weakness and associated numbness.  The symptoms had been intermittent for 2 days but became constant that day.  The patient reported severe back pain and multiple neurological symptoms in the past few weeks.  Vital signs of the patient were documented as blood pressure 157/117, temperature of 98.3 (degree) Fahrenheit, pulse of 80, respirations of 20, and oxygen saturation of 100% (percent) on room air.  The patient rated the pain 8 out of 10.  On exam, the patient appeared comfortable.  The patient was not ill or toxic appearing.  There was weakness present.  The patient had chronic left-sided facial droop.  The patient walked with a limp and dragged the right side.  The patient had decreased strength in the left upper extremity and left lower extremity with decreased sensation on the left side.  There was consideration for acute coronary syndrome, electrolyte disturbance, and transient ischemic attack versus cerebrovascular accident.  Neuroscience recommended admission for magnetic resonance imaging.  Imaging and laboratory work-up showed no acute findings.  The patient's white blood cell count was 7.1, hemoglobin was 12.6, hematocrit was 37.9, and creatinine was 1.07.  An electrocardiogram noted normal sinus rhythm and nonspecific T wave (interval on EKG [electrocardiogram]) abnormality.  The patient was given acetaminophen and ketorolac.  Magnetic resonance imaging of the brain did not show acute cerebrovascular accident.  Computed tomography angiography of the head and neck as well as computer tomography (CT) of the head did not show any large vessel occlusion.  \n\nIt was stated that the inpatient hospital admission was not considered medically necessary as per Milliman Care Guidelines (MCG) stroke guidelines.  The patient did not have neurological findings that warranted inpatient care.  The patient could have been placed in observation under monitoring, had an evaluation, had testing completed, and been treated symptomatically while awaiting test results.  Consultation with other professionals could have been done in observation.  There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care.\n\nPer the cited references, admission for suspected transient ischemic attack is indicated for patients with hemodynamic instability that persists despite appropriate treatment, when focal neurological signs recur, when there are findings on brain imaging that requires inpatient care, when there is altered mental status, when there cardiac arrhythmias of immediate concern, when clinically significant cardiac or vascular disorder is identified, for severe hypertension with systolic blood pressure greater than 180 or diastolic blood pressure greater than 120, when prolonged cardiac telemetry monitoring is needed beyond observation care timeframe, for suspected vasculitis, and when parenteral anticoagulation is required.  In this case, the patient presented to the hospital with acute right-sided arm and leg weakness.  The patient had a history of prior cerebrovascular accident with chronic left-sided weakness.  Initial diagnostic work-up had been unrevealing.  The documentation did not support that the patient had failed observation level of care or had acute indications for inpatient level of care. \n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for inpatient hospital admission is not substantiated.\n", "id": "01d7aae7b63347b0a6ebf6ab2a75f727", "question": "What is the background context in this case summary?", "title": "01d7aae7b63347b0a6ebf6ab2a75f727", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Intrahepatic bile duct carcinoma. \nTreatment: Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. \nThe insurer denied Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. ", "This is a male patient with a medical history notable for intrahepatic bile duct carcinoma and dementia. The patient is currently residing in a skilled nursing facility and his care team is attempting a discharge home. He was approved for 9.5 hours per day, 7 days per week (66.5 hours per week) of personal care aide level 2 services. The patient's care team requested an increase to 24 hour per day split-shift personal care, 7 days per week (168 hours per week) and the request was denied by the health plan. \nThe patient's hospice social worker provided a letter of support for this appeal. The letter states that the patient is terminally ill from intrahepatic bile duct carcinoma with an expected life expectancy of six months or less. He needs total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) and is mostly bedbound. He is nonverbal and unable to direct his own care. He is currently living in a nursing facility. His family lives out of state and cannot assist with care. He has a neighbor in his building that has volunteered to assist with medication management (as home health aides are not permitted to administer medication). \nHospice nurse notes were provided for review. Pressure reduction measures were recommended for the patient, including reposition and turn at least every 2 hours. He did not have any evidence of skin breakdown as evidenced by this care being provided in the nursing facility. \nA Uniform Assessment System (UAS) was completed and was available for review. The patient was alert but non-verbal and unable to interact; cognition was impaired. For Instrumental activities of daily living (IADL), the patient requires total dependence for essentially all. For his activities of daily living (ADL's), the patient requires total dependence or maximal assistance for all. He is bed bound and cannot direct his care; the nursing facility staff assists with all activities and directs care. He did not have any skin breakdown. He was frequently incontinent of stool and urine and wears diapers/chux pads for episodes of incontinence. At issue is the medical necessity of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. ", "The patient is receiving end-of-life hospice care. His dementia is advanced to the point of being nonverbal. He is not able to complete any ADLs or IADLs without human assistance, including bed-mobility. He must be turned and repositioned every 2 hours throughout the day and night to prevent skin breakdown. He is frequently incontinent of stool and urine and cannot direct his own diaper changes"], "answer_start": [0, 347, 2817]}, "context": "Diagnosis: Intrahepatic bile duct carcinoma. \nTreatment: Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. \nThe insurer denied Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. \nThe determination is overturned. \n\nThis is a male patient with a medical history notable for intrahepatic bile duct carcinoma and dementia. The patient is currently residing in a skilled nursing facility and his care team is attempting a discharge home. He was approved for 9.5 hours per day, 7 days per week (66.5 hours per week) of personal care aide level 2 services. The patient's care team requested an increase to 24 hour per day split-shift personal care, 7 days per week (168 hours per week) and the request was denied by the health plan. \nThe patient's hospice social worker provided a letter of support for this appeal. The letter states that the patient is terminally ill from intrahepatic bile duct carcinoma with an expected life expectancy of six months or less. He needs total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) and is mostly bedbound. He is nonverbal and unable to direct his own care. He is currently living in a nursing facility. His family lives out of state and cannot assist with care. He has a neighbor in his building that has volunteered to assist with medication management (as home health aides are not permitted to administer medication). \nHospice nurse notes were provided for review. Pressure reduction measures were recommended for the patient, including reposition and turn at least every 2 hours. He did not have any evidence of skin breakdown as evidenced by this care being provided in the nursing facility. \nA Uniform Assessment System (UAS) was completed and was available for review. The patient was alert but non-verbal and unable to interact; cognition was impaired. For Instrumental activities of daily living (IADL), the patient requires total dependence for essentially all. For his activities of daily living (ADL's), the patient requires total dependence or maximal assistance for all. He is bed bound and cannot direct his care; the nursing facility staff assists with all activities and directs care. He did not have any skin breakdown. He was frequently incontinent of stool and urine and wears diapers/chux pads for episodes of incontinence. At issue is the medical necessity of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. \n\nThe requested health service of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week is medically necessary for this patient. \nThe patient is receiving end-of-life hospice care. His dementia is advanced to the point of being nonverbal. He is not able to complete any ADLs or IADLs without human assistance, including bed-mobility. He must be turned and repositioned every 2 hours throughout the day and night to prevent skin breakdown. He is frequently incontinent of stool and urine and cannot direct his own diaper changes; he will require frequent checking and changes throughout the day and night. By definition, the patient's care needs are expected to be continuous and unscheduled throughout the day and night. Therefore, the requested increase to 24 hour split-shift personal care is medically necessary and reasonable for the patient.", "id": "7c774198075d4093a027bfa793b44062", "question": "What is the background context in this case summary?", "title": "7c774198075d4093a027bfa793b44062", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Alcohol abuse. \nTreatment: Inpatient admission. \nThe insurer denied the inpatient admission.", "The patient is a male who initially presented to the emergency department with request for alcohol detoxification. Pertinent history included diabetes mellitus, alcohol use, and smoking crack. No history of alcohol withdrawal seizure or delirium tremens are noted. Initial vital signs revealed a temperature of 97.5F (Fahrenheit), heart rate (HR) 81, blood pressure (BP) 112/71, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Initial examination documented the patient as alert and oriented with evidence of acute intoxication.", "The patient had a history of alcohol use disorder without prior withdrawal seizures or delirium tremens who presented with acute alcohol intoxication requesting detoxification. Initial examination documented the patient as alert, oriented, and with stable hemodynamics. Initial evaluation was relatively unremarkable with the exception of hyponatremia. Treatment included intravenous fluids and CIWA (Clinical Institute Withdrawal Assessment) with benzodiazepines as needed. Following observation care, the CIWA was documented as 0 and no benzodiazepines had been indicated / administered for a 24 hour period. The patient was deemed medically stable for discharge with a similar serum sodium level as on arrival."], "answer_start": [0, 150, 761]}, "context": "Diagnosis: Alcohol abuse. \nTreatment: Inpatient admission. \nThe insurer denied the inpatient admission. \nThe health plan's determination is upheld. \n\nThe patient is a male who initially presented to the emergency department with request for alcohol detoxification. Pertinent history included diabetes mellitus, alcohol use, and smoking crack. No history of alcohol withdrawal seizure or delirium tremens are noted. Initial vital signs revealed a temperature of 97.5F (Fahrenheit), heart rate (HR) 81, blood pressure (BP) 112/71, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Initial examination documented the patient as alert and oriented with evidence of acute intoxication. \n\nThe inpatient hospital admission was not medically necessary. The patient had a history of alcohol use disorder without prior withdrawal seizures or delirium tremens who presented with acute alcohol intoxication requesting detoxification. Initial examination documented the patient as alert, oriented, and with stable hemodynamics. Initial evaluation was relatively unremarkable with the exception of hyponatremia. Treatment included intravenous fluids and CIWA (Clinical Institute Withdrawal Assessment) with benzodiazepines as needed. Following observation care, the CIWA was documented as 0 and no benzodiazepines had been indicated / administered for a 24 hour period. The patient was deemed medically stable for discharge with a similar serum sodium level as on arrival. No other issues or complications were documented. A lower level of care was appropriate.", "id": "26699bec2f954ab0a7d66a47981d2f66", "question": "What is the background context in this case summary?", "title": "26699bec2f954ab0a7d66a47981d2f66", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: back surgery\nTreatment: inpatient stay\nThe insurer denied an inpatient stay.", "The patient is a female with a history of low back pain and L (left) leg symptoms for 2 years. Prior treatments include physical therapy (PT) and other conservative treatments. The patient was taken to the operating room (OR) and underwent L (lumbar) 4-S (sacral) 1 laminectomy and fusion. Intraoperatively, one drain was placed.", "Foley was discontinued on postoperative day (POD) 1. Lovenox and SCDs (sequential compression devices) were ordered for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and occupational therapy (OT) were ordered for post-operative rehabilitation. A PM&R (physical medicine and rehab) consult was placed for post-operative care."], "answer_start": [0, 137, 499]}, "context": "Diagnosis: back surgery\nTreatment: inpatient stay\nThe insurer denied an inpatient stay. The health plan's determination is overturned. \n\nThe patient is a female with a history of low back pain and L (left) leg symptoms for 2 years. Prior treatments include physical therapy (PT) and other conservative treatments. The patient was taken to the operating room (OR) and underwent L (lumbar) 4-S (sacral) 1 laminectomy and fusion. Intraoperatively, one drain was placed. No complications were reported. Foley was discontinued on postoperative day (POD) 1. Lovenox and SCDs (sequential compression devices) were ordered for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and occupational therapy (OT) were ordered for post-operative rehabilitation. A PM&R (physical medicine and rehab) consult was placed for post-operative care. \n\nThe inpatient hospital admission was medically necessary.\nThe patient underwent a L (lumbar) 4-S (sacral) 1 fusion. She experienced no complications post-operatively. She was able to be safely discharged home on postoperative day (POD) 4 after expected recovery as an inpatient in the hospital. Lumbar fusion benchmark length of stay is 1-3 days and standard of care is to perform this as an inpatient. Given the invasive nature of this major surgical procedure and the necessary post-operative care as per above, inpatient care was medically necessary post-operatively. The treatment received was within generally accepted standards of medical practice and would be clinically appropriate at the inpatient level of care. The patient does not meet a lower level of care due to the complexity of her procedure and necessary care as per above. Therefore, inpatient admission on the denied days was medically necessary.", "id": "3664c98533a544718d5c46f04928bf38", "question": "What is the background context in this case summary?", "title": "3664c98533a544718d5c46f04928bf38", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Viral pharyngitis\nTreatment: Inpatient Hospital Stay\nThe insurer denied the Inpatient Hospital Stay.", "This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) a sore throat associated with a fever. Imaging studies included a chest x-ray (CXR) which showed possible right lower lobe (RLL) community acquired pneumonia (CAP), a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology, a CT scan of the chest showed no pneumonia. The patient was diagnosed with CAP and treated with intravenous (IV) antibiotics and intravenous fluids (IVF), but was eventually diagnosed with viral pharyngitis and antibiotics were discontinued. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care."], "answer_start": [0, 142]}, "context": "Diagnosis: Viral pharyngitis\nTreatment: Inpatient Hospital Stay\nThe insurer denied the Inpatient Hospital Stay.\nThe determination is upheld.\n\nThis is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) a sore throat associated with a fever. Imaging studies included a chest x-ray (CXR) which showed possible right lower lobe (RLL) community acquired pneumonia (CAP), a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology, a CT scan of the chest showed no pneumonia. The patient was diagnosed with CAP and treated with intravenous (IV) antibiotics and intravenous fluids (IVF), but was eventually diagnosed with viral pharyngitis and antibiotics were discontinued. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.\n\nThe hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a sore throat associated with fever. The patient was initially diagnosed with CAP and treated with antibiotics. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 [confusion, uremia, respiratory rate, blood pressure (BP), age greater than or equal to (>=) 65 years) score was 0, indicating a low-risk patient. The pneumonia severity index was risk class I, indicating that outpatient therapy was reasonable. The patient was ultimately diagnosed with viral pharyngitis and treated with IV fluids and antibiotics were discontinued, and overall care could have been safely provided at a lower level of care.", "id": "9d6a811b4e5f4f4f8172444b48cd70a5", "question": "What is the background context in this case summary?", "title": "9d6a811b4e5f4f4f8172444b48cd70a5", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Dental Disorder\nTreatment: Braces and monthly visits\nThe insurer denied Braces and monthly visits.", "This is a female patient who presented with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has a 4 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the spacing, crossbite, and open bite. At issue is the medical necessity of braces and monthly visits."], "answer_start": [0, 144]}, "context": "Diagnosis: Dental Disorder\nTreatment: Braces and monthly visits\nThe insurer denied Braces and monthly visits.\nThe determination is overturned.\n\nThis is a female patient who presented with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has a 4 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the spacing, crossbite, and open bite. At issue is the medical necessity of braces and monthly visits.\n\nPatients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2)\nStudies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with a normal occlusion. (3) It has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. (3) Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.\n", "id": "4a54916a07994481a4a8cc1c318457c8", "question": "What is the background context in this case summary?", "title": "4a54916a07994481a4a8cc1c318457c8", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Throat infection\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission", "The patient is seeking coverage for inpatient admission due to throat infection.  The patient presented to the hospital complaining of sore throat and difficulty swallowing.  The symptoms started approximately 4 days prior while they were traveling.  The patient had presented to the emergency department (ED) and tested negative for mononucleosis and streptococcus.  Computed tomography (CT) showed pharyngitis and tonsillitis.  The patient was treated with amoxicillin and prednisone.  However, their symptoms continued to progress.  Vitals signs noted blood pressure of 92/54, pulse of 88, respirations of 28, temperature of 97.7 degrees Fahrenheit, and oxygen saturation of 99% (percent) on room air.  Laboratory results noted white blood cell (WBC) count of 8.0, red blood cell count of 4.42, hemoglobin of 14.3, creatinine of 0.78, glucose of 109, potassium of 3.9, and sodium of 135.  The patient was given a dose of Decadron 10 milligrams (mg) on 2 consecutive days with significant improvement in pain and swelling.  The physical exam noted erythematous tonsils that were 3+ with exudates.  There was cervical adenopathy.  The patient was continued on intravenous (IV) fluids which were weaned as their oral intake improved.  The patient was given intravenous Unasyn every 6 hours which was transitioned to Augmentin at discharge.  The patient was given a dose of 500 mg of ceftriaxone intravenous for presumptive treatment of Neisseria gonorrhea.  It was indicated that the patient may need tonsillar removal after the infection is resolved.  There was a plan for follow-up in 2 to 3 days with the primary care provider.  The patient was deemed appropriate for discharge.\n\nIt was argued by the hospital that the inpatient admission due to throat infection was medically necessary.  A summary of the patient's admission is detailed.  The patient presented to the emergency department with muffled voice, odynophagia, and sore throat.  The patient had previously been seen at another emergency department.  The patient had been taking amoxicillin and prednisone with worsening symptoms.  The patient reported difficulty swallowing the medication.  The patient was hypotensive at 92/54 and received 2 liters of intravenous fluid.  The patient was admitted to the hospital and received intravenous Unasyn every 6 hours and intravenous Decadron twice.  The patient also received intravenous fluids for greater than 24 hours.  \n"], "answer_start": [0, 136]}, "context": "Diagnosis: Throat infection\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission\n\nThe denial is upheld\n\nThe patient is seeking coverage for inpatient admission due to throat infection.  The patient presented to the hospital complaining of sore throat and difficulty swallowing.  The symptoms started approximately 4 days prior while they were traveling.  The patient had presented to the emergency department (ED) and tested negative for mononucleosis and streptococcus.  Computed tomography (CT) showed pharyngitis and tonsillitis.  The patient was treated with amoxicillin and prednisone.  However, their symptoms continued to progress.  Vitals signs noted blood pressure of 92/54, pulse of 88, respirations of 28, temperature of 97.7 degrees Fahrenheit, and oxygen saturation of 99% (percent) on room air.  Laboratory results noted white blood cell (WBC) count of 8.0, red blood cell count of 4.42, hemoglobin of 14.3, creatinine of 0.78, glucose of 109, potassium of 3.9, and sodium of 135.  The patient was given a dose of Decadron 10 milligrams (mg) on 2 consecutive days with significant improvement in pain and swelling.  The physical exam noted erythematous tonsils that were 3+ with exudates.  There was cervical adenopathy.  The patient was continued on intravenous (IV) fluids which were weaned as their oral intake improved.  The patient was given intravenous Unasyn every 6 hours which was transitioned to Augmentin at discharge.  The patient was given a dose of 500 mg of ceftriaxone intravenous for presumptive treatment of Neisseria gonorrhea.  It was indicated that the patient may need tonsillar removal after the infection is resolved.  There was a plan for follow-up in 2 to 3 days with the primary care provider.  The patient was deemed appropriate for discharge.\n\nIt was argued by the hospital that the inpatient admission due to throat infection was medically necessary.  A summary of the patient's admission is detailed.  The patient presented to the emergency department with muffled voice, odynophagia, and sore throat.  The patient had previously been seen at another emergency department.  The patient had been taking amoxicillin and prednisone with worsening symptoms.  The patient reported difficulty swallowing the medication.  The patient was hypotensive at 92/54 and received 2 liters of intravenous fluid.  The patient was admitted to the hospital and received intravenous Unasyn every 6 hours and intravenous Decadron twice.  The patient also received intravenous fluids for greater than 24 hours.  \n\nPer the cited guidelines, admission to the hospital for tonsillitis may be indicated when there is hemodynamic instability such as with hypotension that persist despite appropriate treatment, when there is airway obstruction or impending obstruction, when there is extension of infection into the deep tissues of the neck or superior mediastinum, when surgical drainage is needed that cannot be performed in observation care, or for thrombophlebitis of internal jugular vein.  In this case, the patient was admitted to the hospital due to suspected throat infection/tonsillitis with swelling.  While it is noted that the patient had hypotension, this responded to intravenous fluids.  The patient did not have hemodynamic instability such as with hypotension that persisted despite appropriate treatment, airway obstruction or impending obstruction, extension of infection into the deep tissues of the neck or superior mediastinum, a need for surgical drainage which could not be performed in observation care, or evidence of thrombophlebitis of internal jugular vein.  Thus, the patient's care could have been completed at a lower level such as observation.  \n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for inpatient admission due to throat infection is not substantiated.\n", "id": "8b8cabe59cd745d4b36d26cabddf50f9", "question": "What is the background context in this case summary?", "title": "8b8cabe59cd745d4b36d26cabddf50f9", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Dementia\n\nTreatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week\n\nThe insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week", "The patient is diagnosed with Alzheimer's disease, unspecified under hospice care for end stage dementia. The patient lives with their spouse in a 2-bedroom apartment. \n\nOn the Uniform Assessment System New York (UAS-NY) Assessment, the patient's spouse requested an increase because the patient is experiencing weakness and the inability to walk. Based on the assessment the patient's current declines were noted as dressing upper body- maximal assistance; personal hygiene- maximal assistance; walking- total assistance; and locomotion- total assistance. The patient is able to take care of their toileting needs and transfer on and off the toilet with assistance; bathe themselves with assistance; and take medications with assistance from their spouse. The patient's spouse is supportive and involved in the patient's care. The patient has incontinent supplies, gloves, glucometer, Personal Emergency Response System (PERS), cane, shower chair, shower grab bar, bedside commode, walker, wheelchair, and hospital bed in your home that can assist you with your needs. The patient was recently in the hospital for altered mental status and for high blood pressure.\n\nThe statement of support for an external appeal for Personal Care Aide services noted that the patient's spouse is frail and weak and can no longer provide for the patient's care need. It was also noted that the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers. \n\nThe statement of homebound status noted that the patient is bedbound, non-ambulatory and unable travel to a hearing by any means including public transportation.", "the patient has had frequent hospital admission due to urinary tract infection (UTI), sepsis and altered mental status, and falls", "the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers"], "answer_start": [2, 388, 2793, 2984]}, "context": " \nDiagnosis: Dementia\n\nTreatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week\n\nThe insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week\n\nThe denial is overturned\n\nThe patient is diagnosed with Alzheimer's disease, unspecified under hospice care for end stage dementia. The patient lives with their spouse in a 2-bedroom apartment. \n\nOn the Uniform Assessment System New York (UAS-NY) Assessment, the patient's spouse requested an increase because the patient is experiencing weakness and the inability to walk. Based on the assessment the patient's current declines were noted as dressing upper body- maximal assistance; personal hygiene- maximal assistance; walking- total assistance; and locomotion- total assistance. The patient is able to take care of their toileting needs and transfer on and off the toilet with assistance; bathe themselves with assistance; and take medications with assistance from their spouse. The patient's spouse is supportive and involved in the patient's care. The patient has incontinent supplies, gloves, glucometer, Personal Emergency Response System (PERS), cane, shower chair, shower grab bar, bedside commode, walker, wheelchair, and hospital bed in your home that can assist you with your needs. The patient was recently in the hospital for altered mental status and for high blood pressure.\n\nThe statement of support for an external appeal for Personal Care Aide services noted that the patient's spouse is frail and weak and can no longer provide for the patient's care need. It was also noted that the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers. \n\nThe statement of homebound status noted that the patient is bedbound, non-ambulatory and unable travel to a hearing by any means including public transportation.\n\nPer the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support. The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines. Based on the assessment, the provider's declaration and the statement letter of supporting information the patient will requires additional personal assistance due to the current change and decline in functional status and the inability for the continued care from the primary caregiver. In addition, the patient has had frequent hospital admission due to urinary tract infection (UTI), sepsis and altered mental status, and falls; therefore, additional assistance is supported. Furthermore, the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers and is thus at risk for skin breakdown. The need for toileting in view of the patient's deterioration is unpredictable.\n\nAs such, the request for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week is overturned as medically necessary.  \n\nBased on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week services is substantiated.\n", "id": "6b3eb8fb448e470d86afb0418980f3a0", "question": "What is the background context in this case summary?", "title": "6b3eb8fb448e470d86afb0418980f3a0", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Chest pain\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission", "According to the documentation submitted, this is the case of a patient with a history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) due to chest pain, and headache. The patient was admitted to inpatient telemetry level for continued evaluation, monitoring, and treatment. The patient had a cardiology consult, X-ray, intravenous (IV) Toradol, cardiac monitoring, and continuous pulse oximetry.\n\nThe insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that a review of the records shows that the patient could have been placed in observation under monitoring.", "This is a patient with a past medical history of diabetes mellitus and hypertension that presented to the hospital with chest pain.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 126/84, pulse 82.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities.  Serum blood testing revealed no major abnormality.  Computed tomography (CT) chest revealed coronary artery calcium.  The patient was treated with Toradol and discharged with cardiology follow up.", "This patient presented with atypical chest pain and a past medical history of hypertension."], "answer_start": [0, 131, 988, 1576]}, "context": "Diagnosis: Chest pain\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission\n\nThe denial is upheld \n\nAccording to the documentation submitted, this is the case of a patient with a history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) due to chest pain, and headache. The patient was admitted to inpatient telemetry level for continued evaluation, monitoring, and treatment. The patient had a cardiology consult, X-ray, intravenous (IV) Toradol, cardiac monitoring, and continuous pulse oximetry.\n\nThe insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that a review of the records shows that the patient could have been placed in observation under monitoring. The patient could have had an evaluation by professional(s), had testing and been treated symptomatically while awaiting test results. The admission does not meet clinical criteria.\n\nThis is a patient with a past medical history of diabetes mellitus and hypertension that presented to the hospital with chest pain.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 126/84, pulse 82.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities.  Serum blood testing revealed no major abnormality.  Computed tomography (CT) chest revealed coronary artery calcium.  The patient was treated with Toradol and discharged with cardiology follow up.\n\nThis patient presented with atypical chest pain and a past medical history of hypertension. The patient's pretest probability of coronary artery disease was low (1).  Utilizing the HEART (identifies cardiac risk) score the patient was considered low risk (2).  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed (3).  Using the HEART  score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.\n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for inpatient hospital admission is not substantiated.\n", "id": "342c918647fa480bb6e36291682988f9", "question": "What is the background context in this case summary?", "title": "342c918647fa480bb6e36291682988f9", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease\n\nTreatment: Home Health Care/Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.\n\nThe health plan denied the requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week as not medically necessary. ", "The patient is a female with a history of osteoarthritis (OA), Alzheimer's and diabetes mellitus (DM). They were recently hospitalized for congestive heart failure (CHF) and aspiration pneumonia. As a result, the patient has severe limitation in activities of daily living such as weight bearing support for dressing, bathing and commode use. They have stiffness, weakness, limited range of motion, incontinence and cognitive impairment. They require maximum to total assistance, as well as oxygen treatment.\nAt issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week."], "answer_start": [0, 431]}, "context": "Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease\n\nTreatment: Home Health Care/Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.\n\nThe health plan denied the requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week as not medically necessary. \n\nThe health plan's determination is overturned.\n\nThe patient is a female with a history of osteoarthritis (OA), Alzheimer's and diabetes mellitus (DM). They were recently hospitalized for congestive heart failure (CHF) and aspiration pneumonia. As a result, the patient has severe limitation in activities of daily living such as weight bearing support for dressing, bathing and commode use. They have stiffness, weakness, limited range of motion, incontinence and cognitive impairment. They require maximum to total assistance, as well as oxygen treatment.\nAt issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.\n\nThe health plan's determination of medical necessity is overturned, in whole.\n\nYes. The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is medically necessary for this patient\nSkilled nursing home health care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care. Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively. Care that can be given by non-professional staff is not considered skilled nursing care. The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.\nIn this case, the patient has severe or extensive functional limitations which would substantiate the need for the requested health care services.", "id": "7b6b7dda18a8483caa1774ffc775744e", "question": "What is the background context in this case summary?", "title": "7b6b7dda18a8483caa1774ffc775744e", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Septic arthritis and osteomyelitis\nTreatment: Subacute rehab stay\nThe insurer denied Subacute rehab stay.", "This a male patient who was admitted to subacute rehabilitation for septic arthritis and osteomyelitis. The treating facility provided a letter of support for this appeal. He was admitted following treatment for septic arthritis of the left ankle and osteomyelitis of the distal tibia. He required a left ankle incision and drainage and hardware removal. The letter states that the patient would benefit from continued skilled services. He is continuing to receive physical and occupational therapy with a goal of increasing his lower extremity range of motion and strength. Further rehabilitation (rehab) will help him to improve his activities of daily living participation and require less help from others. They would like an extension of inpatient rehab care.\nTherapy notes were provided as part of this review. They demonstrate that the patient showed continued improvement with ongoing therapy. His bed mobility progressed to set up assistance only from a baseline of caregiver assist. His trunk strength improved from 3-/5 to 4-/5. Dynamic standing improved from poor to fair. His wheelchair mobility improved from moderate to supervised and distance increased from 150 feet to 250 feet. He showed improvements across multiple domains.\nThe health plan denied coverage for an ongoing rehab stay. They stated that the patient requires a small amount of help with daily activities and walking. His pressure ulcer is getting smaller and does not require complex care. They stated that 10 additional days were authorized to help with continued improvement. At issue is the medical necessity of the subacute rehab stay.", "The patient is being treated for rehabilitation following a surgical procedure and infection of the leg.", "The patient had a substantial decline in functional status as a result of his infection and surgery."], "answer_start": [53, 204, 1891, 2177]}, "context": "Orthopedic/Musculoskeletal\nInpatient Rehabilitation\n\nDiagnosis: Septic arthritis and osteomyelitis\nTreatment: Subacute rehab stay\nThe insurer denied Subacute rehab stay.\nThe determination is overturned.\n\nThis a male patient who was admitted to subacute rehabilitation for septic arthritis and osteomyelitis. The treating facility provided a letter of support for this appeal. He was admitted following treatment for septic arthritis of the left ankle and osteomyelitis of the distal tibia. He required a left ankle incision and drainage and hardware removal. The letter states that the patient would benefit from continued skilled services. He is continuing to receive physical and occupational therapy with a goal of increasing his lower extremity range of motion and strength. Further rehabilitation (rehab) will help him to improve his activities of daily living participation and require less help from others. They would like an extension of inpatient rehab care.\nTherapy notes were provided as part of this review. They demonstrate that the patient showed continued improvement with ongoing therapy. His bed mobility progressed to set up assistance only from a baseline of caregiver assist. His trunk strength improved from 3-/5 to 4-/5. Dynamic standing improved from poor to fair. His wheelchair mobility improved from moderate to supervised and distance increased from 150 feet to 250 feet. He showed improvements across multiple domains.\nThe health plan denied coverage for an ongoing rehab stay. They stated that the patient requires a small amount of help with daily activities and walking. His pressure ulcer is getting smaller and does not require complex care. They stated that 10 additional days were authorized to help with continued improvement. At issue is the medical necessity of the subacute rehab stay.\n\nThe requested treatment is medically necessary for the patient.\nThe patient is being treated for rehabilitation following a surgical procedure and infection of the leg. Rehabilitation in an inpatient setting is typically continued until patients reach their maximum therapeutic potential as outcomes are maximized with intensive early interventions. The patient had a substantial decline in functional status as a result of his infection and surgery. Given his favorable prognosis for meaningful recovery of function, ongoing therapy services were recommended as medically necessary by his treating team. They were correct in this assessment, as the patient did show improvement in functional status with ongoing therapy support. The continued rehabilitation was medically necessary and reasonable for the patient.", "id": "8d77eae49fd14511a0897ea3802d6703", "question": "What is the background context in this case summary?", "title": "8d77eae49fd14511a0897ea3802d6703", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: atopic dermatitis\nTreatment: Dupixent\nThe insurer denied Dupixent. ", "The patient is a male with psoriasis and atopic dermatitis. He also has psoriatic arthritis. He has tried and failed Excimer, Otezla, Tremfya, methotrexate, acitretin, Siliq and Taltz. He has also been on Skyrizi and Sotyktu. ", "It is noted that the patient has tried and failed methotrexate."], "answer_start": [0, 124, 954]}, "context": "Diagnosis: atopic dermatitis\nTreatment: Dupixent\nThe insurer denied Dupixent. \nThe health plan's determination is upheld. \n\nThe patient is a male with psoriasis and atopic dermatitis. He also has psoriatic arthritis. He has tried and failed Excimer, Otezla, Tremfya, methotrexate, acitretin, Siliq and Taltz. He has also been on Skyrizi and Sotyktu. \n\nDupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis.\nA Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that \"In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults\".\nIt is noted that the patient has tried and failed methotrexate. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient based on the evidence-based literature.", "id": "de6073fb3d5b44f889ed4f8745607383", "question": "What is the background context in this case summary?", "title": "de6073fb3d5b44f889ed4f8745607383", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Intracranial Hemorrhage\n\nTreatment: Air Ambulance Services (procedure codes A0431, A0436)\n\nThe insurer denied coverage for Air Ambulance Services (procedure codes A0431, A0436).", "The patient is seeking coverage for Air Ambulance Services (procedure codes A0431 and A0436).\n\nAir transportation was requested as the patient's condition was time critical.  The patient's condition required critical life care support and monitoring including electrocardiogram.  The receiving facility provided specialized care, treatment, and diagnostics not available at the referring facility or facility that may have been closer to the scene.  The patient required interventional neurology.  The patient reported that they had become nauseous.  Then they had weakness, dizziness, and vomiting with difficulty speaking.  The patient was brought to the facility.  Imaging of the head showed a hyperdensity consistent with acute hemorrhage within the cerebellum within the midline. There is significant hemorrhage seen surrounding the cerebellar folia bilaterally.  Out of concern that the bleed may be a result of underlying vascular malformation, it was recommended that the patient be transferred to a tertiary facility where they could be observed and if necessary, an angiogram could be performed.  Immediate dispatch was completed for transfer of stroke patient going from St. Luke's Hospital to Westchester Emergency Department (ED) for neurology specialty care that was not available at the sending facility.  The drive time was 65 minutes versus flight time of 17 minutes.  The air transport was notified and dispatched 5 minutes later.  \n\nThe provider certified that the transfer by air transport was medically necessary", "The patient was suffering from bleeding in the brain", "The services not available at the referring facility.", "Ground transport was estimated to take approximately 65 minutes with transport by air taking", "17 minutes.", "The patient was suffering from intracranial bleeding potentially requiring advanced airway support"], "answer_start": [0, 219, 1818, 1933, 2275, 2373, 2775]}, "context": "Diagnosis: Intracranial Hemorrhage\n\nTreatment: Air Ambulance Services (procedure codes A0431, A0436)\n\nThe insurer denied coverage for Air Ambulance Services (procedure codes A0431, A0436).\n\nThe denial is overturned.\n\n \nThe patient is seeking coverage for Air Ambulance Services (procedure codes A0431 and A0436).\n\nAir transportation was requested as the patient's condition was time critical.  The patient's condition required critical life care support and monitoring including electrocardiogram.  The receiving facility provided specialized care, treatment, and diagnostics not available at the referring facility or facility that may have been closer to the scene.  The patient required interventional neurology.  The patient reported that they had become nauseous.  Then they had weakness, dizziness, and vomiting with difficulty speaking.  The patient was brought to the facility.  Imaging of the head showed a hyperdensity consistent with acute hemorrhage within the cerebellum within the midline. There is significant hemorrhage seen surrounding the cerebellar folia bilaterally.  Out of concern that the bleed may be a result of underlying vascular malformation, it was recommended that the patient be transferred to a tertiary facility where they could be observed and if necessary, an angiogram could be performed.  Immediate dispatch was completed for transfer of stroke patient going from St. Luke's Hospital to Westchester Emergency Department (ED) for neurology specialty care that was not available at the sending facility.  The drive time was 65 minutes versus flight time of 17 minutes.  The air transport was notified and dispatched 5 minutes later.  \n\nThe provider certified that the transfer by air transport was medically necessary as evidenced by the assigned physician certification statement.  The patient was suffering from bleeding in the brain which required immediate interventional radiology treatment.  The services not available at the referring facility.  Rapid and immediate transport to the receiving facility was medically necessary.  Research has shown that in cases of reduced blood flow to the brain, each minute the patient was without treatment increase the amount of brain tissue death with delay in treatment causing poor outcomes.  Ground transport was estimated to take approximately 65 minutes with transport by air taking just 17 minutes.  Therefore, the ground transport would delay the patient's access to care, threatening their survival, and endangering their health.  Thus, the transport by air ambulance was medically necessary and reasonable.  The air ambulance had all of the equipment and supplies needed to address the patient's needs including specialty critical care providers trained in advanced airway procedures.  The patient was suffering from intracranial bleeding potentially requiring advanced airway support to make another mode of transport contraindicated.  Transport by ground would endanger the patient survival and threaten their health as it would delay access to care and increased out of hospital time.  The patient was suffering from a life-threatening condition.  Air transport was more than 30 minutes faster than transport by ground.\n\nBrain hemorrhage is a medical emergency that requires prompt treatment to prevent complications or death.  The patient had a life-threatening condition which required transport for additional management.  The drive time was more than double the air transport time.  The patient required prompt treatment and ground transport time increased risk for complications and mortality, which made the air transport medically necessary for the patient.  \n\nBased on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for Air Ambulance Services (procedure codes A0431, A0436) is substantiated.\n", "id": "790fe5bdf1394e209e1f84f0b575e06f", "question": "What is the background context in this case summary?", "title": "790fe5bdf1394e209e1f84f0b575e06f", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Bile duct obstruction\nTreatment: Continued Stay in Skilled Nursing Facility\nThe insurer denied: Continued Stay in Skilled Nursing Facility", "This adult female patient was admitted to an acute inpatient level of care with bile duct obstruction. She underwent exploratory laparotomy with Roux-en-Y-Hepaticojejunostomy. Her past medical history includes cardiomyopathy, depression, hypertension, panic attack, post-traumatic stress disorder (PTSD), and suicidal ideation. The patient was admitted to a skilled nursing facility (SNF) level of care for nursing and rehab services. Her level of function required moderate assist with activities of daily living (ADLs), and transfer. The health plan covered services through day #26. Services after the approved dates are being appealed. As of the last covered day, the patient was tolerating a regular diet. The patient's level of functioning had progressed to supervised with supine to sit and wheelchair; contact guard assistance with lower body dressing and toileting; and stand by assistance with hygiene. The patient is receiving pan management with oral medications.", "This patient was in an acute inpatient level of care for surgical treatment of bile duct obstruction. She was admitted to a skilled nursing facility level of care. As of day #26, the patient was clinically stable."], "answer_start": [0, 173, 1209]}, "context": "Diagnosis: Bile duct obstruction\nTreatment: Continued Stay in Skilled Nursing Facility\nThe insurer denied: Continued Stay in Skilled Nursing Facility\nThe denial is upheld.\n\nThis adult female patient was admitted to an acute inpatient level of care with bile duct obstruction. She underwent exploratory laparotomy with Roux-en-Y-Hepaticojejunostomy. Her past medical history includes cardiomyopathy, depression, hypertension, panic attack, post-traumatic stress disorder (PTSD), and suicidal ideation. The patient was admitted to a skilled nursing facility (SNF) level of care for nursing and rehab services. Her level of function required moderate assist with activities of daily living (ADLs), and transfer. The health plan covered services through day #26. Services after the approved dates are being appealed. As of the last covered day, the patient was tolerating a regular diet. The patient's level of functioning had progressed to supervised with supine to sit and wheelchair; contact guard assistance with lower body dressing and toileting; and stand by assistance with hygiene. The patient is receiving pan management with oral medications.\n\nThe requested health service is not medically necessary. \n\nThis patient was in an acute inpatient level of care for surgical treatment of bile duct obstruction. She was admitted to a skilled nursing facility level of care. As of day #26, the patient was clinically stable. She was not receiving skilled nursing care. Her level of functioning had improved to supervision, stand by, and contact guard assistance with activities of daily living. Her level of functioning did not require ongoing skilled therapy that could only be provided at a skilled nursing facility level of care. Therefore, the continued stay in the skilled nursing facility was not medically necessary. ", "id": "2db482fe5252468ab50c74c2c7bef2d7", "question": "What is the background context in this case summary?", "title": "2db482fe5252468ab50c74c2c7bef2d7", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Alzheimer's Dementia\n\nTreatment: consumer direct personal assistance service - 80 hours per week\n\nThe insurer denied coverage for in consumer direct personal assistance service - 80 hours per week", "The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as \"Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times.\" The patient reportedly requires extensive to maximal assistance for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  There have been no reported falls over the prior 90 days.", "This is an elderly patient with chronic medical problems including hypertension, glaucoma and progressive Alzheimer's dementia. The patient lives with their daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 63 hours per week and the request is for CDPAS 80 hours per week"], "answer_start": [0, 600, 235]}, "context": "Diagnosis: Alzheimer's Dementia\n\nTreatment: consumer direct personal assistance service - 80 hours per week\n\nThe insurer denied coverage for in consumer direct personal assistance service - 80 hours per week\n\nThe denial is overturned\n\nThis is an elderly patient with chronic medical problems including hypertension, glaucoma and progressive Alzheimer's dementia. The patient lives with their daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 63 hours per week and the request is for CDPAS 80 hours per week, leading to an external review.\n\nThe Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as \"Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times.\" The patient reportedly requires extensive to maximal assistance for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  There have been no reported falls over the prior 90 days.\n\nBased on the documents submitted for review, the patient's medical condition/functional deficits are substantial, progressive and unpredictable as to require the requested increased CDPAS from 63 to 80 hours/day. The letters from the patient's treating medical providers as well as from the daughter were particularly persuasive.  Again, based on the documented submitted for review, the patient's health and safety are more appropriately provided and maintained at home with the requested increase CDPAS of 80 hours/week.   \n\nBased on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for increase in consumer direct personal assistance service - 80 hours per week is substantiated.\n", "id": "7c54417bcf1d46b8b2a1285ad80d416d", "question": "What is the background context in this case summary?", "title": "7c54417bcf1d46b8b2a1285ad80d416d", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Low back surgery due to back and bilateral leg pain. \nTreatment: Full hospital admission. \nThe insurer denied the full hospital admission.", "The patient is a female who presented for an elective L (lumbar)3/4 laminectomy with diskectomy. Indication for surgery was back and bilateral leg pain which failed non-operative management. The patient had left lower extremity (LLE) weakness pre-operatively. Past surgical history (PSH) was significant for prior L4-S (sacral) 1 fusion. Intraoperative, the patient experienced a small durotomy which was primarily repaired and further addressed with Duragen and Duraseal. Post-operatively, hospitalist and physical therapy (PT) services were consulted. The patient was slow to progress with PT. She required several days of therapy in order to be able to be safely discharged home.", "this patient experienced intra-operative and post-operative challenges such as durotomy and extensive physical therapy. The patient had pre-operative weakness in her left lower extremity (LLE)"], "answer_start": [0, 200, 1044]}, "context": "Diagnosis: Low back surgery due to back and bilateral leg pain. \nTreatment: Full hospital admission. \nThe insurer denied the full hospital admission. \nThe health plan's determination is overturned. \n\nThe patient is a female who presented for an elective L (lumbar)3/4 laminectomy with diskectomy. Indication for surgery was back and bilateral leg pain which failed non-operative management. The patient had left lower extremity (LLE) weakness pre-operatively. Past surgical history (PSH) was significant for prior L4-S (sacral) 1 fusion. Intraoperative, the patient experienced a small durotomy which was primarily repaired and further addressed with Duragen and Duraseal. Post-operatively, hospitalist and physical therapy (PT) services were consulted. The patient was slow to progress with PT. She required several days of therapy in order to be able to be safely discharged home. \n\nThe inpatient hospital admission was medically necessary. Lumbar laminectomy is typically performed as an outpatient. Unfortunately, as can happen in surgery, this patient experienced intra-operative and post-operative challenges such as durotomy and extensive physical therapy. The patient had pre-operative weakness in her left lower extremity (LLE) which can slow down physical therapy progress. Given the patient's need to remain in the hospital for more than 2 midnights, her appropriate level of care would be inpatient. The patient was not able to be safely discharged prior to postoperative day (POD) 7. Her care could not have been rendered at a lower level of care for the duration of her stay.", "id": "bc89dda70d584dc0b0bdfd420d6de9e0", "question": "What is the background context in this case summary?", "title": "bc89dda70d584dc0b0bdfd420d6de9e0", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Rheumatoid Arthritis\nTreatment: Orencia \nThe insurer denied Orencia.", "This is a female patient with rheumatoid arthritis (RA). Prior treatments included Cimzia, intravenous (IV) Orencia, subcutaneous (SQ) Orencia and Plaquenil (stopped due to gastrointestinal (GI) side effects). The patient has been on Orencia in the past and her provider would like to re-start it. Subcutaneous (SQ) Orencia is being denied by the health plan as the preferred formulary drugs have not been tried. The primary preferred formulary drugs, include Humira, Hyrimoz, Rinvoq and Xeljanz. The secondary preferred drug is Kevzara. Of note, the patient has a latex allergy. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects."], "answer_start": [0, 111]}, "context": "Diagnosis: Rheumatoid Arthritis\nTreatment: Orencia \nThe insurer denied Orencia.\nThe determination is upheld.\n\n\nThis is a female patient with rheumatoid arthritis (RA). Prior treatments included Cimzia, intravenous (IV) Orencia, subcutaneous (SQ) Orencia and Plaquenil (stopped due to gastrointestinal (GI) side effects). The patient has been on Orencia in the past and her provider would like to re-start it. Subcutaneous (SQ) Orencia is being denied by the health plan as the preferred formulary drugs have not been tried. The primary preferred formulary drugs, include Humira, Hyrimoz, Rinvoq and Xeljanz. The secondary preferred drug is Kevzara. Of note, the patient has a latex allergy. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.\n\nAll formulary medications would be as effective for the treatment of RA. However, Humira and hyrimoz (Humira biosimilar) are not options as the patient has a latex allergy and the needle cover of prefilled syringe and autoinjector of these medications may contain latex. Xeljanz, Rinvoq and Kevzara do not contain latex and thus there is no medical reason the patient cannot try one of these preferred medications as they are indicated for the treatment of RA. For example, as published in N Engl J Med in 2012, \"in patients with active rheumatoid arthritis, tofacitinib monotherapy was associated with reductions in signs and symptoms of rheumatoid arthritis and improvement in physical function\". Moreover, a paper in Arthritis Rheumatol in 2017 concluded that \"sarilumab 150 milligrams (mg) and sarilumab 200 mg every 2 weeks plus conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) improved the signs and symptoms of RA and physical function in patients with an inadequate response or intolerance to anti-tumor necrosis factor (TNF) agents. Safety data were consistent with interleukin-6 receptor blockade and the known safety profile of sarilumab\". Like Orencia, Xeljanz, Rinvoq and Kevzara would need to be stopped when pregnant as well. As stated, Humira is not an option due to the patient's latex allergy. There is no reason the patient cannot try one of the latex free drugs on the health plan's formulary.", "id": "bc5dcf6c82fe4757a097dd864a475fc3", "question": "What is the background context in this case summary?", "title": "bc5dcf6c82fe4757a097dd864a475fc3", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Toenail fungus\nTreatment: Jublia \nThe insurer denied Jublia.", "The patient is a female who was treated for toenail fungus. She was treated with ciclopirox topical medication. She was also given Itraconazole. She had been treated by a different podiatrist and tried Formula 3 and terbinafine orally with minimal improvement. The patient was recommended and prescribed Jublia. At issue is whether the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.", "The patient has tried terbinafine tablets, itraconazole tablets, and ciclopirox solution."], "answer_start": [0, 102, 842]}, "context": "Diagnosis: Toenail fungus\nTreatment: Jublia \nThe insurer denied Jublia.\nThe determination is upheld.\n\nThe patient is a female who was treated for toenail fungus. She was treated with ciclopirox topical medication. She was also given Itraconazole. She had been treated by a different podiatrist and tried Formula 3 and terbinafine orally with minimal improvement. The patient was recommended and prescribed Jublia. At issue is whether the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.\n\nBased on the review of medical records, standards of care, and literature, all of the formulary drugs (Kerydin, tavaborole solution, terbinafine tablets, itraconazole tablets and ciclopirox) are known to be as effective as or more effective then the non-formulary drug. The patient has tried terbinafine tablets, itraconazole tablets, and ciclopirox solution. However, the patient does not have documentation of trying Kerydin or tavaborole solution.", "id": "577bb5de71fe48d6b1954df2efe11aeb", "question": "What is the background context in this case summary?", "title": "577bb5de71fe48d6b1954df2efe11aeb", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Seizure\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission", "The patient presented to the hospital for evaluation of altered mental status and loss of consciousness concerning for seizure or syncope.  The patient had a history of seizures.  The patient described an aura sensation and believed that they had seizures the previous day and today.  The patient described racing heart and then waking up on the ground.  It was unclear if the patient had focal or generalized seizures in the past.  The patient was on Fycompa and Briviact and was adherent with the medications.  The patient reported that they would typically get aura sensation prior to seizure around the time of their period.  The patient reported that they felt that they were about to get their period.  The patient stated that they felt that they had a third episode with emergency medical services.  It was indicated that the patient nodded their head and there was no generalized tonic-clonic activity.  The patient's neurologist was called.  The provider stated that the patient has suspected psychogenic seizures, but the patient had been discharged from their clinic as the patient was no longer following the recommendations.  The patient was given the current medications but advised to find a new provider.  The patient had continuous electroencephalogram for 3 days and had some events that were captured on video but not associated with any electrographic seizure activity.  The patient had a history of real epilepsy in the past, but it was now suspected to be more psychogenic.  There were episodes in the past in which the patient stated that they could not walk but demonstrated full strength on exam.  While in the emergency department, the patient had an episode of possible seizure that lasted less than 1 minute and broke spontaneously.  Ativan was given prophylactically after the seizure broke.  The patient had turning of the head to the right, tense body, and was not responsive.  There was slight jerking of the leg but no overt tonic-clonic jerking motion.  There was slight right gaze deviation during the episode.  After the episode, the patient was awake and talking but had some twitching around the eye which resolved in less than 1 minute.  There was consideration for admission for syncope versus seizure.  Vital signs noted temperature of 98.7 Fahrenheit, heart rate of 108, and blood pressure 106/68.  Laboratory testing noted elevated troponin of 12.2.  Electrocardiogram demonstrated normal sinus rhythm.  Computed tomography (CT) of the head was unremarkable.  The urine drug screen was negative.  The patient was treated with intravenous (IV) fluid, Keppra, and Ativan."], "answer_start": [0, 128]}, "context": "Diagnosis: Seizure\n\nTreatment: Inpatient admission\n\nThe insurer denied coverage for inpatient admission\n\nThe denial is upheld \n\nThe patient presented to the hospital for evaluation of altered mental status and loss of consciousness concerning for seizure or syncope.  The patient had a history of seizures.  The patient described an aura sensation and believed that they had seizures the previous day and today.  The patient described racing heart and then waking up on the ground.  It was unclear if the patient had focal or generalized seizures in the past.  The patient was on Fycompa and Briviact and was adherent with the medications.  The patient reported that they would typically get aura sensation prior to seizure around the time of their period.  The patient reported that they felt that they were about to get their period.  The patient stated that they felt that they had a third episode with emergency medical services.  It was indicated that the patient nodded their head and there was no generalized tonic-clonic activity.  The patient's neurologist was called.  The provider stated that the patient has suspected psychogenic seizures, but the patient had been discharged from their clinic as the patient was no longer following the recommendations.  The patient was given the current medications but advised to find a new provider.  The patient had continuous electroencephalogram for 3 days and had some events that were captured on video but not associated with any electrographic seizure activity.  The patient had a history of real epilepsy in the past, but it was now suspected to be more psychogenic.  There were episodes in the past in which the patient stated that they could not walk but demonstrated full strength on exam.  While in the emergency department, the patient had an episode of possible seizure that lasted less than 1 minute and broke spontaneously.  Ativan was given prophylactically after the seizure broke.  The patient had turning of the head to the right, tense body, and was not responsive.  There was slight jerking of the leg but no overt tonic-clonic jerking motion.  There was slight right gaze deviation during the episode.  After the episode, the patient was awake and talking but had some twitching around the eye which resolved in less than 1 minute.  There was consideration for admission for syncope versus seizure.  Vital signs noted temperature of 98.7 Fahrenheit, heart rate of 108, and blood pressure 106/68.  Laboratory testing noted elevated troponin of 12.2.  Electrocardiogram demonstrated normal sinus rhythm.  Computed tomography (CT) of the head was unremarkable.  The urine drug screen was negative.  The patient was treated with intravenous (IV) fluid, Keppra, and Ativan.  \n\nHowever, the documentation did not detail that there was hemodynamic instability that was not readily corrected by appropriate treatment, status epilepticus, that there was a brain disorder such as tumor, edema, trauma, or encephalitis that required monitoring or intervention available only at inpatient level of care, that the etiology was related to factors such as drug toxicity, withdrawal, or nonadherence that required monitoring or intervention available only at inpatient level of care, that there was altered mental status that was severe or persistent, that there was new focal neurologic deficit, that there was a metabolic disorder that persisted despite observation care, that there was recurrent seizure without known seizure disorder, that the seizure was a different seizure type than previously known, or that there was baseline of infrequent seizure and the recurrence was not thought to be due to readily modifiable etiology.  \n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for an inpatient admission is not substantiated.\n", "id": "479b4001dff74eaba5d6949efcb45181", "question": "What is the background context in this case summary?", "title": "479b4001dff74eaba5d6949efcb45181", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Duchenne Muscular Dystrophy\t\n\nTreatment: 39 Home Health Visits\n\nThe insurer denied coverage for 39 Home Health Visits", "This is a patient diagnosed with Duchenne Muscular Dystrophy (DMD). The patient is dependent for activities of daily living (ADL) and non-ambulatory. Under review is the medical necessity of occupational therapy (OT) 39 home health visits.", "According to the notes, the patient \"has been going for physical therapy (PT)/OT 3 times a week.\"  The provider also includes medical literature regarding the diagnosis, management and rehabilitation of DMD (1, 2)."], "answer_start": [0, 153, 784]}, "context": "Diagnosis: Duchenne Muscular Dystrophy\t\n\nTreatment: 39 Home Health Visits\n\nThe insurer denied coverage for 39 Home Health Visits\n\nThe denial is upheld \n\nThis is a patient diagnosed with Duchenne Muscular Dystrophy (DMD). The patient is dependent for activities of daily living (ADL) and non-ambulatory. Under review is the medical necessity of occupational therapy (OT) 39 home health visits.\n\nThe clinical records submitted are insufficient to support the medical necessity for the requested OT services. The letter from the patient's treating physician describing the patient's underlying diagnosis (DMD), limited functional ability, and reported medical necessity of physical and occupational therapy was reviewed. Also reviewed were the office visit notes and \"Video-Visit note\". According to the notes, the patient \"has been going for physical therapy (PT)/OT 3 times a week.\"  The provider also includes medical literature regarding the diagnosis, management and rehabilitation of DMD (1, 2). However, the actual PT/OT notes, which require evidence of continued and sustained functional improvement, were not included for review.   \n\nThe health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies and boards. All decisions are evidenced based. \n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for occupational therapy 39 home health visits is not substantiated.\n", "id": "0887d5d8327e42eb9e68db2f28ba7c66", "question": "What is the background context in this case summary?", "title": "0887d5d8327e42eb9e68db2f28ba7c66", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Malocclusion\n\nTreatment: D8080 Braces and D8670 monthly visits\n\nThe insurer denied coverage for D8080 Braces and D8670 monthly visits", "Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, appeal letter the patient's orthodontist with references, as well as insurer correspondence, it appears that this patient with muscular dystrophy, presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including mandibular protrusion, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 36 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. attaining 7 points by internal reviewers. The orthodontist is appealing the decision."], "answer_start": [0, 170]}, "context": "Diagnosis: Malocclusion\n\nTreatment: D8080 Braces and D8670 monthly visits\n\nThe insurer denied coverage for D8080 Braces and D8670 monthly visits\n\nThe denial is upheld. \n\nUpon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, appeal letter the patient's orthodontist with references, as well as insurer correspondence, it appears that this patient with muscular dystrophy, presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including mandibular protrusion, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 36 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. attaining 7 points by internal reviewers. The orthodontist is appealing the decision.\n\nUpon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index. Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. \n\nIn this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 36 points to justify orthodontic care. The reviewer concurs with the index completed by the insurer attaining a total of 7 points on the HLD index (2 overjet, 2 overbite, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. \n\nRegarding the validity of the Handicapping Labio-Lingual Deviation Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. \n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.\n\nThe medical necessity for D8080 Braces and D8670 monthly visits is not substantiated.\n", "id": "38e345cf235043429f1e385916293488", "question": "What is the background context in this case summary?", "title": "38e345cf235043429f1e385916293488", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Multiple Sclerosis\n\nTreatment: Subacute rehabilitation\n\nThe insurer denied coverage for subacute rehabilitation", "This is a patient with diagnosed multiple sclerosis and more recently urinary tract infection(s).  The patient's ability to perform activities of daily living (ADLs) and functional mobility has gradually declined.  The patient was admitted (from home) to the skilled nursing facility (SNF).  The patient received physical and occupational therapy.  Under review is the medical necessity for subacute rehabilitation.", "The patient presented from home to the skilled nursing facility (SNF).  Upon presentation, the patient required a foley urinary catheter and drainage bag.  The patient's ability to perform activities of daily living and functional mobility ranged from maximal assistance to total dependence.  \n\nOver the next several weeks, the foley catheter was eventually removed, and the patient was able to urinate on their own.", "the patient's ability to perform activities of daily living and functional mobility had demonstrated only limited improvement.  According to the physical therapy notes, the patient was unable to ambulate with or without an assistive device.  The patient required the assistance of 2 people, an Eva support walker and a wheelchair followed close behind; being upright for approximately 15 feet.  The patient also required 2 people to transfer from sitting to standing.  A similar lack of progress was documented by the occupational therapist.  The patient continued to require moderate to maximal assistance for bathing, dressing and toileting activities."], "answer_start": [0, 147, 761, 1194]}, "context": "Diagnosis: Multiple Sclerosis\n\nTreatment: Subacute rehabilitation\n\nThe insurer denied coverage for subacute rehabilitation\n\nThe denial is upheld \n\nThis is a patient with diagnosed multiple sclerosis and more recently urinary tract infection(s).  The patient's ability to perform activities of daily living (ADLs) and functional mobility has gradually declined.  The patient was admitted (from home) to the skilled nursing facility (SNF).  The patient received physical and occupational therapy.  Under review is the medical necessity for subacute rehabilitation.\n\nThe submitted SNF records do not support that the patient continued to be an appropriate candidate for the subacute rehabilitation SNF level of care during the time period under review (1, 2, 3).  The patient presented from home to the skilled nursing facility (SNF).  Upon presentation, the patient required a foley urinary catheter and drainage bag.  The patient's ability to perform activities of daily living and functional mobility ranged from maximal assistance to total dependence.  \n\nOver the next several weeks, the foley catheter was eventually removed, and the patient was able to urinate on their own.  Unfortunately, the patient's ability to perform activities of daily living and functional mobility had demonstrated only limited improvement.  According to the physical therapy notes, the patient was unable to ambulate with or without an assistive device.  The patient required the assistance of 2 people, an Eva support walker and a wheelchair followed close behind; being upright for approximately 15 feet.  The patient also required 2 people to transfer from sitting to standing.  A similar lack of progress was documented by the occupational therapist.  The patient continued to require moderate to maximal assistance for bathing, dressing and toileting activities. Subsequent treatment for the time period under review could have been safely provided at a lower level of care (e.g., long term care or home care with visiting therapy services). There were also no other specific acute medical or complicated nursing issues that warranted continued subacute rehabilitation level of care for the time period under review.  \n\nBased on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. \n\nThe medical necessity for subacute is not substantiated.\n", "id": "e5cead8378b4468fabe0dad076ed1cc2", "question": "What is the background context in this case summary?", "title": "e5cead8378b4468fabe0dad076ed1cc2", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Diabetes, thrombocytopenia, dementia. \nTreatment: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In). \nThe insurer denied: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In).", "This elderly female patient has medical conditions that include hypertension, diabetes, hypothyroidism, anemia, and thrombocytopenia. She lives alone. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. The Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient's daughter administers medications and assists as needed. The patient has occasional bowel and bladder incontinence. She had a fall 2 months ago due to dizziness. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with her cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. A letter from the Provider reports the patient has dementia that impacts her ability to perform activities of daily living (ADLs).", "she wanders when alone. The patient has need for frequent toileting and has incontinence. She is at risk for falling.", "This patient has multiple chronic conditions. She lives alone. Her daughter provides informal support. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows the patient has moderately impaired cognition and requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with the patient's cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. The appeal statement supports the patient needs assistance with all activities of daily living. She requires unscheduled assistance with toileting due to urinary frequency and incontinence. Additional assistance is requested for the patient's safety due to in-house accidents and wandering."], "answer_start": [0, 245, 1632, 2057]}, "context": "Diagnosis: Diabetes, thrombocytopenia, dementia. \nTreatment: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In). \nThe insurer denied: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In). \nThe denial is overturned. \n\nThis elderly female patient has medical conditions that include hypertension, diabetes, hypothyroidism, anemia, and thrombocytopenia. She lives alone. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. The Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient's daughter administers medications and assists as needed. The patient has occasional bowel and bladder incontinence. She had a fall 2 months ago due to dizziness. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with her cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. A letter from the Provider reports the patient has dementia that impacts her ability to perform activities of daily living (ADLs). Additional hours are needed for prevent onset of disability, to prevent in-house accidents as she will turn the stove on, and her safety because she wanders when alone. The patient has need for frequent toileting and has incontinence. She is at risk for falling. \n\nThe requested health service is medically necessary. \n\nLive-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions. She lives alone. Her daughter provides informal support. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows the patient has moderately impaired cognition and requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with the patient's cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. The appeal statement supports the patient needs assistance with all activities of daily living. She requires unscheduled assistance with toileting due to urinary frequency and incontinence. Additional assistance is requested for the patient's safety due to in-house accidents and wandering. The information provided shows that this patient has significant limitations in cognition and functioning that have progressed over Uniform Assessment System evaluations. Her limitations and need for frequent assistance with unscheduled toileting cannot be met with the approved personal care services of 56 hours per week. The proposed increase home /personal care personal care services to 24 hours per day (live-in) is medically indicated.", "id": "6148233f528249c9975e4ffbb8fa08cc", "question": "What is the background context in this case summary?", "title": "6148233f528249c9975e4ffbb8fa08cc", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Obesity and pre-diabetes.\n\nTreatment: Wegovy 2.4 mg/0.75 ml, pen injectors.\n\nThe insurer denied coverage for Wegovy 2.4 mg/0.75 ml, pen injectors.", "This is a patient diagnosed with obesity. This request is for Wegovy. As per the visit note, the patient had pre-diabetes with a hemoglobin A1C of 5.4%, dyslipidemia, obstructive sleep apnea (OSA), and hypertension (HTN). The patient is on Ozempic 2 milligrams (mg) weekly. The patient is noticing with Ozempic some stomach cramps and loose stools. \n\nThe patient's starting weight was 293 pounds (lbs.). On subsequent visits, the patient's weights and body mass index (BMI) were: 262.4 lbs., BMI 33.7; 262.8 lbs., BMI 33.7; and most recently, 258 lbs., BMI 33.1. \n", "The patient had a BMI of 33.1 recently"], "answer_start": [0, 182, 1401]}, "context": "Diagnosis: Obesity and pre-diabetes.\n\nTreatment: Wegovy 2.4 mg/0.75 ml, pen injectors.\n\nThe insurer denied coverage for Wegovy 2.4 mg/0.75 ml, pen injectors.\n\nThe denial is upheld.\n\nThis is a patient diagnosed with obesity. This request is for Wegovy. As per the visit note, the patient had pre-diabetes with a hemoglobin A1C of 5.4%, dyslipidemia, obstructive sleep apnea (OSA), and hypertension (HTN). The patient is on Ozempic 2 milligrams (mg) weekly. The patient is noticing with Ozempic some stomach cramps and loose stools. \n\nThe patient's starting weight was 293 pounds (lbs.). On subsequent visits, the patient's weights and body mass index (BMI) were: 262.4 lbs., BMI 33.7; 262.8 lbs., BMI 33.7; and most recently, 258 lbs., BMI 33.1. \n\nSemaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist that is approved by Food and Drug Administration (FDA) in treating type II diabetes and obesity. Recent studies published in major peer-reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for treating obesity in the form of Wegovy. The standard of care based on multiple societal guidelines requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. \n\nThe patient had a BMI of 33.1 recently; however, there is no documentation of participation in lifestyle modifications. \n\nBased on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for Wegovy 2.4 milligrams (mg)/0.75 milliliters (ml), pen injectors services is not substantiated.\n", "id": "620de914db204af79f0ce016b1ee0a2c", "question": "What is the background context in this case summary?", "title": "620de914db204af79f0ce016b1ee0a2c", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Decreased mobility. \nTreatment: Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week. \nThe insurer denied Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week. ", "This is a case review for a male with medical history notable for mobility issues, incontinence, and end stage renal disease. The patient and his care team requested Personal Care Services. ", "The most recent Uniform Assessment System (UAS) functional assessment reports that there was no significant functional decline, however in the text of the assessment it does report that his functional status has been worsening and that he does require personal care assistance with all activities of daily living."], "answer_start": [0, 305, 988]}, "context": "Diagnosis: Decreased mobility. \nTreatment: Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week. \nThe insurer denied Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week. \nThe health plan's determination is overturned. \n\nThis is a case review for a male with medical history notable for mobility issues, incontinence, and end stage renal disease. The patient and his care team requested Personal Care Services. \n\nThe Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week service is medically necessary for this patient. \nThe patient requires personal care assistance for nearly all activities of daily living, including ambulating, toileting, and transfers. Given that some of these personal care needs will be unscheduled throughout the day, the requested increase from 7 to 11 hours per day is reasonable and appropriate to meet the patient's functional needs. The most recent Uniform Assessment System (UAS) functional assessment reports that there was no significant functional decline, however in the text of the assessment it does report that his functional status has been worsening and that he does require personal care assistance with all activities of daily living. The increase in hours is therefore medically necessary and appropriate for the patient. His fall in the previous 30 days before the assessment is evidence of unmet personal care needs, as he requires assistance with ambulation and further attempts to do so without assistance could result in additional injuries.", "id": "4038f3a231d344df9d8b19b1aa0aeddf", "question": "What is the background context in this case summary?", "title": "4038f3a231d344df9d8b19b1aa0aeddf", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Alzheimer's dementia. \nTreatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. \nThe insurer denied  Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.", "The patient is a female with a medical history notable for Alzheimer's dementia. The patient was approved for 12 hours per day, 7 days per week for a total of 84 hours per week of personal care worker services. \nThe patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has deteriorated over the last two to three months. She has been falling while walking to the bathroom at night and also while getting out of bed. She has had inappropriate hygiene overnight due to a lack of personal care support. She is no longer able to care for herself independently and requires constant assistance. \nA Uniform Assessment System (UAS) was completed. The patient lives alone in a two-bedroom apartment. She was alert and oriented to person and place during the visit. They noted that she has worsening sundowning and confusion at night. She is occasionally incontinent of urine and infrequently incontinent of stool. Compared to an assessment performed approximately 3 months prior, the patient showed a significant decline in level of function for activities of daily living. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. "], "answer_start": [0, 412]}, "context": "Diagnosis: Alzheimer's dementia. \nTreatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. \nThe insurer denied  Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. \nThe determination is overturned in part. \n\nThe patient is a female with a medical history notable for Alzheimer's dementia. The patient was approved for 12 hours per day, 7 days per week for a total of 84 hours per week of personal care worker services. \nThe patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has deteriorated over the last two to three months. She has been falling while walking to the bathroom at night and also while getting out of bed. She has had inappropriate hygiene overnight due to a lack of personal care support. She is no longer able to care for herself independently and requires constant assistance. \nA Uniform Assessment System (UAS) was completed. The patient lives alone in a two-bedroom apartment. She was alert and oriented to person and place during the visit. They noted that she has worsening sundowning and confusion at night. She is occasionally incontinent of urine and infrequently incontinent of stool. Compared to an assessment performed approximately 3 months prior, the patient showed a significant decline in level of function for activities of daily living. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. \n\nThe services are medically necessary in part. The requested health service of Personal Care Worker (PCW) services 7 days per week, 12 hours per day x 2 split shifts continuous by more than one person; 168 hours per week has not been demonstrated to be medically necessary for this patient. Personal Care Worker (PCW) services 7 days per week, 24 hours per day live-in is medically necessary for this patient. \nThe patient requires assistance with essentially all activities of daily living, including toileting, transfers, and ambulation. Because of this, the patient will have personal care needs that are continuous and unscheduled throughout the day and occasionally at night as well. Her recent falls are evidence of unmet personal care needs. Therefore, it is medically necessary that the patient receive 24-hour per day personal care assistance.\nThere is insufficient documentation that the patient requires 24-hour split shift personal care assistance. Split shift personal care is medically necessary for patients whose personal care needs have been demonstrated to be continuous overnight and of such frequency that a live-in personal care assistant would not be able to receive adequate rest at night. There were no overnight care logs provided for review. The patient is not being treated for a pressure ulcer that requires frequent turning and repositioning. Supervision and safety monitoring alone is not an allowable personal care function, and 24-hour split shift care cannot be authorized merely to provide supervision. However, a live-in personal care aide would be medically appropriate to address any care needs such as toileting which would occur infrequently in the evening and night time.", "id": "9a419471a50449528ebba8c1a5d22021", "question": "What is the background context in this case summary?", "title": "9a419471a50449528ebba8c1a5d22021", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Decrease in kidney function\nTreatment: Inpatient Hospital Admission\nThe insurer denied: Inpatient Hospital Admission", "The patient is an adult female who was admitted for worsening kidney function on outpatient labs with hyperkalemia. She was evaluated by nephrology service and was started on intravenous fluid and treated with Lokelma for elevated potassium level. The patient was noted to have adequate urine output and her creatinine was trending down appropriately, which was consistent with prerenal azotemia. Her condition stabilized and she was discharged on day #4.", "The patient was admitted for dehydration and was noted to have elevated creatinine", "This patient's kidney function improved back to baseline in 48 hours", "she was hemodynamically stable and was able to tolerate an oral diet"], "answer_start": [0, 151, 667, 1517, 1789]}, "context": "Diagnosis: Decrease in kidney function\nTreatment: Inpatient Hospital Admission\nThe insurer denied: Inpatient Hospital Admission\nThe denial is upheld.\n\nThe patient is an adult female who was admitted for worsening kidney function on outpatient labs with hyperkalemia. She was evaluated by nephrology service and was started on intravenous fluid and treated with Lokelma for elevated potassium level. The patient was noted to have adequate urine output and her creatinine was trending down appropriately, which was consistent with prerenal azotemia. Her condition stabilized and she was discharged on day #4.\n\nThe requested health service was not medically necessary.\n\nThe patient was admitted for dehydration and was noted to have elevated creatinine; however, the patient's acute kidney injury could have been treated safely under a lower level of care. The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent acute tubular necrosis. This patient's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis, which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy. In addition, she was hemodynamically stable and was able to tolerate an oral diet. When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, she had no requirements for inpatient level of care. Therefore, the requested health service was not medically necessary. ", "id": "38647d04d91a45a595ef128bd0859ac2", "question": "What is the background context in this case summary?", "title": "38647d04d91a45a595ef128bd0859ac2", "sufficiency_score": 4}
+{"answers": {"text": ["Diagnosis: Crohn's disease and celiac disease\nTreatment: Rinvoq\nThe insurer denied Rinvoq", "The patient is a female with Crohn's disease and celiac disease. She has failed 6-mercaptopurine, Remicade, Entyvio, and Stelara (started in 2018) every 4 weeks. While on Stelara every 4 weeks, she had improvement, but persistent rectal disease. She had improvement in rectal disease with the addition of Rinvoq.", "The patient's disease is severe and diagnosed at a young age, with history of multiple medication failures, including all primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease."], "answer_start": [0, 139, 602]}, "context": "Diagnosis: Crohn's disease and celiac disease\nTreatment: Rinvoq\nThe insurer denied Rinvoq\nThe health plan's determination is overturned. \n\nThe patient is a female with Crohn's disease and celiac disease. She has failed 6-mercaptopurine, Remicade, Entyvio, and Stelara (started in 2018) every 4 weeks. While on Stelara every 4 weeks, she had improvement, but persistent rectal disease. She had improvement in rectal disease with the addition of Rinvoq.\n\nRinvoq is medically necessary for this patient.\nThe current medical literature supports the request for Rinvoq for the treatment of Crohn's disease. The patient's disease is severe and diagnosed at a young age, with history of multiple medication failures, including all primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease. Several studies have assessed the use of multiple therapies concurrently, including biologic therapy (such as Stelara) with small molecule therapy (such as Rinvoq). In aggregate, no significant safety issues were attributed to combination therapy, and the therapy was broadly successful in improving response in patients who had failed biologic therapy. Rinvoq is Food and Drug Administration (FDA) -approved for the treatment of Crohn's disease, and has demonstrated safety and efficacy.", "id": "d4dd06fa98e245c7924d515d54daf328", "question": "What is the background context in this case summary?", "title": "d4dd06fa98e245c7924d515d54daf328", "sufficiency_score": 4}