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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa (hyaluronan) injections. As evidenced by the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for chondromalacia of the knees. Researchers reported on 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 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 chondromalacia. As such, Euflexxa (hyaluronan) injections are medically necessary for treatment of this 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a second magnetic resonance imaging (MRI) of the facial area. This patient has a mass on her face that is producing facial deformity. The mass has increased in size and two biopsies were different pathologically. It is well known that liposarcoma may be difficult to diagnose on punch biopsy as this type of tumor may be eccentric and non-uniform. A high resolution contrast enhanced MRI with appropriate marking of the skin superficial to the mass may provide critical diagnostic information. The MRI may help target an area for biopsy, which in turn may provide a diagnosis suitable for treatment. Pathologic analysis and imaging findings thus far have not yielded a confirmed diagnosis, nor have they pinpointed a target for directed biopsy. The patient has symptoms which are progressive leading to facial deformity. Thus, the requested repeat MRI is supported as medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg, three tablets daily for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASSLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets daily for eight weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 70 tablets of Percocet 5-325 mg.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. Clinical practice guidelines do not support the use of opiates for chronic low back pain. Further, the use of marijuana violates her opiate maintenance agreement. Per the medical evidence, the use of marijuana increases her risk of using other drugs and opiate misuse. Therefore, 70 tablets of Percocet 5-325 mg are not medically necessary 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing services, which include physical therapy, occupational therapy, and speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients hemorrhagic stroke. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records did not indicate that SNF services were medically necessary to safely and effectively provide reasonable treatment for this patient. On 7/01/18, the patient did not require complex wound care, enteral feeds, tracheostomy care, or other skilled nursing services. This patient did not require skilled therapy services with a specialized skill, knowledge, and judgment of a qualified therapist at a SNF level of care. The patient may benefit from additional physical therapy, occupational therapy, and speech therapy; however, the documentation does not support that the patient requires inpatient level of care in a SNF on a daily basis. Therefore, the requested skilled nursing services (SNF) at South Coast Post-Acute, which include physical therapy, occupational therapy, and speech therapy are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. Per the current medical evidence, the focus of treatment should be patient education, self-care, analgesics, independent exercise and remaining active.  The benefit of prolonged formal exercise therapy services is not established in the medical literature for this patients condition. There is no proven marginal benefit of passive modalities, such as massage/manual therapy, and modalities provided in a formal setting on a prolonged basis on pain, health or functional outcomes over self-massage and topical treatments, such as ice or heat applied independently. There is as lack of proven benefit of manual therapies for idiopathic scoliosis. In this case, the patient does not have documented impairments that would preclude her from performing an appropriate exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, such as self-massage using foam rollers or massage balls, and topical treatments, such as ice or heat. Overall, although the patient has ongoing symptoms, there is no expectation of a marginally significant difference in clinical course or outcomes with the proposed therapies in question over an independent program. Therefore, the requested physical therapy 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for urogynecologist consultation. The submitted documentation supports the medical necessity of the requested services. This patient presents with mild symptoms consistent with pelvic floor weakness and prolapse. Her clinical presentation is not one typically seen with this disease. She does not have typical risk factors for prolapse. In this patients case, she is likely to achieve benefit from conservative medical management of her prolapse. The management of uterine prolapse depends on the degree of prolapse and the resultant increase in patient symptoms. Per the records, the degree of prolapse is a combination of early stage change, grade one and grade two prolapse. When the symptoms are mild and the degree of prolapse is grade one, the patient may benefit from conservative measures, such as pelvic floor training. Additionally, a variety of different pessaries can be fitted and tried. In this patients case, evaluation with a urogynecologist is medically appropriate for further evaluation and treatment. Therefore, the requested urogynecologist consultation 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest wall oscillation unit (InCourage Airway Clearance System). Findings:  Two of the three physician reviewers found bronchiectasis is a syndrome of chronic cough and daily sputum production associated with airway dilatation and bronchial wall thickening that is associated with multiple conditions. Treatment includes the use of antibiotics to treat or prevent infections, regular use of airway clearance techniques and inhaled medications, including bronchodilators. There are many forms of chest physiotherapy to decrease obstructing respiratory secretions, including aerobic exercise, autogenic drainage, postural drainage and percussion methods. Of note, the long-term improvement in clinical outcome has not been shown.  High-frequency chest wall oscillation is not considered a first-line method for airway clearance. The evidence shows that it is not as effective as other airway clearance techniques.  There has not been a significant difference in lung function shown with patients using high-frequency chest wall oscillation versus other methods for chest percussion therapy. In this case, the requested high frequency chest wall oscillation unit (InCourage Airway Clearance System) is not likely to be of greater benefit than other treatment options. Final Result: The 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: Physician reviewers 1 and 2 are board certified in in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet. 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. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain. 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for titration polysomnography. Findings:  The physician reviewer found that current diagnostic standards for obstructive sleep apnea require that a patient have an apnea-hypopnea index (AHI) or respiratory event index (REI) of at least 5.0 events per hour. In this case, the patients recorded AHI was four events per hour. This is below the diagnostic threshold for obstructive sleep apnea. This patient does not have a medical condition that would necessitate nocturnal respiratory assistance, such as severe pulmonary disease or neuromuscular disease, for which positive air pressure is used. The use of CPAP in patients who do not meet diagnostic criteria for OSA is not otherwise supported within current practice guidelines. In this setting, the requested titration polysomnography is not medically necessary 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that Neuralgia is a type of neuropathic pain. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia specifically refers to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. The patient has been diagnosed with occipital neuralgia on examination. Per the records, she had a severe form of occipital neuralgia which was unresponsive to noninvasive, minimally invasive, and invasive procedures.  Although the data is limited, there is evidence to suggest effectiveness of nerve decompression for the treatment of her condition. However, the patients history is well-documented, and the chronicity of her complaints combined with her treatment history speak against the emergent nature of her disease process. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for physical therapy. Physical therapy is appropriate to treat individuals with poor health or injury so that they can return to past level of functioning with the hope that they will show significant improvement in a short period of time. In this case, the submitted records document that the patient has completed 22 physical therapy sessions for back and foot pain. The patient has been taught a home exercise program to continue on his own. The records reviewed do not support the patients compliance with the home physical therapy or with continued use of orthotics which were recommended for treatment of his plantar fasciitis. As such, the medical necessity of the requested physical therapy has not been established. 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  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. 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. It is not clear how the ten-year Balch data relates to the five-year DecisionDx-Melanoma testing data. Additionally, it is not clear if the assay can be used to make clinical decisions. There is a lack of support for the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma testing was not likely to have been more effective than other methods of evaluating this patient.Final Result: Two of 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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.