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

Nature of Statutory Criteria/Case Summary: An enrollee has requested viscosupplementation injections for treatment of the enrollees knee osteoarthritis.  Findings: The physician reviewer found that based on the available medical records, the requested viscosupplementation injections for treatment of this patients medical condition are not medically necessary. Additional hyaluronan injections is not supported in the evidence based literature. Further, there is a documented possibility of complications such as iatrogenic intraarticular infection and sensitivity reactions which may jeopardize future total knee arthroplasty. This patient has undergone multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. A recent meta-analysis of the efficacy of viscosupplementation on a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation reported a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects in a patient likely to come to total knee arthroplasty issues of iatrogenic infection (Navarro-Sarabia, et al; Rutjes, et al). All told, the requested viscosupplementation injections (Orthovisc J7324) for both knees are not medically necessary for treatment of this patients knee osteoarthritis.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sclerotherapy injections. Findings:  Three physician reviewers found that the documentation does not support an indication for sclerotherapy for treatment of this patients varicose veins. There is no formal duplex report provided and no confirmation of a patent deep venous system. In addition, there is no record of an effort to treat conservatively and there is no indication that any of the procedures were urgent or emergent. Furthermore, the majority of the procedures were performed in the absence of symptoms. Given the availability of standard treatment options that were not considered or attempted, the use of sclerotherapy injections provided. Final Result: 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: All three physician reviewers are board certified in surgery with sub-specialty certification in vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90/400 mg 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 non-cirrhotic treatment-naive genotype 1 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Euflexxa injections for treatment of the enrollees osteoarthritis. Findings: The physician reviewer found that the evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. 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 the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. In addition, 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 which failed conservative treatment was found efficacious during a 54-month follow-up period. This has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with right knee tricompartmental osteoarthritis. She has undergone prior viscosupplementation series with documentation of six months pain reduction and the ability to avoid surgery. She has failed to respond to other conservative treatment including corticosteroid injections and activity modification. Therefore, the requested Euflexxa injections have been established as medically necessary for treatment of the patients right knee tricompartmental osteoarthritis.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that n the peer-reviewed medical literature, researchers found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. Final Result: The 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: Reviewers 1, 2 and 3 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, 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. 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viagra 50 mg for treatment of the enrollees erectile dysfunction. Findings: The physician reviewer found that this patient had very limited evaluation of his erectile dysfunction. There should be detailed sexual history obtained. There should also be detailed genitourinary examination performed on this patient. Blood work including serum testosterone should also be assessed. In the absence of this documentation, the requested Viagra 50 mg is not supported 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 20 mg.Findings:  The physician reviewer found that the patients height is not less than the 3rd percentile for his age and gender. His height on 10/16/15 was 62 5/8 inches which was within the 17th percentile for his age and gender. The data point plotted on the growth chart, was within normal range. There was no evidence of growth-fall off over time. The growth hormone (GH) levels on provocative testing were not sampled over several hours. The standard serial measurement of GH in response to provocative testing should be performed over two or three hours after administration of each provocative agent.  The low levels of GH in a boy who has delayed puberty cannot be taken as definitive evidence of GH deficiency. The tests have poor sensitivity and specificity for a diagnosis of GH deficiency and are typically low in the setting of delayed puberty. The bone age, by radiology report, was normal.  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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute inpatient rehabilitation facility (SNF) services for treatment of the enrollees medical condition status post left below knee amputation.  Findings: The physician reviewer found that based on the available documentation, acute inpatient rehabilitation facility services including physical therapy and occupational therapy are not medically necessary for treatment of this patients medical condition. The patient does have a below the knee amputation that would benefit from prosthetic training with physical and occupational therapy since she does have decreased functional ability. However, her overall medical condition and medical needs do not demonstrate a risk for medical instability or requirement for 24-hour availability of a nurse and physician who are skilled in rehabilitation medicine. The patient is capable of participating in a rehabilitation program, but the records do not support that she is consistently able to participate in a minimum of three hours of active rehabilitation daily. Further, the records do not demonstrate that the patient will be able to show measurable functional improvement within a reasonable and predictable time period with the requested acute inpatient rehabilitation services. The patient is medically stable and on oral antibiotics. Her current needs can be met at a lower level of care such as SNF or home health services. Accordingly, the requested acute inpatient rehabilitation facility services including physical therapy and occupational therapy are not medically necessary for treatment of the patients medical 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 board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidurography and moderate sedation for treatment of the enrollees back pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Epidurogram is a diagnostic procedure performed to assess the structure of the epidural space in the spine. This procedure is done before epidural steroids are administered to ensure accurate delivery of this therapeutic material to the source of pain. Bosscher and Heavner evaluated the significance of diagnostic markers obtained through epiduroscopy by evaluating the accuracy of outcome prediction after treatment of epidural pathology using epiduroscopy. The study showed that lumbosacral epiduroscopy predicts outcome of treatment accurately in the majority of patients. The study suggests that information obtained through epiduroscopy may carry significant diagnostic and prognostic value in patients demonstrating radicular pain. In this case, the medical records lack documentation of a history and physical demonstrating radiculopathy requiring treatment with an epidurogram prior to epidural steroid injections. Therefore, the requested therapy for epidurography and moderate sedation has not been established as medically necessary for treatment of the patients medical 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 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 lumbar spine magnetic resonance imaging MRI for evaluation of the enrollees medical condition.  Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  There is considerable controversy concerning when to order imaging studies to evaluate pain.  In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then MRI may be the most appropriate study.  There was insufficient evidence to support the routine use of MRI in patients with chronic low back pain.  In general, plain x-rays are often of very limited value.  Plain x-rays serve to evaluate the patient for significant structural abnormalities, such as fractures, malalignments and congenital anomalies. To that extent, plain x-rays have some value.  However, plain x-rays are not beneficial for evaluating patients for a cause for radiculopathy.  Patients can have significant disc herniations with normal plain x-rays.  Conversely, patients with degenerative change in the lumbar spine may not have significant disc encroachment.  In this particular patient, given the history of prior surgery, the patient will be expected to have radiographic/MRI findings.  The primary question is whether those findings have a direct causal relationship to the patient's symptoms.  The appropriate reason to obtain an MRI is in anticipation of some sort of intervention.  Prior to an intervention, it is reasonable to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs.  Thus, there is a lack of support for the requested services in this clinical setting.  All told, the requested lumbar spine MRI 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested admission to an inpatient recovery program for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the documentation does not support the medical necessity of the requested services. The records do not show that this patient had enduring efficacy following a treatment course identical to the requested service. The records reviewed indicate the patient previously participated and completed an equivalent recovery program as the one being requested.  Consequently, another iteration of the same program would not be reasonably expected to improve the patients condition or prevent an exacerbation of the addictive illness.  Moreover, the documentation does not advocate a more restrictive setting for the treatment of this patient, nor do the records describe the patients current status, treatment needs and barriers to care.  Therefore, an outpatient, community-based services would be medically appropriate for the treatment of this patient per the records submitted. As such, the requested authorization and coverage for admission to a 60-day inpatient recovery program 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for insertion of artificial intervertebral disc for treatment of the enrollees neck pain. Findings:  Two physician reviewers found that the North American Spine Society state that cervical artificial disc replacement may be indicated for the following diagnoses with qualifying criteria, when appropriate. The guidelines include radiculopathy related to nerve root compression from one or two-level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-4 to C6-7 with or without neck pain that has been refractory to medical or non-operative management or myelopathy or myeloradiculopathy related to central spinal stenosis from one or two level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-4 to C6-7 with or without neck pain. In this case, the patient meets the North American Spine Society criteria for a C5-6 cervical disc arthroplasty. Therefore, the requested insertion of artificial intervertebral disc 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 surgery 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 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.