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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. The patient received a right knee cortisone injection and bilateral knee Orthovisc injections. The patient reported significant relief from previous Orthovisc injections with increased activity. The patient requested repeat Orthovisc injections. The patient has requested authorization and coverage for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections are medically necessary for the treatment of the patients medical condition. 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 by Campos and colleagues 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 had lasting benefit from prior viscosupplementation injections. Furthermore, his options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Medical evidence supports the requested services in this clinical setting. Therefore, bilateral knee Orthovisc 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient psychiatric services. Applying CALOCUS, this patient met the criteria for inpatient psychiatric services. The patient was at extreme risk of harm (score 5) due to consistent self-harm and physical aggression toward herself. The provider noted that the patient demonstrated a lack of insight and judgment resulting in significant bruising of her body. During treatment, the patient showed severe functional impairment (score 5) given her serious deterioration of her interpersonal interactions with family and with other peers on the unit. The patient was unable to function in an academic setting and was aggressive toward herself despite being in treatment. For comorbidity, the patients psychiatric symptoms impaired her functioning and ability to participate in treatment (score 4). The patients recovery environment was minimally stressful (score 1) as the patient performed role expectations consistent with her age and developmental level. In addition, her recovery environment provided limited support (score 3) due to inadequate community resources available to address the patients behavior and condition. The patient was inaccessible in treatment (score 5) as she continued to engage in self-harm behavior when exposed to stress. Although the patient did not make substantial progress, she was constructive in treatment (score 2), due to passive cooperation in treatment. This gives the patient a composite score of 25, which is consistent with Level 5, medically monitored residence based services. However, due to the severity of the patients condition and the lack of medically monitored residence services available, placement in a Level 6, medically managed residence based program, such as inpatient psychiatric level of care, was appropriate until she could be placed in a Level 5 facility. All told, the records demonstrate that the inpatient 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Physical examination revealed that the patients breasts were without masses. The patient underwent a mammogram, and the results were negative for any suspicious abnormalities. The patients breast tissue was noted to be dense. In the independent medical review application, the patient reported she has a family history of breast cancer. The patient has requested reimbursement for bilateral digital breast tomosynthesis and prospective authorization and coverage for yearly bilateral digital breast tomosynthesis. The Health Plan denied the request and reported the services at issue were not and are not medically necessary for the evaluation of this patient. At issue in this case is whether bilateral digital breast tomosynthesis and prospective yearly bilateral digital breast tomosynthesis was and/or is medically necessary for the evaluation of the patients medical condition. Current medical evidence supports the services at issue in this clinical setting. Helvie reported, While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breast. This results, at least in large part, from the masking or camouflaging of noncalcified cancers by surrounding dense tissue. The author also noted digital breast tomosynthesis mammography would allow visualization of cancers not apparent by conventional mammography thus improving sensitivity. Friedewald and colleagues reported that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in the cancer detection rate. In this case, the patient has dense breast tissue and a family history of breast cancer. The medical evidence supports the services at issue in this clinical setting. Therefore, bilateral digital breast tomosynthesis and prospective yearly bilateral digital breast tomosynthesis was and is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service was and is 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: The patient has been diagnosed with chronic migraine. The records noted that the patient had four migraine headaches in the previous month, lasting approximately eight hours. The provider noted that prior to the patient beginning treatment with Botox, the patient had 26 migraines each month, lasting approximately 14 hours. The patients migraines have decreased by 22 migraines per month since beginning treatment with Botox. In an application for independent medical review, the patient reported that she has had Botox injections in the past, and by the 11th week after injection the medication had completely worn off, resulting in daily migraine headaches. The patient reported previously receiving Botox injections every 11 weeks, which resulted in an improved quality of life. The patient has requested authorization and coverage for Botox 200 unit (HCPCS J0585) injections at a frequency of every 11 weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. The Health Plan has approved Botox (J0585) 200 unit injections, one treatment every 12 weeks, for a maximum of four treatments. At issue in this case is whether Botox 200 unit (HCPCS J0585) injections at a frequency of every 11 weeks are medically necessary for the treatment of the patients medical condition. The pharmacologic profile of OnabotulinumtoxinA makes it an appealing candidate for chronic migraine patients. Its good safety profile makes Botox the best option when other preventive medications are poorly tolerated or ineffective. Several studies have demonstrated that repeated injections over time are able to increase the benefit obtained after the first cycle of treatment, with a prophylactic cumulative effect. In this case, the patient had previously received Botox injections at an interval of every 11 weeks with benefit. The patient has reported that with Botox injections at an interval of every 12 weeks, she is experiencing two weeks of constant migraine headache four times per year. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Botox 200 unit (HCPCS J0585) injections at a frequency of every 11 weeks are 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) guidelines, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (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. Applying the ASAM framework, this patient met the medical necessity criteria for RTC services. The patient was placed on a detoxification protocol due to her imminent withdrawal and the associated risks. Given her heavy use of opiates and sedatives, the patient remained at elevated risk for relapse. She self-harmed while in RTC, which required intermittent monitoring. The patients medical history includes seizures, which places her at risk for recurrent seizures during withdrawal. The provider noted the patient has comorbid GAD. The patient has demonstrated a willingness to change, but has had difficulty finding successful coping strategies. The use of head banging as a coping strategy needs to be replaced with effective coping strategies. In addition, despite seizures, blackouts, and seizures, the patient has continued to use. This suggests that the patient has a strong pull to continue to use, which elevates her risk of relapse. The patients mother has been generally supportive but is noted to be unreliable as a source of support. Lower levels of care have thus far been inadequate support for her as evidenced by her continued use. The patient required a safe and stable living environment in order to develop her recovery skills. The records support that the patient qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. Given the severity of the patients illness, the RTC 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 expertise 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Cartiva Synthetic Cartilage Implant. This patient presented with persistent and worsening left great toe pain with a diagnosis of hallux rigidus status post prior bone spur surgery at the left first MPJ without sustained pain relief. Clinical examination findings were consistent with imaging evidence of severe first MPJ arthritis. The records included documentation of failed reasonable and comprehensive non-operative treatment including activity modification, taping, and shoe wear modification. He underwent decompression arthroplasty with Cartiva Synthetic Cartilage Implant on the first MPJ of the left foot. Evidence-based medical literature supports the use of the Cartiva Synthetic Cartilage Implant as an option in this patients medical condition to maintain first MPJ motion.  Given this support, the Cartiva Synthetic Cartilage Implant was 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 Cartiva Synthetic Cartilage Implant was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for an insulin pump.  Insulin pump therapy can be beneficial in patients with diabetes type 1 who are able to monitor and inject bolus insulin prior to meals. Insulin pump therapy can improve the rates of nocturnal hypoglycemia, whereas multiple doses of insulin or basal bolus therapy has been associated with less frequent diabetes ketoacidosis. Blood glucose targets should be individualized for patient age, insulin regimen, level of supervision, and other lifestyle issues, with the goal of achieving as many glucose values as close to target as possible without excessive hypoglycemia. This patient has been treated with the Medtronic 670G insulin pump that has the added technology of automated suspension of insulin delivery when a hypoglycemic threshold is crossed. However, the records indicate that the patient has been using the pump in manual mode. The patient would likely benefit from additional diabetes education to maximize the effectiveness of her current device. In addition, the records do not document that the patient has been checking her glucose levels before meals, which is essential to self-management of diabetes type 1. All told, the requested insulin pump is not medically necessary for 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the pelvis without dye. The diagnostic evaluation for defecatory dysfunction consists mainly of a history and physical examination. The examination includes assessment of the anatomy and confirmation of prolapse, evaluation of the perineal body and posterior vaginal wall, performance of a focused neurologic examination, and examination of the anal sphincter. The posterior vaginal wall and perineal body are best evaluated by rectovaginal examination. Since clinical examination is the main diagnostic modality for posterior vaginal defects, radiologic confirmation of the presence or absence of a rectocele is not recommended. There is a lack of standardization for establishing a radiological diagnosis of a rectocele. All told, the MRI of the pelvis without dye was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the MRI of the pelvis without dye was not likely to be more beneficial for evaluation of the patients 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for maxillofacial computed tomography (CT) scan without dye. The records provided for review document that this patient does have over-retained primary teeth with impacted permanent teeth. Given the patients prior medical history and the need for definitive surgical plan, obtaining a cone-beam CT prior will facilitate surgical planning. Two-dimensional imaging for surgical planning has several limitations, including magnification, distortion, superimposition of structures and misinterpretation. Cone-beam CT will allow the provider to determine the best clinical approach to reduce invasiveness of the surgery and will permit further appreciation of adjacent anatomy, including presence of any resorption of her adjacent teeth, which can change the treatment plan. Given these considerations, the requested maxillofacial CT scan without dye is medically necessary for treatment of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for a breast ultrasound. Digital mammography preferably with three-dimensional (3D) tomosynthesis is the standard of care for breast cancer screening with highest American College of Radiology (ACR) appropriateness rating. In some circumstances, an ultrasound of the breast is an alternative to standard imaging. Although ultrasound in the screening setting can be utilized as an adjunct to a mammogram in patients with dense breasts to increase cancer detection, ultrasound alone has been shown to have cancer detection similar to mammography. The drawback to ultrasound is increased false positive rates and decreased sensitivity of detection of cancerous calcifications and ductal carcinoma in situ (DCIS). The authors concluded that a screening ultrasound is a viable alternative to mammography in situations where mammography is not available, or not appropriate. Given the patients PTSD-related to sexual trauma, the requested breast ultrasound is medically necessary for evaluation of this patient. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for proton beam radiation therapy.  This patient has a history of squamous cell carcinoma of the left tonsil with ipsilateral cervical lymphadenopathy. According to the National Comprehensive Cancer Network (NCCN) guidelines, standard therapy consists of surgical resection and neck dissection followed by chemotherapy and standard radiation therapy or induction chemotherapy and systemic radiation therapy. Proton beam radiation is a method with the potential to reduce the side effects of intensity modulated radiation therapy (IMRT) such as desiccation of the oral mucosa and salivary tissues, nausea, and other immunologic side effects of treatment. A potential advantage of intensity modulated proton therapy (IMPT) over IMRT in the treatment of oropharyngeal carcinoma is lower radiation dose to several critical structures involved in the development of nausea and vomiting, mucositis, and dysphagia. However, current studies lack long-term data to support the merits of this proton beam radiation over standard radiation and chemotherapy. All told, the proton beam radiation therapy provided was 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 proton beam radiation therapy provided 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 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 otolaryngology 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.