Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for platelet-rich plasma injection for temporomandibular joint disorder. The enrollee has a history of teeth grinding and temporomandibular joint disorder. She complained of jaw pain, neck pain, and ringing in her ears. Findings: the physician reviewer found that  She has been treated with ear insufflation and a transcutaneous electrical nerve stimulation (TENS) unit. She underwent a sleep study for snoring and non-refreshing sleep. The study showed a low oxygen saturation of 89% during sleep and she was given a retainer. She also has been given fixed orthotics for her mouth, different mouth guards, Invisalign, as well as chiropractic treatment. She continues to have tinnitus, as well as pain in the ears, teeth, neck, cheeks, shoulder, and arms. She has a deviation of her right jaw at maximum opening and crepitus on the right. Due to failure of resolution of symptoms, ultimately she was referred to a provider who recommended platelet rich plasma injections into the temporomandibular joint. The medical literature indicates attempts are being made to determine whether platelet rich plasma injections are helpful in mitigating temporomandibular joint pain and discomfort. Although this treatment shows promise, it was found the studies performed to date were of low quality evidence with equivocal results, with many studies showing no better outcome than standard therapy, and therefore they could not recommend this treatment at this time.  Other studies were more direct and felt that PRP should not be first line treatment. There is no definitive nationally recognized standard for PRP or a high quality evidence study to support PRP over other modality treatment. Evidence of its efficacy has been highly variable depending on the specific indication.  Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in oral and maxillofacial surgery, another is board certified in pain management, and the third is board certified in otolaryngology and facial plastic reconstructive 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
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for injection, Synvisc, for both knees. The enrollee is diagnosed with bilateral primary osteoarthritis of the knees, chronic neck pain, and chronic tension type headache. His orthopedist administered bilateral Synvisc injections for his knee pain. He was prescribed hydrocodone/acetaminophen and hydromorphone, as part of his pain management. He was seen for follow up and was referred back to an orthopedist for continuation of care with Synvisc injections. An x-ray, of the right knee was negative and the left knee showed minimal patellar spurring. His physician prescribed one Synvisc injection to each knee. Review of the medical records indicates the x-rays do not show arthritis of the knee.  In the x-ray report, there is no joint space narrowing, and therefore there is not an indication for injection for knee arthritis without documentation of knee osteoarthritis.  Even in the setting of osteoarthritis, there is limited data to support the use of viscosupplementation. In general, the use of hyaluronic acid is not supported due to the fact that most studies do not show superiority over other treatments, including placebo.  This is highlighted in several studies. Guidelines in the medical literature do not recommend hyaluronic acid injections.  They indicate the evidence is strong, based on multiple studies with consistent findings for recommendations against the use of hyaluronic acid injections.  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 orthopedics and sports 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 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 reimbursement for residential treatment center (RTC) services. The enrollee has a history of attention deficit hyperactivity disorder (ADHD). Her parents enrolled her in residential treatment level of care after she had been displaying increasingly defiant and self-destructive behavior. According to the medical literature, children and adolescents with mental illness should be treated in the least restrictive environment, unless community-based settings are not appropriate as a result of the severity of an individuals psychiatric illness and then, in those instances, residential treatment may be considered. This enrollee, at the time of admission, was exhibiting some oppositional and socialization problems. However, the most critical symptoms were those of mood instability and difficulties with emotional self-regulation.  The purpose of residential services is typically to provide 24-hour care and monitoring inclusive of daily individual and group interventions. Based on the enrollees presentation at the time of admission, she could have been safely treated at a lower level of care. Her symptoms of low-grade anxiety and depression combined with behavioral opposition and substance abuse did not warrant the residential (RTC) level of care. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The clinical reviewer is board certified in Psychology 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement of Decision Dx-Melanoma Gene Assay. Findings:  Three physician reviewers found that the enrollee underwent shave biopsy of the right buttock and the dermatopathology report showed invasive malignant melanoma; arising with dermal nevus, Clarks level II, Breslow depth of invasion 0.20 MM. She then underwent a wide excision of the lesion. The Decision Dx-Melanoma Gene Assay was ordered for the prediction of metastatic recurrence. The result was Class 1, Sub-Class 1A which is associated with a low risk of recurrence within five years. She continues with office visits for skin cancer surveillance. Per the medical literature, diagnostic molecular techniques are still largely investigative and are not recommended for routine diagnostic use in cutaneous melanoma. The Decision Dx-Melanoma Gene Assay has not been validated against prognostic factors that could be used to determine prognosis. The data is based on a small sample size. The sample size would need to be larger to reduce the risk of false positives and to advise an enrollee previously thought of as low risk to proceed with invasive procedures based on the results of the testing. DecisionDx-Melanoma Gene Assay is not currently recommended by any standard treatment guidelines. Assessment of the sensitivity and specificity of this test in prospective enrollees, along with guidance on results interpretation, is of critical importance. Clinicians may suggest more frequent clinical evaluations and surveillance imaging for enrollees predicted by this test to be at high risk for metastasis; however, in settings in which adjuvant therapies are either contraindicated or not available, this categorization may increase enrollee anxiety without real benefit to the enrollee.Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for 30 hours/week of direct one-on-one and 15 hours/week of direct supervision applied behavioral analysis (ABA) services.  Findings:  The physician reviewer found that the enrollee has autism and displays behaviors, such as aggression and screaming. Vineland scores were low in areas of communication, daily living skills, socialization, motor skills, and adaptive behavior composite. A treatment plan update indicates the domains addressed with ABA therapy include social skills, communication, self-help, behavioral management, play, and parent training. The therapy has been effective in reducing problem behaviors and has increased replacement behavior/mitigating skill deficits.  However, she continued to demonstrate difficulties in communication, socialization, self-help skills, play and behavior management. The BCBA indicates that 30 hours per week of intensive one-to-one ABA treatment is medically necessary for the enrollee to reach her goals since she is still low in all domain areas and under the last ABA authorization period, she met approximately 65% of the recommended goals written for 30 hours per week of treatment. According to the medical literature, ABA therapy is a behavioral intervention used to treat autism spectrum disorders (ASD). Typical ABA programs are 25 to 40 hours per week. ABA is effective in improving communication, social skills, and management of problem behavior for children with ASD. ABA treatment is generally appropriate to continue until such time that the enrollee has reached their maximum attainable goals or until no further progress is seen.  Decreasing the recommended frequency of therapy would not be appropriate, as doing so may result in a significant decline in skills achieved. Vineland Adaptive Behavior Scale scores indicate the enrollees current adaptive level was low. Baseline skills including receptive, expressive and written were low.  Scores were low with personal and community and moderately low with domestic.  The fine motor skills adaptive level was moderately low. The enrollee had made progress in communication and self-help but continued to demonstrate difficulties in communication, socialization, self-help skills, play, and behavior management.  Final Result: The reviewer determined the requested service is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient underwent genetic testing, which revealed a BRCA1 mutation of uncertain clinical significance. She has a calculated lifetime risk of 27.7% of developing breast cancer utilizing the Tyrer-Cusick model. Repeat genetic testing utilizing the International Breast Intervention Study (IBIS) model revealed the patient had a 12.3% lifetime risk of developing breast cancer. Magnetic resonance imaging of the breasts revealed no evidence of malignancy. A bilateral digital diagnostic mammogram and targeted left breast ultrasound revealed benign results and heterogeneously dense breast tissue. The patient has requested authorization and coverage for a mammogram, sonogram, and a 3D mammogram of both breasts. The Health Plan has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. At issue in this case is whether a mammogram, sonogram, and a 3D mammogram of both breasts are medically necessary for the evaluation of this patients medical condition. The breast cancer detection rate is increased with use of digital breast tomosynthesis (3D mammogram) compared with two-dimensional mammography alone. Additionally, false-positives can be decreased. The sensitivity of screening mammography is decreased in women with dense breast tissue, as cancers can be obscured by the dense tissue. In this population, a sonogram can be used to detect mammographically occult cancers. In the study found, the addition of a screening ultrasound or magnetic resonance imaging to mammography in women at increased risk of breast cancer resulted in a higher cancer detection yield. In this patients case, her calculated lifetime risk of breast cancer is greater than 20% utilizing the Tyrer-Cusick model.  This patient underwent two-dimensional mammography with targeted left breast ultrasound. At this time, screening bilateral sonogram is medically necessary. Since this patient underwent bilateral mammogram, 3D mammogram is not indicated at this time. Annual mammography and tomosynthesis will be appropriate in February 2020. Therefore, the requested sonogram of both breasts is medically necessary for the evaluation of this patient. The requested mammogram of both breasts and 3D mammogram of both breasts is not medically necessary at this time.Final Result: The reviewer determined that the requested services are partially 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 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: The patient has requested authorization and coverage for Synvisc One injection in the right knee. A recent health technology assessment concluded that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. However, there are questions remaining about the most effective formulations, which patients benefit most, and whether hyaluronic acid injections combined with other agents will increase effectiveness. Current evidence based medical guidelines support hyaluronic acid injections in the knees for patients who have failed to respond adequately to conservative treatment and to potentially delay total knee replacement in patients with severe osteoarthritis and pain that interferes with functional activity. In this case, this patient presents with complaints of severe right knee pain with associated cracking and inward tilting. Clinical examination findings are consistent with imaging findings of moderate tricompartmental osteoarthritis. The requested Synvisc One injection in the right knee 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Intensive outpatient program (IOP) services.  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. 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. Based on the records provided for review, this patient was at minimal risk of harm (score 1) due to a lack of current suicidal ideation and no self-harming behaviors. The patient denied any suicidal or homicidal ideation. He did not have any auditory or visual hallucinations or psychosis. The patient presented with some functional issues (score 2) due to some problems with comorbidities affecting his progress. There was no report of this patient requiring assistance with performing activities of daily living. The patients diagnoses included no medical condition that required the IOP level of care (score 1). The patients recovery environment was mildly stressful (score 1) due to a stable living situation. The records suggest the patients recovery environment was also supportive (score 1) due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regard to treatment and recovery history, the patient demonstrated recent success at the IOP program level of care (score 3) following prior treatment at the residential treatment level of care. The patient was cooperative with care while being involved in his treatment (score 1). The provider documented that the patient participated in his treatment plan and attended 12-step groups. The patient demonstrated insight into his need for treatment and treatment needs. Thus, the patient has a composite score of 10, which correlates with treatment in a community-based outpatient clinic setting. Thus, the patient was a candidate for treatment in a less restrictive than IOP level of care during the period under review. All told, the IOP 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. The enrollees provider noted that the hair on the patients face, chest, and stomach exacerbated her gender dysphoria and caused stress, anxiety, and depression. The patient has requested reimbursement and prospective authorization and coverage for previous and future laser hair removal. The presence of facial hair causes many transgender women distress due to gender dysphoria. Findings:  The physician reviewer found that a nationally recognized health organization lists facial hair removal as a medically necessary treatment. Hair removal through electrolysis and laser treatments are options to help alleviate gender dysphoria. Hormone therapy alone is insufficient for complete facial and body hair removal. Current medical evidence supports the services at issue in this clinical setting. Therefore, laser hair removal was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service was and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for physical therapy with a board certified orthopedic clinical specialist (OCS). According to the medical record, the enrollee has a history of right shoulder dislocations. A magnetic resonance imaging showed a large tear of the superior labrum and the enrollee underwent right shoulder superior labrum anterior posterior (SLAP) lesion repair, arthroscopic subacromial decompression, distal clavicle undersurface resection, and lysis of adhesions with manipulation under anesthesia. Physical therapy was prescribed post-operatively.  The treating physician assistant indicated it is imperative the enrollee start physical therapy as soon as possible to gain back strength and motion.  It is standard of care for enrollees to undergo physical therapy after any intra-articular shoulder surgery, including a shoulder stabilization and superior labrum anterior posterior (SLAP) lesion repair. It is typically written for a series of progressive exercises, starting with passive range of motion for the first four to six weeks, followed by active range of motion for six weeks, and subsequently strengthening for the shoulder until return to sports/work is allowed.  The outcomes of the procedure performed suggest there is not a need for specialized physical therapy for this procedure.  In a review of SLAP repairs and biceps tenodesis, the medical literature found good outcomes with SLAP repair. The majority of surgeons do not require a certified physical therapist and the use of a specialized orthopedic physical therapist is relatively uncommon. Therefore, a board certified orthopedic clinical specialist is not necessary.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 orthopedics 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.