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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for hyaluronan injections for osteoarthritis of both knees. Symptoms include pain, swelling, clicking, and painful range of motion. She has difficulty walking and using the stairs. Her symptoms are exacerbated by kneeling and squatting. Past treatments include bracing, icing, physical therapy, non-steroidal anti-inflammatories, cortisone injections, and a knee aspiration. A magnetic resonance imaging scan of the left knee showed osteoarthritis and a lateral meniscal tear. She was assessed by two different orthopedists, one who recommended surgery and one who did not. The enrollee obtained a third opinion. This orthopedist discussed treatment options, including hyaluronan injections, arthroscopic surgery, and joint replacement. The current treating orthopedist has requested hyaluronan, one injection per knee, once per week, for three weeks. The enrollee is requesting hyaluronan injections for both knees instead of surgery, because the treatment plan put in place by her orthopedist was to try everything else possible before surgery. The enrollee suffers from bilateral knee osteoarthritis, as indicated in a radiographic study but is not a total knee replacement candidate at this time. Viscosupplementation as pain management is the next logical choice of management. Literature indicates repeated treatments with intra-articular hyaluronic acid injections are an effective and safe treatment for knee osteoarthritis. Repeated treatments were shown to maintain or improve pain reduction without additional safety risks. Hyaluronic acid injection has become a viable treatment option for the non-operative management of enrollees with knee osteoarthritis. Use of this treatment for managing osteoarthritis knee pain has been well documented in research; both cellular studies and clinical investigations. Research has demonstrated improvement to the local biology within the knee with the use of hyaluronic acid injections, resulting in decreased pain and improved function. Literature notes hyaluronic acid is effective due to its many methods of actions, including lubrication and anti-inflammatory effects.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for bioimpedance-derived physiologic cardiovascular analysis, which allows for remote monitoring of the enrollees implanted cardiovascular device. The enrollee has a history of dyslipidemia, systolic congestive heart failure, status post cardiac resynchronization therapy defibrillator; and atrial fibrillation with rapid ventricular response, resulting in inappropriate automatic implantable cardioverter defibrillator shocks. The enrollee had two prior accessory pathway ablations for atrial fibrillation-related ventricular tachycardia/ventricular fibrillation, and atrioventricular nodal ablation for recurrent ventricular tachycardia arrest. His systolic function has since normalized. The fluid status monitoring feature on the enrollees device previously indicated persistent fluid retention. This, along with transaminitis, has improved. The record indicates an echocardiogram showed normal left ventricular systolic function with a left ventricular ejection fraction of 55-60%. An electrocardiogram showed atrial fibrillation with third-degree atrioventricular block and 100% biventricular pacing. Pacemaker interrogation revealed a biventricular implantable cardioverter-defibrillator. The enrollee had biventricular pacing at 99%, with an estimated battery life greater than five years. There were no significant ventricular events and no implantable cardioverter-defibrillator therapy. Remote monitoring of heart failure enrollees may help in the early detection of acute heart failure decompensation before the onset of symptoms. Appropriate early intervention in these enrollees may reduce heart failure-related hospitalizations. Whether patient management strategies that incorporate device-based hemodynamic sensors have a beneficial impact on outcomes need to be investigated in large clinical trials. This technology has not been shown in large, randomized clinical trials to confer clinical benefit when compared with the conventional management of chronic heart failure. This technology may have a physiologic basis in detecting increased thoracic impedance due to the presence of pulmonary edema from heart failure. However, this technology has not been well-studied enough to identify pitfalls and to establish it as offering proven clinical benefit for patients with suspected heart failure.The enrollees recurrent ventricular tachycardia from his accessory pathway resolved after ablation. At the time of this evaluation, the enrollee had no symptoms of heart failure. 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 cardiovascular disease 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

An enrollee has requested authorization and coverage for axillary lymph node biopsy.The patients lymph nodes have not changed significantly over a two-month interval. However, it is appropriate for the patient to undergo a biopsy in an attempt to determine the etiology of the enlarged lymph nodes. The mammogram and ultrasound revealed that some of the patients lymph nodes measure up to 1.5 cm, which is abnormal. Evaluation with lymph node biopsy to confirm or rule out pathologic abnormality including inflammatory, infectious, or malignant processes is consistent with the recommendations in current medical literature. All told, the requested axillary lymph node biopsy is medically necessary for further evaluation and 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 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

An enrollee has requested authorization and coverage for Roxicodone 30 mg (146 pills every 30 days), and fentanyl (10 patches every 30 days).The patient had cervical spine surgery and he is still complaining of neck and right hand pain. He is currently on high dose opioid therapy, and he is requesting to be re-started on fentanyl patches which were stopped two years ago. The patient is also requesting the brand name medication Roxicodone because he feels that the generic version of this medication (oxycodone) is not as effective. Records indicate that alternative treatments have been offered and were declined, or the patient has not expressed interest at this time. With regards to the differences between the brand name and generic medications, the FDA mandates that generics perform exactly the same way as a brand name drug would. The active ingredient in this case, oxycodone, is the same in both name brand and generic formulations, and the patient has used the generic version in recent months with no adverse effects. With regards to the patients request to restart the fentanyl patch, the patient has been off the patches for two years, and he is already on high doses of opiates (225 mg morphine equivalents). Resuming the use of fentanyl patches at this time would put the patient at very high risk for overdose and death, since he is also using diazepam. CDC guidelines do not recommend that patients be on both opiates and benzodiazepine medications at the same time, and the provider has developed a treatment plan that is consistent with the most recent national guidelines regarding opioid therapy that include non-pharmacological treatments. Under these circumstances, the requested Roxicodone 30 mg (146 pills every 30 days), and fentanyl (10 patches every 30 days) are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medications 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 subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for liposuction and excess skin removal of the upper arms, and excess skin removal of the legs. Tthe submitted documentation includes photographs of the patients upper arms and legs, and they do not have the appearance of abnormal structures of the body, particularly given the patients history of weight loss. Furthermore, the condition of the patients upper arms and her legs is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. While lipedema is a diagnosis seen in the medical literature, it is not supported by well-designed, controlled, high level of evidence, peer reviewed literature, and there is no objective testing for the disease. Consequently, while the performance of liposuction is proposed to improve function, there are no well controlled, peer reviewed, high level of evidence studies that support the efficacy of the procedure either in the short or long term. Additionally, there is limited evidence if any in the peer reviewed literature to support skin excision as a treatment for lipedema. Accordingly, under these circumstances, the requested services are not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has been diagnosed with osteoarthritis on both knees. The provider noted the patient had good results with viscosupplementation injections in the past. The patient has tried and failed treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and corticosteroid injections. X-rays of bilateral knees revealed mild to moderate tricompartmental osteoarthritis of the right knee and mild osteoarthritis in the medial compartment of the left knee. The patient reported worsening knee pain. Physical examination findings included tenderness to palpation of the knees with grinding on range of motion. The patient has requested authorization and coverage for Synvisc injections in both knees. 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 Synvisc injections in both knees 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. Researchers found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, there is a history of good results from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties at a young age in the presence of mild to moderate osteoarthritis. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections in both knees 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for the medication Kineret 100 mg.Medical literature does not support that the requested medication is medically necessary at this time. The submitted documentation indicates that the patient has recurrent pericarditis. Glucocorticoid therapy should generally be avoided in patients with recurrent pericarditis due to side effects and the risk of increasing recurrences. There are no adequately controlled clinical trials that have evaluated the efficacy of Kineret as a steroid sparing agent in patients where steroids are administered. Accordingly, the medical literature does not support the use of Kineret to treat recurrent pericarditis at this time. Therefore, Kineret 100 mg is not medically necessary to treat the 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 internal medicine, with subspecialty certification in cardiovascular disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for full body Magnetic Resonance Imaging.The submitted documentation does not support that the requested services are medically necessary. The patient has had multiple chronic complaints since he sustained an industrial injury and was also reportedly exposed to some chemicals in the workplace before that as well. The patient has had symptoms that have persisted, and he has undergone various evaluations and tests that have included spine MRIs, spine surgery evaluation, pain management evaluation, gastrointestinal evaluation, esophagoduodenoscopy, and colonoscopy. There are no documented indications that any of the health care providers he has seen have recommended this test. In this case, there is no specific clinical indication for the proposed full body MRI in the records received for review. There is no documented differential diagnosis or treatment decision-making that requires the proposed testing. The rationale for the proposed test would appear to be a screening test. This test, however, is not appropriate as a screening test, outside of potential applications in oncological management. At this time, there are no indications that the requested full body MRI would result in any changes in clinical management or improvements in outcomes. There is also a potential that this testing would result in false positive findings that would result in further testing and interventions, including invasive interventions that are unnecessary. Under these circumstances, the requested full body MRI is not medically necessary to treat 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 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

An enrollee has requested authorization and coverage for trigger point injections. The submitted documentation does not support that the requested trigger point injections are medically necessary at this time. Trigger point injections may be considered for treatment of patients with myofascial pain as part of a multimodal approach to pain management. In this case, the submitted documentation does not include physical exam findings consistent with myofascial trigger points. While the providers notes make reference to tenderness to palpation in various muscle groups, there is no documentation of any palpable, tense bands of skeletal muscle fibers that elicit a twitch response when palpated, with referral of concordant pain. In addition, the providers notes indicate that it is their plan to refer the patient to physical therapy for conservative care prior to considering further interventional treatment, with follow-up scheduled one month later. While the submitted records show that the patient had an earlier series of physical therapy appointments, there is no documentation that the patient attended physical therapy pursuant to the providers most recent referral. Furthermore, while records reflect that the patient received multiple prior trigger point injections this year, there is no documentation of the patients response to previous injections, including any change in pain-free range of motion, improvement in function, or reduced need for medications. Under these circumstances, the requested trigger point injections are not medically necessary to treat the patients medical condition at this time.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 subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Vyvanse. The enrollee has a history of major depressive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder. The enrollee reported concerns of binge eating over the last two months with an eight-pound weight gain over the last month. She reported increased stress, and increased symptoms of anxiety, depression, and attention deficit hyperactivity disorder. The enrollee requested a medication that would help to curb her excessive hunger. Her provider prescribed Vyvanse to control attention deficit hyperactivity disorder and binge-eating symptoms. The record indicates the enrollee stopped taking Ritalin, as it was not controlling her symptoms. Subsequently, the provider ordered extended-release Concerta. The enrollee indicates Ritalin caused weight gain, Concerta resulted in severe headaches, and Wellbutrin elevated her heart rate and blood pressure. Therefore, Vyvanse has been prescribed. Vyvanse is a long-acting amphetamine indicated for attention deficit hyperactivity disorder. The record shows Ritalin was prescribed for difficulty with concentration. However, there is insufficient evidence in the record of other symptoms, or the use of rating scales to support this diagnosis and to evaluate the enrollees response to treatment. Difficulty with concentration is one of the symptoms demonstrated in patients with attention deficit hyperactivity disorder, but the diagnosis cannot be made based on this one symptom alone. Difficulty with concentration is seen in many other medical and psychiatric conditions. The enrollee was taking short-acting Ritalin twice per day, with the second dose in the evening, which was contributing to her insomnia. Ritalins average effect is three to four hours. It is generally not taken in the evening, as inadequate sleep is often one of the contributing factors to difficulty with concentration. The records indicate the patient was reporting weight gain on Ritalin. However, Ritalin causes a decrease in appetite. Vyvanse was recommended because of the patients binge eating. Although Vyvanse is approved for the diagnosis of binge eating disorder, the medical record contains insufficient evidence of symptoms to support the diagnosis of binge eating disorder.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 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.