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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the right knee (J7325). Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has osteoarthritis and is status post arthroscopy of the right knee. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc-One injection in the right knee (J7325) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 Rezum procedure (transurethral water vapor thermal therapy; CPT 53854).Findings:  The physician reviewer found that The Rezum System is a novel technique available to treat male urinary symptoms secondary to benign prostatic hyperplasia (BPH) due to an enlarged prostate. The Rezum technology uses water vapor therapy to create necrosis within the transitional zone, which eventually shrinks the prostate, thereby improving urinary symptoms. Overall, current medical literature does not support improved patient health outcomes with the Rezum procedure over current standard of care with transurethral resection of prostate (TURP). In addition, long-term outcomes of the procedure are largely unknown. On review of the available guidelines and literature, the Rezum procedure is not considered standard of care for the treatment of BPH refractory to medical therapy. For these reasons, the Rezum procedure (transurethral water vapor thermal therapy; CPT 53854) 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 Rezum procedure (transurethral water vapor thermal therapy; CPT 53854) 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 urology 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: The patient has requested authorization and coverage for bilateral radiofrequency ablation of the perforator veins. This patient is status post bilateral greater saphenous vein and small saphenous vein ablations in September 2020. The patients provider has recommended bilateral radiofrequency ablation of the perforator veins. However, based on the available documentation, the patients perforator veins are not supported as the likely cause of his persistent symptoms. There is an absence of an assessment of arterial perfusion, which is especially important given the patients history of pelvic injury and persistent disabling symptoms despite ablation of all four major superficial veins. Moreover, there is inadequate documentation in the medical records that the patient continues to have function limiting symptoms despite bilateral greater saphenous and small saphenous vein ablations. A duplex examination of the right leg noted that the patients persistent symptoms are mild. The reflux in the perforator veins does not establish an indication for radiofrequency ablation procedures. For these reasons, the requested bilateral radiofrequency ablation of the perforator veins is not medically necessary for 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 surgery with subspecialty certification in general vascular 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 patient has requested authorization and coverage for seven-level lumbar spinal fusion. This patient presents with longstanding neck and back pain due to degenerative scoliosis with clinical evidence of associated radiculopathy. She has failed conservative treatment including opioids and pregabalin, physical therapy, and bilateral T12-L1 epidural steroid injections. Her provider has recommended long segment fusion, which has been demonstrated to be superior to short segment fusion for correcting lumbar scoliosis curvature and coronal imbalance, as well as improving rotational subluxation of the apical vertebra. With regard to the length of the fusion, the horizontal vertebra should be selected to balance the spine. Fusion to T10, as in this case, is appropriate to prevent junctional problems at the proximal adjacent vertebra. Proximal adjacent segment disease is a long-term complication that can develop at the upper end vertebrae in patients with degenerative lumbar scoliosis. Given these findings, the requested seven-level lumbar spinal fusion is medically necessary for 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan. Findings:  The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan. The National Comprehensive Cancer Network (NCCN) guidelines do not support routine use of PET scans for the surveillance of patients with triple negative breast cancer. Current data have reported that PET imaging has high false-negative rates in the detection of lesions that are smaller than 1 cm or are low grade. For these reasons, the requested PET scan is not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 and prospective authorization and coverage for IOP services provided by Center for Discovery Sherman Oaks. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had risk of harm, due to passive suicidal ideation and homicidal ideation without plan or intent. In terms of functional status, the records support a score of 3. The documentation noted that the patient reported feeling overwhelmed by school and had issues with focus and concentration.With regard to comorbidity, the records support a score of 1. The patient had no significant comorbidity, due to medical, substance use or developmental disability. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a stressful environment due to ongoing feelings of being overwhelmed by school, and continued to have nightmares secondary to trauma.With regard to level of support of the recovery environment, the records support a score of 2 due to parental engagement in family therapy. In terms of resiliency and treatment history, the records support a score of 3. The patient had poor resiliency and/or response to treatment as previous individual outpatient therapy and medication management had not ameliorated anxiety, depression, and PTSD symptoms and suicidal ideation.With regard to treatment acceptance and engagement, the records support a score of 2. The patient had recently begun to act on constructive feedback instead of withdrawing and shutting down. Thus, the patient has a total score of 18. In this case, the recommended level of care was high intensity community-based services or IOP. Therefore, IOP services provided by Center for Discovery Sherman Oaks were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty 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: The patient has requested authorization and coverage for consultation at the tertiary level of care.Findings:  The physician reviewer found that This patient has confirmed type 2 hereditary angioedema. She has received appropriate treatment by a provider who specializes in diagnosing and treating this type of condition. Per the World Allergy Organization (WAO) in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI), Early diagnosis and appropriate therapy are essential. It is important for this patient to continue to be treated by a specialist who is also able to manage her asthma with spirometry and other essential testing as needed. The available documentation supports an indication for a consultation at the tertiary level of care. Given these findings, the requested consultation at the tertiary level of care is medically necessary for 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 internal medicine with subspecialty certification in allergy and immunology 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 hair transplant to cover scar at hairline on forehead, rhinoplasty revision, and tracheal shave. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. The WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. Medical literature demonstrated that facial feminization surgery improved mental health-related quality of life. The records provided for review demonstrate that this patient underwent facial feminization surgery and is not satisfied with the results. The patient reports difficulty securing employment due to discrimination and being misgendered. However, the documentation does not include evidence from the patients providers that the requested facial feminization surgery revision including hair transplant, revision of rhinoplasty, and tracheal shave, are indicated to address the patients distress related to her gender dysphoria. For these reasons, the requested hair transplant to cover scar at hairline on forehead, rhinoplasty revision, and tracheal shave are 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 psychiatry with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services at a hospital while the patient stayed in Thailand. At issue is whether the services provided at the hospital in Thailand were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plans service area.The American College of Rheumatology (ACR) recommendation for the management of hip osteoarthritis includes nonpharmacologic modalities such as exercise, weight loss for overweight patients, psychosocial interventions, physical therapy, and walking aids, as well as pharmacologic modalities such as medication management and intraarticular hyaluronate injections, duloxetine, and opioids for patients with inadequate response to initial therapy. The authors recommend total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. In this case, the patient had a diagnosis of right hip osteoarthritis and presented for total right hip replacement following five months of progressively worsening pain. While initially approved, the surgery was delayed due to scheduling issues and for the resolution of a urinary tract infection. The documentation did not reflect that the patients procedure was emergent or urgent, or that recommended conservative treatment to manage the symptoms had been trialed. Therefore, the services provided at the hospital in Thailand were not urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plans service area.Final Result: The reviewer determined that the services at issue were not urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Oxbryta (voxelotor) 500 mg tablets. The  U.S. Food and Drug Administration (FDA) describes Oxbryta (generic name voxelotor) as a hemoglobin S polymerization inhibitor indicated for the treatment of sickle cell disease. Vichinsky and colleagues reported that in a double-blind, randomized, placebo-controlled trial on the efficacy and safety of two dose levels of voxelotor with placebo, voxelotor significantly increased hemoglobin levels and reduced markers of hemolysis. In this case, the patient likely had sickle beta thalassemia disease and suffers from significant anemia. The requested medication is medically indicated in this clinical setting as it has the benefit of increasing hemoglobin. Therefore, Oxbryta (voxelotor) 500 mg tablets are medically necessary for the treatment of this patient.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 certifications in medical oncology and hematology 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 authorization and coverage for acupuncture services two times a week. Findings:  The physician reviewer found that Yang and colleagues concluded that acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with chronic neck and low back pain. Trinh and colleagues reported that there was moderate-quality evidence indicating that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up, and that those who received acupuncture reported less pain and disability at short-term follow-up than those on a wait-list. Vickers and colleagues noted that acupuncture treatment is a reasonable option for a patient with chronic pain. In this case, the patient has seen several providers and reports constant pain throughout his body, joints, and muscles. He reports that for a couple of days following each acupuncture treatment, he is able to function without constant pain. Given current medical literature and the documented benefits from prior acupuncture treatments in this case, the requested services are medically indicated. Therefore, acupuncture services two times a week 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 chiropractic 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.