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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Orthovisc injections in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. 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, there is a history of benefit from bilateral knee injections of Euflexxa in the past. Additionally, other conservative treatments, including physical therapy and corticosteroid injections, have been exhausted. The current medical evidence supports the requested services in this clinical setting. Therefore, the requested Orthovisc 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for whole genome sequencing (WGS) diagnostic test. The records provided for review document that this patient has a complex history including microcephaly, hydrocephalus, multi-suture craniosynostosis, septo-optic dysplasia, dysmorphic features, and others. There is likely a genetic cause for her health concerns. Her prior genetic testing, including WES, has been non-diagnostic. Further evaluation for her is warranted, and WGS is a reasonable diagnostic testing approach based on current medical literature and guidelines. Recent studies have shown advantages with WGS over WES or other tiered methods of analysis, even as a first-line assessment. Lionel and colleagues discussed their study of 103 patients in which targeted gene sequencing panels helped identify genetic diagnoses in 18 patients that would not have been diagnosed with other diagnostic methods. Additional studies have reported similarly high diagnostic rates with WGS diagnostic testing (Lindstrand, et al.; Stranneheim, et al.). Identification of an accurate genetic diagnosis has significant implications for management of affected patients. Moreover, the requested WGS diagnostic test is medically necessary to prevent disease, disability, and other health conditions or their progression, prolong life, promote physical health and efficiency, and correct or ameliorate physical conditions. Given these findings, the requested WGS diagnostic test is medically necessary for evaluation and 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 pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics 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 Euflexxa injection series in both knees. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of benefit from prior viscosupplementation for 18 months in the treatment of bilateral knee osteoarthritis. Furthermore, the patient has exhausted other standard measures and the alternative is bilateral total knee arthroplasty. For these reasons, the requested Euflexxa injection series in both knees 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81295 MSH2 gene full seq; CPT 81292 1 MLH1 gene full seq; CPT 81300 MSH6 gene dup/delete variant; CPT 81317 PMS2 gene full seq analysis; CPT 81403 MOPATH procedure level 4). Colorectal cancer can occur in patients with hereditary predisposition to cancer such as Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC). Sharaf and colleagues report that genetic testing appears to be underutilized by first-degree relatives of patients with Lynch syndrome. Sinicrope notes that it is critical to recognize inherited syndromes that are associated with colorectal cancer, of which the Lynch syndrome is the most common. The author further notes that once the diagnosis of the Lynch syndrome is confirmed in a proband by the identification of a germline mutation in a mismatch-repair gene, genetic testing is recommended for at-risk family members, beginning with first-degree relatives. In this case, in an application for independent medical review, the patient reported a family history that was positive for Lynch syndrome, noting that a cousin was diagnosed with colorectal cancer, and that five family members including an uncle, aunt, two cousins, and a brother had tested positive for Lynch syndrome. In this clinical setting, comprehensive testing would guide recommendations for surveillance of this patient and is supported by the National Comprehensive Cancer Network (NCCN) guidelines for genetic/familial high-risk assessments. Therefore, genetic testing (CPT 81295 MSH2 gene full seq; CPT 81292 1 MLH1 gene full seq; CPT 81300 MSH6 gene dup/delete variant; CPT 81317 PMS2 gene full seq analysis; CPT 81403 MOPATH procedure level 4) was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the genetic testing (CPT 81295 MSH2 gene full seq; CPT 81292 1 MLH1 gene full seq; CPT 81300 MSH6 gene dup/delete variant; CPT 81317 PMS2 gene full seq analysis; CPT 81403 MOPATH procedure level 4) at issue was likely to have been 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 have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in hematology and in medical oncology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is 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 brachioplasty. According to the American Society of Plastic Surgeons (ASPS) criteria for the surgical treatment of skin redundancy for obese and massive weight loss patients, only in rare circumstances are buttock, thigh, or arm lifts needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature. In this case, the records noted massive weight loss following bariatric surgery. Notes reported that the patients highest weight was 294 pounds, and that her present weight was 151 pounds. The patient has redundant skin on her upper arms. She reports a recurrent rash underneath her arms, however, despite being requested, the submitted records did not show documentation of appropriate medical treatment of the rash or of failure of appropriate medical treatment of the rash. The patient does not have a functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. Photographs submitted by the patient of the upper arms show widespread erythema, lichenification, and scaling characteristic of a dermatologic skin problem, not intertrigo. Therefore, bilateral brachioplasty is not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the patient has lax skin on her upper arms that is an expected result of the gain and loss of weight and is not an abnormal structure of the body. The patient has an untreated skin rash that is not intertrigo, and is not an abnormal structure of the body. Thus, bilateral brachioplasty is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for referral to an orthopedic surgeon for evaluation of the ganglion cyst on the right wrist. Current evidence-based peer reviewed medical literature supports decision aids in the orthopedic treatment of patients in utilizing appropriate levels of care for initial evaluation and treatment (Sepucha, et al.; Mangla, et al.). The records provided for review document that this patient is being treated for a ganglion cyst. However, there is a lack of evidence that the involved body part has been physically examined by the patients provider or that initial conservative management has been attempted. Overall, the available documentation does not support an indication for a referral to an orthopedic specialist when initial evaluation and management of the patients ganglion cyst is within the expertise of the patients primary care physician. All told, the requested referral to an orthopedic surgeon for evaluation of the ganglion cyst on the right wrist 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly eye movement desensitization and reprocessing (EMDR) therapy for one year. The records provided for review document that this patient is now halfway through her high-risk pregnancy with her second child. As per the clinical documentation, the patients first delivery was traumatic with retained placenta and severe hemorrhage. The patient has been diagnosed with post-traumatic stress disorder (PTSD) and she is being triggered daily due to the impending delivery of her second child. Based on the patients current presentation, diagnosis, and history, the requested weekly individual psychotherapy with EMDR for trauma is indicated to stabilize her psychiatrically and medically during this pregnancy. EMDR will assist in transitioning the patient to delivery of this child as well as provide support in the postpartum phase. However, there is a lack of support for the provision of EMDR therapy for one year. EMDR is generally administered over six to 12 sessions over approximately 90 days. Re-evaluation of the patient at that time would be indicated to determine if additional EMDR therapy is medically necessary. For these reasons, weekly EMDR therapy for 90 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services at Regional Medical Center of San Jose. The patient presented to the emergency department with two days of pain not controlled with pain medications and was anxious and in mild distress due to pain. Halawi and Morwood report that open fractures are complex injuries associated with high morbidity and mortality, establishing the need for emergent treatment of an open fracture. Kloen and colleagues note that temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct, and the patients external fixation followed this typical protocol. Kosters and colleagues report that the surgical treatment of comminuted fractures of the distal humerus remains a challenging problem. In this case, the location of the patients fracture is relatively unique in orthopedics as the elbow is significantly prone to stiffness and the emergent treatment left her with an immobilized elbow, which has been shown to yield significant elbow stiffness. In this patients case, the absence of immediate medical attention could be reasonably expected to result in serious dysfunction of a body part. Therefore, the services provided at Regional Medical Center of San Jose were emergency services. Final Result: The reviewer determined that the services at issue were emergency services. 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain (CPT 70553). Dizziness is a nonspecific term often used by patients to describe symptoms. Furman and colleagues explain that vertigo is one type of dizziness, and that other symptoms that patients may identify as dizziness include presyncopal faintness, disequilibrium, and nonspecific or ill-defined light-headedness. The authors further note that patients often experience vertigo as an illusion of motion, the most common being a spinning sensation, although vertigo may also be a sense of swaying or tilting. Differential diagnosis of vertigo includes peripheral vestibular causes such as acute labyrinthitis, acute vestibular neuronitis, benign positional vertigo, or Meniere's disease, central vestibular causes such as vestibular schwannoma, intracranial tumor, stroke, migraine, or multiple sclerosis, and other conditions such as drug-induced or psychological. The authors note that neuroimaging may be indicated if the examination is not entirely consistent with a peripheral lesion, if there are prominent risk factors for stroke, if there are neurologic signs or symptoms, if the patient cannot walk, or if there is a new headache accompanying the vertigo. In neuroimaging for a diagnosis of vertigo, MRI is superior to computed tomography due to its superior ability to visualize the posterior fossa. In this case, the patient initially presented with recurrent episodes of dizziness and lightheadedness accompanied by other symptoms including tinnitus, subjective hearing loss, loss of balance, and headaches. In this clinical setting, neuroimaging with an MRI of the brain is indicated due to the presence of other neurologic symptoms for a possible diagnosis of vertigo. Therefore, MRI of the brain (CPT 70553) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acupuncture. The records provided for review document that this patient has a history of low back pain. The patient has been treated with chiropractic therapy and acupuncture. The patients provider has recommended continued treatment with acupuncture. As noted by Liu and colleagues, Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP [low back pain]. Regarding the use of acupuncture for chronic pain, MacPherson and colleagues reported that, the effects of acupuncture compared to no acupuncture for chronic pain do not appear to decrease importantly over 12 months. The available records state that prior acupuncture care was beneficial for this patient. However, there is a lack of documentation of pre-acupuncture and post-acupuncture baselines of activities of daily living, range of motion, medication intake, and level of function to support an indication for additional acupuncture. In addition, the total number of sessions completed, and any measurable, significant, objective functional improvement obtained with previous acupuncture was not reported to support additional acupuncture services. Moreover, a current physical examination was not documented with clinical findings specifying the deficits to be addressed with additional acupuncture. For these reasons, the requested acupuncture 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in both knees. Findings: 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 reports persistent severe pain despite rest, activity restrictions, icing, and NSAIDs, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series 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.