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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Orthovisc injections. This patient presents with a history of bilateral knee pain due to osteoarthritis. The patient underwent treatment with a series of Orthovisc injections for both knees. 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, there is no history of prior viscosupplementation. However, the patient has been treated for severe osteoarthritis of the hip in addition to bilateral knee pain. Furthermore, the degree of osteoarthritis of the knees is mild per the available records and the patient is not a candidate for total knee arthroplasties. Given these findings, the Orthovisc injections were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injection (0232T). This patient presents with elbow epicondylitis that has been treated with Naproxen and diclofenac gel, cortisone injection with some relief for three months, and physical therapy with short-term benefit. The patients provider has recommended treatment with PRP injections. However, the results of numerous quality trials on the efficacy of PRP for treatment of chronic lateral epicondylitis have yielded variable results. A review of current literature by Kwapisz and colleagues, and a meta-analysis of Level 1 evidence by Chen and colleagues, concluded that more studies on larger cohorts, with comparable formulations, and longer follow-up are required to determine whether PRP injections are an effective treatment modality in patients with elbow pathologies. Linnanmaki and colleagues found that PRP injections did not improve pain or function at one year of follow-up in patients with lateral epicondylitis compared with those who were given a saline injection. All told, the requested PRP injection (0232T) is 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 requested PRP injection (0232T) is 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 requested services are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Freestyle Libre 14-day sensors for use with a Freestyle Libre CGM system. Medical literature shows that glycemic variability is an integral component of glucose homeostasis for the management of type 2 diabetes. Medical literature shows that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. Medical literature shows that CGMs are a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety, efficacy, and accuracy of CGMs, the supplies at issue were and are medically indicated. Therefore, Freestyle Libre 14-day sensors for use with a Freestyle Libre CGM system were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the supplies 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an increase of testosterone gel 1.62% to six pumps a day. Male hypogonadism may lead to reduced sexual desire, decreased spontaneous erections, loss of axillary and pubic hair, declining testicular volume, hot flashes, low or zero sperm count. Other less suggestive symptoms include depressed mood, poor concentration, increased body fat, decreased physical performance, reduced muscle mass. Thirumalai and colleagues report that there are a number of testosterone formulations currently available for the treatment of hypogonadism, including intramuscular and transdermal preparations, and several additional formulations under development. Values outside of a mid-normal range of serum testosterone level, between 400 ng/dL to 700 ng/dL may require a dose adjustment. In this case, given that the patients testosterone level is subtherapeutic, the requested medication regimen is medically indicated. Therefore, an increase of testosterone gel 1.62% to six pumps a day is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an oral appliance provided by Fresno Snoring and Sleep Therapy. Medical literature notes that oral appliances are recommended for patients with obstructive sleep apnea (OSA). In this case, the patient has moderate OSA and is symptomatic. Left untreated, OSA may increase the risk for hypertension, cardiac disease, and stroke. In this case, given that current medical literature supports the use of oral appliances for the treatment of mild-to-moderate OSA, the device at issue was medically indicated. Therefore, the oral appliance provided by Fresno Snoring and Sleep Therapy was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 certification in sleep 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital stay services. Findings:  The physician reviewer found that the documented high risk of sudden death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter-defibrillators in this group of patients (Kutyifa, et al.; Klein, et al.). Current data from multiple trials support the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction less than or equal to 35%, along with guideline directed medical therapy. This patients ejection fraction was 25% per echocardiogram. Per the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, the approved and recommended timing of placement of a LifeVest wearable cardioverter defibrillator is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of congestive heart failure with severely reduced ejection fraction. This patients provider recommended a LifeVest early after the initial diagnosis by echocardiogram. In this clinical setting, it was reasonable to keep the patient hospitalized on a cardiac monitor maintaining surveillance for severe ventricular arrhythmias while the arrangements were made for a LifeVest wearable cardioverter defibrillator. The patient was noted to have an episode of non-sustained ventricular tachycardia. The risk of life threatening ventricular arrhythmia given the patients very low ejection fraction supports the medical necessity of the inpatient stay while awaiting the LifeVest. For these reasons, the inpatient hospital stay services provided from were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiology 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: The parent of an eight-year-old female enrollee has requested reimbursement for allergy testing services performed by Foundation Labs, LLC. Medical literature notes that the general approach to diagnosis of food allergy include modalities such as medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin (Ig) E measurements, and oral food challenges. While the measurement of IgE levels to specific foods in question may be included as part of a food allergy evaluation, the current medical literature does not support the use of an extensive array of blood tests that examine aeroallergen component IgE and food IgG4 testing. The blood testing at issue is not demonstrated as being of any benefit in the evaluation of food allergies. Therefore, allergy testing services performed by Foundation Labs, LLC, were not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the allergy testing services performed by Foundation Labs, LLC, at issue were not 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 not 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 upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old female enrollee has requested reimbursement for allergy testing services performed by Foundation Labs, LLC. Medical literature notes that the general approach to diagnosis of food allergy include modalities such as medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin (Ig) E measurements, and oral food challenges. While the measurement of IgE levels to specific foods in question may be included as part of a food allergy evaluation, the current medical literature does not support the use of an extensive array of blood tests that examine aeroallergen component IgE and food IgG4 testing. The blood testing at issue is not demonstrated as being of any benefit in the evaluation of food allergies. Therefore, allergy testing services performed on by Foundation Labs, LLC, were not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the allergy testing services performed by Foundation Labs, LLC, at issue were not likely to have been 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 have been 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 reviewer 1 is board certified in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for allergy testing services. This patient presents with a history of food allergies. The patient underwent allergy testing in January of 2021 as part of his treatment regimen. While oral food desensitization has reportedly been achieved in the majority of patients in randomized controlled studies, few patients successfully develop tolerance or sustained unresponsiveness. The standard of care in this clinical setting includes measurement of IgE levels to specific foods for an individual patient. However, an extensive array of blood tests and oral desensitization to a multitude of foods in the absence of a history of anaphylaxis is not supported by the peer-reviewed medical literature or clinical guidelines. Moreover, an extensive array of blood tests that examine aeroallergen component IgE as well as food IgG4 testing has not been shown to add clinical benefit in the evaluation of patients with food allergies. All told, the allergy testing services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the allergy testing services were not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in allergy and immunology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for allergy testing services. The patient has a history of food allergies, and the provider has recommended treatment with oral immunotherapy. The provider recommended laboratory testing to help direct the patients treatment program. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend oral immunotherapy as a standard of care treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment. Although several studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials are too inconsistent to establish oral immunotherapy as superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal symptoms. For these reasons, the allergy testing services was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the allergy testing services were not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in allergy and immunology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series 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 lasting benefit from prior viscosupplementation. Furthermore, the documentation indicates other conservative measures including physical therapy and cortisone injections have been tried, with limited success. The medical evidence supports the requested services in this clinical setting. Therefore, the requested Orthovisc injection series in both knees  is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) procedure code 72148. Findings:  The physician reviewer found that the utility of MRI for patients with low back pain and radiculopathy and surgical intervention candidates with persistent or progressive symptoms during or following six weeks of conservative management. The ACR guidelines support MRI only if severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition are present, or if the patient is a candidate for invasive treatment approaches. Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic deficits. This patient is being treated for bilateral low back pain with radiculopathy. The patient had an inpatient admission in September 2021, during which time she underwent a lumbar puncture. Since that procedure, the patient complains of persistent low back pain with radiation to both lower extremities. The patients symptoms may be associated with post-lumbar puncture adverse effects. However, the records fail to document that adequate attempts at conservative care have been attempted prior to consideration for an imaging study. There are limited large-scale, long-term references showing the safety and efficacy of the requested MRI in this clinical setting. Therefore, the request for MRI lumbar spine (CPT 72148) is not medically reasonable or necessary.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 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.