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

Nature of Statutory Criteria/Case Summary: A 64-year-old female enrollee has requested authorization and coverage for a CT Coronary Calcification (EBCT) (electron beam computed tomography). Findings:  The physician reviewer found that this patient presents with increased coronary risk and significantly elevated low density lipoprotein (LDL) cholesterol. In this circumstance, guidelines for the evaluation and management of hyperlipidemia are available, endorsed by several national organizations and do not recommend routine screening with coronary CT scans in this patient population. Specifically, in this patient, statin therapy is indicated based on clinical parameters and basic lipid analysis alone, regardless of results of coronary CT scanning results. Moreover, there is a lack of evidence of improved cardiac outcomes with the use of coronary CT scanning when compared to information obtained based on clinical risk profiling and basic lipid analysis. All told, CT Coronary Calcification EBCT is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. One reviewer found that CT Coronary Calcification EBCT is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for knee surgery at a facility with a pediatric cardiac transplant program/team.The current medical evidence supports subchondral drilling in the knee for small to mid-sized lesions. Surgical indications include conservative treatment for a minimum of two months and joint pain and swelling. Objective clinical findings which are required include full thickness chondral defect on the weight-bearing portion of the medial or lateral femoral condyle, stable knee with intact and fully functional menisci and ligaments, normal knee alignment and normal joint space. A study concluded that although multiple drilling is a safe and minimally invasive surgery, its effect is limited, particularly in solid organ transplantation patients with osteonecrosis of the femoral head (ONFH) due to long-term corticosteroid use. Thus, solid organ transplantation patients should be closely monitored in terms of ONFH development. This patient presents with a complex cardiac history with bilateral knee pain. He is status post heart transplant and developed bilateral knee avascular necrosis due to prolonged steroid use. His provider has recommended subchondral drilling to attempt to delay major reconstructive surgery. There is sufficient support for the requested services in this setting. This patient has open growth plates, which further supports the less invasive treatment. Additionally, it is medically necessary that the patient undergo surgery at a facility with a pediatric cardiac transplant program/team. Potential perioperative issues would be optimally addressable by cardiac providers already cognizant of the patients prior ongoing cardiopulmonary status, which may be labile. Therefore, the requested knee surgery at a facility with a pediatric cardiac transplant program/team 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a right hand wrist regional nerve block. The current evidence-based medical literature supports the use of distal peripheral nerve blocks for patients undergoing hand surgery. Regional anesthesia provides adequate pain control, permits timely discharge home, and has a low complication rate. This patient presents with persistent severe right hand pain and unstable fifth digit fracture. Clinical examination findings are consistent with radiographic evidence of an acute mallet fracture deformity of the distal fifth phalanx, intra-articular, minimally displaced, with mild volar subluxation of the distal phalanx. She has been recommended for closed reduction, possible open reduction and internal or external fixation of the fifth digit using a right hand wrist regional block for anesthesia. Given the available data, regional anesthesia is consistent with the current peer-reviewed medical literature and standard of care in this clinical scenario. Therefore, a right hand wrist regional nerve block is likely to be more beneficial for treatment of the patients medical condition that any standard therapy.Findings:  Three physician reviewers found a right hand wrist regional nerve block is likely to be more beneficial for treatment of the patients medical condition that any standard therapy.Final Result: The reviewers determined that a right hand wrist regional nerve block is likely to be more beneficial for treatment of the patients medical condition that any standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Transoral Incisionless Fundoplication (TIF) procedure utilizing the EsophyX device. Findings:  Three physician reviewers found that the requested TIF procedure utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While the efficacy of the TIF procedure has been studied in randomized controlled trials, the conclusions are contradictory. One large randomized trial that included 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months. In this trial, normalization of pH was accomplished in only 29 percent in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61 percent. The study concluded that although TIF resulted in a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved. A recent meta-analysis has concluded that further safety and efficacy comparison is needed to directly compare TIF with conventional treatment such as Nissen fundoplication. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) report that the long-term follow-up data for TIF is limited. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. For these reasons, the requested TIF procedure utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the requested procedure is 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 a history of delayed gross motor milestones and has a diagnosis of congenital myopathy. An occupational therapy evaluation noted hypotonia in both arms. She was independent with most basic tasks, except for more challenging tasks such as managing snaps for dressing and opening food containers. She had a shower seat but was not using it. She was wearing a spinal brace. On examination, vision and hearing were within functional limits. Upper limb strength was three plus to four plus out of five. A physical therapy evaluation noted that the patient was independent with transfers and ambulation. The patient had severe dextroscoliosis. Her standing tolerance was approximately 10 minutes. She was ambulating at a slower pace due to fatigue. The patient was able to walk approximately one block in the community before experiencing fatigue and requiring a sitting break. The patients leg strength was rated as three plus to four plus out of five. End range tightness in the hamstrings and gastrocnemius muscles was noted. The patient has requested coverage for a power wheelchair with accessories. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue is whether the requested power wheelchair with accessories is medically necessary for the treatment of this patient. The patient has motor impairments and has been diagnosed with myopathy. There have been complications or consequences that include scoliosis and functional deficits.  The patient has been independent with most aspects of mobility, including managing at school with accommodations. The patients difficulties revolve around longer distance community mobility. She requires rest breaks for ambulation greater than one block. There are no indications that her higher level mobility needs would not be met with a manual wheelchair, which would provide better general accessibility. The patient does not require a power wheelchair with accessories for accomplishing her mobility-related activities of daily living. The medical evidence does not support the requested device in this clinical setting. Therefore, the requested power wheelchair with accessories is not medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block injection. Findings:  Two of the three physician reviewers found that the current medical evidence supports the service at issue in this clinical setting. This patient presented with signs and symptoms consistent with severe, intractable occipital neuralgia. The records indicate that the patients symptoms did not improve with standard conventional treatments, including medications and activity modification. She continued to experience pain despite these measures. A right occipital nerve block was appropriate in this setting. In sum, occipital nerve block injection was likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are likely to be 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, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned Decision of Health Plan

An enrollee who has been diagnosed with alcohol use disorder and depression. He reported drinking 10 drinks per day during the week prior to presenting for treatment. The records noted that the patient consumed six to eight drinks per day prior to that at baseline. He reported a history of blackouts. The patient began an intensive outpatient program (IOP), relapsing during the program. His medications included Zoloft.  The patient has requested reimbursement for residential treatment center services that were provided from. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The American Psychiatric Association treatment guidelines indicate that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The patient required a safe and stable living environment in order to develop his recovery skills. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness with regular blackouts, his risk factors in relationship stress and stressors, such as loss of parent, residential treatment was in accordance with generally accepted standards of medical practice. Therefore, the requested residential treatment center services provided were medically necessary.Final Result: The reviewer determined that the requested services 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 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 history of gender dysphoria. The provider noted that the patient was diagnosed with gender dysphoria and she has been on hormone therapy. She has a history of anxiety and depression, which were worsened by gender dysphoria. The patient relates much of her continued gender dysphoria to her facial features not aligning with her identified gender.  The patient has requested authorization and coverage for facial feminization surgeries. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. According to researchers, medically necessary gender affirming/confirming surgical procedures include certain facial plastic reconstruction procedures. Researchers noted that other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women includereconstructive facial feminization surgery.   In this patients case, the records document anxiety and depression that are worsened by gender dysphoria. There is support for the requested services in this clinical setting. Therefore, the requested services 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Epidural injections may be indicated for radicular pain that has not responded to at least six weeks of conservative care. The records provided for review do not document that the patient has participated in an adequate course of physical therapy and a home exercise program as recommended by her provider for her current complaints. The literature indicates that a home exercise program after physical therapy can provide a patient with long-term results without an epidural injection. In the absence of documentation that the patients condition has persisted following adequate conservative care, the requested foramen epidural injection (CPT codes 64483, 64484, 99213 and HCPCS code J1100), is not medically necessary for treatment of 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 57-year-old male with bilateral primary osteoarthritis of the knees. X-rays reportedly demonstrated osteoarthritis of both knees, particularly severe in the right patellofemoral joint with abnormal configuration of the distal patella. The patient failed noninvasive treatment. Per the records, the patient benefitted from Euflexxa injections in both knees previously. The patient has requested authorization and coverage for Euflexxa injections. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. This patient has had significant benefit from prior injections. Current literature supports the use of viscosupplementation for osteoarthritis of the knees. Intra-articular hyaluronic acid provides a moderate symptomatic benefit for knee osteoarthritis without major safety concerns. Viscosupplementation may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis symptoms, gain in quality of life, and substantial delay in time to total knee replacement. There is evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function that lasts up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The medical evidence supports the requested Euflexxa injections in this clinical setting. Therefore, the requested Euflexxa injections 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program services that were provided for 33 days. The Health Plan denied the request and reported that the services at issue were not medically necessary for the treatment of this patient. At issue is whether the intensive outpatient program services were medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that based on the records, the patient denied suicidal or homicidal ideation and did not have psychosis or any medical issues. There was no report of the patient requiring assistance with activities of daily living. She was cooperative with care and actively involved in her treatment. She was participating in her treatment plan and attending 12-step groups. The American Association of Community Psychiatrists Level of Care Utilization System is used to determine the necessary level of care for adults. The patient has a composite score of 10 to 11. This correlates with treatment in a community-based outpatient clinic setting. The medical evidence does not support the services at issue in this clinical setting. Therefore, the requested intensive outpatient program services that were provided for 33 days were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.