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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for oxycodone/acetaminophen 10/325mg, every four hours. The submitted documentation does not support that the requested medication regimen is medically necessary. The Centers for Disease Control (CDC) clinical practice guidelines clearly delineate that opiates at a high dose are not appropriate for chronic non-malignant pain. Researchers indicate that the risk of overdose dramatically increases when greater than 50mg of morphine equivalent per daily dosage (MED) is prescribed, which would be the requested MED dosage by the patient. In this case, the patient seeks more frequent opiate dosing to treat chronic non-malignant pain. The requested dosing would amount to a MED dosage that statistically carries a greater risk of overdose. The submitted records reflect that the patient has made this request while numerous other medications and other therapeutic options have been declined but remain available. Under these circumstances, the requested medication regimen of oxycodone-acetaminophen 10/325mg, one tablet every four hours, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for continued substance related disorders, residential behavioral health level of care, adult services. Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines recommends that residential treatment, or similar care higher than outpatient, 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...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Per the American Society of Addiction Medicine (ASAM), patients require safe and stable living environments in order to develop their recovery skills. In this case, ASAM Level III treatment is appropriate, and is similar to the level of care the patient has received thus far at the facility. Given the severity of the patients illness, he poses a significant risk to himself. In this clinical setting, substance related disorders, residential behavioral health level of care, adult services are in accordance with generally accepted standards of medical practice and are medically necessary. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cervical/thoracic facet joint block injection. In this case, the patient has pain complaints that are noted to be 8/10 in severity in the cervical spine. The patients pain complaints are corroborated by physical examination and imaging studies which demonstrate reduced cervical range of motion, facet tenderness and spondylosis. Further, the patient has failed to progress with adequate conservative measures including formal physical therapy, anti-inflammatory medications and opioid therapy. In a 2016 publication, found that the available evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. Given this support, the requested cervical/thoracic facet joint block injection is medically necessary for treatment of this patients medical condition. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator. Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and safety for treatment of OSA. In patients who do not tolerate CPAP and fail to improve with an oral appliance, surgical intervention may be required. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. As reported in the published medical literature, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. The authors reported the hypoglossal nerve stimulator is safe and effective in patients with OSA who have nonconcentric airway collapse, an apnea/hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. This patient meets the criteria for the requested procedure with an AHI between 20 and 50, a BMI of less than 32, and nonconcentric airway collapse. Moreover, he has failed CPAP, which is the gold standard treatment for OSA, and treatment with an oral appliance. For these reasons, implantation with a hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that implantation with a hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in otolaryngology with subspecialty certification in plastic reconstructive surgery and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology with subspecialty certification in sleep medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the breasts. Contrast enhanced breast MRI is a highly sensitive examination helpful in identifying abnormalities that may be are occult on mammography and ultrasound. The indications for breast MRI include high risk screening, new diagnosis of breast cancer to evaluate for additional sites of disease, and patients with positive margins after lumpectomy. Additional indications include evaluation of response to chemotherapy prior to surgery, evaluation for breast cancer recurrence, evaluation of metastatic cancer of an unknown primary source, and when mammographic or ultrasound findings are inconclusive. Studies show breast MRI may be used for lesion characterization in the setting in which mammographic and ultrasound findings are inconclusive and biopsy cannot be performed. This indication is only applicable after additional diagnostic mammographic views as well as targeted ultrasound examinations have been performed. Contrast enhanced breast MRI was therefore not indicated in this case. If the ultrasound findings were suspicious, then short-term ultrasound follow-up or biopsy should have been performed. Accordingly, the breast MRI was not likely to be more beneficial for evaluation of the patients condition than available standard imaging.One reviewer found that the breast MRI was likely to be more beneficial for evaluation of the patients condition than available standard imaging.Final Result: Two of the three 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:  One reviewer is board certified in radiology and is actively practicing. One Reviewer is board certified in radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology 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

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for growth hormone (GH). The submitted documentation supports that the requested medication is medically necessary. Federal Drug Administration and Pediatric Endocrine Society guidelines have approved the use of GH for children who meet the diagnosis of ISS. In this case, the patient has a short stature that meets the definition of ISS, as his height is below the accepted -2.25 standard deviation below the mean for age and sex. The patient has an estimated predicted adult height of 5 feet and 3 inches. This height is below normal for an adult male. The patient has an estimated adult height that is below the mid-parental target height of 5 feet 10 inches, and without treatment, he will not meet his genetic potential. Nutropin AQ Nuspin is an approved growth hormone medication for the treatment of ISS. Accordingly, the requested Nutropin AQ Nuspin is medically necessary for the treatment of the patients medical condition.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 pediatrics, with subspecialty certification in pediatric endocrinology, 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: An enrollee has requested authorization and coverage for sleeve gastrectomy. According to the American Society for Metabolic and Bariatric Surgery, qualifications for bariatric surgery in most areas include a BMI greater or equal to 40, or more than 100 pounds overweight; a BMI greater or equal to 35, with at least one or more obesity-related co-morbidities such as type II diabetes, hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease; or an inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.In this case, the patient meets all nationally accepted criteria for bariatric surgery, including those published by the American Society for Metabolic and Bariatric Surgery. The patient is an adult with a BMI that is greater than 35 kg/m2, with morbid obesity and the presence of an obesity-related co-morbid condition, sleep apnea. The patient has failed dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. Therefore, the requested sleeve gastrectomy is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested procedure 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 general 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: An enrollee has requested authorization and coverage for Orthovisc injections to the knee. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting. Evidence from studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, 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 reviewer found that the current highest level suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Reviewer found the use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections for the knee are medically necessary to treat the patients medical condition at this time.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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the knee. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of various studies. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses, comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. That review concluded that the current highest level of evidence suggests that an intra-articular hyaluronic acid injection is a viable option for knee osteoarthritis. In this case, the patient presents with a history of bilateral knee osteoarthritis and increasing knee pain. Clinical examination findings are consistent with radiographic evidence of tricompartmental degenerative changes in both knees. Conservative treatment had reportedly included corticosteroid injection, physical therapy, and medications, without sustained improvement. He previously underwent hyaluronic acid injections with long-term pain alleviation and functional improvement. Evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for a delay of knee replacement surgery. Given the previous significant long-term response, repeat injections are indicated. Therefore, the requested Orthovisc injections are medically necessary for the treatment of the patients medical condition.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: An enrollee has requested authorization and coverage for Euflexxa (Hyaluronan) injections for both knees. The submitted documentation supports the medical necessity of the requested services. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of various studies. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was found efficacious. In this case, this patient presented with chronic bilateral knee pain. Clinical examination findings are consistent with x-ray evidence of severe osteoarthritis in the lateral and patellofemoral compartments. Reasonable conservative treatment, including activity modification and NSAIDs, has failed to provide adequate symptom relief to this patient. Prior Euflexxa injections to both of the patients knees provided pain relief and good functional improvement in activities of daily living, allowing him to reduce NSAID use. Evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for the delay of knee replacement surgery. Given the patients previous significant long-term response, repeat Euflexxa injections are supported. Therefore, the requested bilateral Euflexxa injections (Hyaluronan) for the knees are medically necessary for treatment of the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for platelet rich plasma (PRP) for the knee. Currently, there is limited reliable clinical evidence to guide the use of PRP for treatment of knee pain. In addition, transient side effects, such as post-injection swelling and pain, short duration nausea and dizziness, have been reported in up to 20% of recipients, compared to hyaluronan and placebo. Further, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for treatment of osteoarthritis of the knee give an inconclusive recommendation for the use of PRP use in the treatment of knee arthritis, which means that there is a lack of compelling evidence that the treatment is safe and effective at long-term follow-up. Accordingly, PRP injections are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.One reviewer found that PRP injections are likely to be more beneficial for treatment of the patients 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 treatment 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 orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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.