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

The patient has requested authorization and coverage for bilateral Euflexxa injections. Evidence from systematic reviews and randomized controlled trials indicate that 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 those with limited treatment options. In this case, the records document the patient has failed three months of conservative treatment including physical therapy. Imaging studies show narrowing of the medial compartments and patellofemoral joints with the presence of small osteophytes. The remaining treatment options are limited to total knee arthroplasties, which are not warranted in the setting of mild osteophytosis. Therefore, bilateral Euflexxa injections are 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Synvisc One injections in both knees. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. 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. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the data on safety and efficacy remain inconclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the remaining options are limited. In this case, the patients available treatment options are limited. Treatment with NSAIDs and corticosteroid injections did not provide the patient substantial relief. A total knee arthroplasty in the presence of mild narrowing of the joint spaces is not a recommended course of treatment. As such, Synvisc One injections in both knees are likely to be more beneficial for the treatment of the 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for minimally invasive urologic surgery. The records provided for review document that the patient has been diagnosed with left ureter transitional cell carcinoma (UTUC). The provider referred the patient for surgery. The provider states that the patient will undergo this surgery within three months of initial diagnosis. The patient is requesting surgery within one month of diagnosis. However, current medical literature does not support improved outcomes in patients who undergo surgery less than three months versus delayed surgery. Researchers concluded that their results showed no difference in survival between patients undergoing early versus delayed extirpative surgery for UTUC. Therefore, the requested minimally invasive urologic surgery is not medically necessary for treatment of this 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 urology 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

The patient has requested authorization and coverage for Euflexxa injections. An exhaustive review of current medical literature pertaining to the viscosupplementation reveals mixed results. 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. Current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy remain inconclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the remaining options are limited. In this case, there is a lack of documentation of substantial relief of symptoms with prior Euflexxa injections. The course of three injections performed did not result in significant pain relief. Medical records document the need for weight reduction prior to total knee arthroplasty. Based on the lack of documentation of significant relief from three Euflexxa injections, the requested Euflexxa injections are not medically necessary. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with receptive and expressive language delays. The records noted that the patient does not have any meaningful words. She waved and clapped appropriately. The provider noted that speech therapy was not recommended due to the patients limited ability to participate in therapy in a one-on-one clinical setting. The patients parent has requested coverage for speech therapy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested speech therapy is medically necessary for treatment of the patients medical condition. The patient was described as shaking her head for no and using symbolic gestures. She babbled, waved and clapped appropriately. This would suggest that she has the pre-linguistic requisites to benefit from speech therapy. Researchers reported the identification of developmental problems in a childs acquisition of speech, language and/or communication is a core activity in child surveillance. These delays can confer disadvantages in the long-term, adversely affecting language, cognition, academic attainment, behavior and mental health. Patients presenting with significant speech and language delay should be investigated with a comprehensive hearing assessment and be considered for speech and language therapy assessments. Medical evidence supports the requested services in this clinical setting. Therefore, the requested speech therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with a special qualification in child neurology 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 power wheelchair with accessories. Respiratory insufficiency, cardiac disease, and contractures are common findings of this patients type of progressive myopathy. The disease involves muscles of the face, neck, trunk, and extremities. The records document that the patient has frequent falls and is unable to functionally ambulate. The patient requires a custom power seating and mobility device that enables appropriate positioning, weight shifts, skin protection, fatigue prevention and easy access to gastric tube for feedings. Due to the progressive nature of her disease, consistently propelling a manual wheelchair in a safe, energy efficient and effective manner inside or outside of her home in not expected. The custom power chair with necessary accessories will allow her to function independently at home, school and community settings. Postural support and pressure redistribution will help reduce the patients risk of skin breakdown. Prevention of overuse injuries and fatigue of upper body, trunk, and extremities will improve her access to timely and safe feedings. These improvements will provide a means of independence for school and family functioning, quality of life, and psychosocial development. Therefore, the requested power wheelchair is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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:  According to the records, the enrollee is requesting excision abdomen skin infraumbilical panniculectomy. The record indicates the enrollee lost over 200 lbs. by eating a vegetarian diet. She has maintained a weight of 175 lbs. She has excess abdominal skin (pannus) from the weight loss, which causes pain and rashes that itch (pruritic intertrigo). She has tried multiple different creams and powders (seven total), as well as oral medications, but none were effective at resolving the skin condition. Her nurse practitioner states that she has chronic dermatitis and skin degeneration underneath the pannus that causes hives and blisters, which are difficult to treat leading to areas of open wounds. Treatment for pannus rashes has failed. This condition limits her abilities to perform daily activities, such as walking, cleaning, and shopping for groceries. Her skin condition has never completely resolved because it is made worse by the skin-to-skin contact from her pannus and the enrollee would greatly benefit from surgery to remove the excess abdominal skin.  A review of the record substantiates this enrollees condition meets the expanded concept of medically necessary reconstructive surgery defined in California law. The record indicates recurrent infection, dermatitis and skin degeneration under the pannus that persist despite application of numerous creams and powders. Conservative management of this condition has not been successful and impairs the enrollees ability to function.  The medical evidence supports the panniculectomy is medically necessary for the treatment of this enrollee. A note from the provider indicates the pannus limits the enrollees ability to walk and manage her home. The alleged abnormality, pannus, constitutes an abnormal structure of the enrollees body, which results from treatment of her disease (obesity). The surgery will create a normal appearance to the extent possible and provide more than a minimal improvement in the patients appearance. The American Society of Plastic Surgeons indicates panniculectomy has been shown to improve functional quality of life and ability to perform activities of daily living. It should be considered a reconstructive procedure when performed to improve skin health within the fold beneath the pannus. A review of the record substantiates the requested surgery, excision abdomen skin infraumbilical panniculectomy, is reconstructive in nature and will improve function.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition and is reconstructive in nature.Credentials/Qualifications: The physician 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 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 direct manipulation techniques, such as compression, trigger point pressure release, deep massage, spray and stretch, ultrasound transverse friction massage and/or laser therapy. Current evidence-based literature regarding the management of hypermobile Ehlers-Danlos syndrome and myofascial pain syndrome is limited in size and quality. A few studies have shown positive effects with physiotherapy. While the optimal rehabilitation program has not been identified, research supports that proprioception, strength, and motor control, in addition to education, physical activity, and fitness are important components. However, there is a limited body of high quality evidence supporting the efficacy of techniques such as ultrasound, trigger point pressure release, compression, deep massage, spray and stretch and laser therapy. Therefore, the requested direct manipulation techniques (such as compression, trigger point pressure release, deep massage, spray and stretch, ultrasound transverse friction massage and laser therapy) are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the left knee. Hyaluronic acids are naturally occurring connective tissues materials that help cushion and lubricate joints. Intra-articular injection of avian-derived or synthetic hyaluronic acids, or viscosupplementation, can decrease osteoarthritis symptoms in some patients. Guidelines do not recommend hyaluronic acids for patients with symptomatic osteoarthritis, based on strong evidence. The submitted clinical documentation does not support the use of viscosupplementation injections to treat the patients left knee osteoarthritis. Therefore, the requested Orthovisc injections for the left knee are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the requested Orthovisc injections for the left knee are not likely to be more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the requested Orthovisc injections for the left knee are not likely to be more beneficial for treatment of the patients 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Kineret 100 mg/0.67 mL syringe. This patient has been diagnosed with Erdheim-Chester disease, which is a malignant disorder that involves pro-inflammatory cytokines, most importantly, interleukin-1. The patients provider recommended treatment with Kineret, which is a recombinant form of an interleukin-1 receptor antagonist. Kineret is currently U.S. Food and Drug Administration (FDA) approved for rheumatoid arthritis and cryopyrin-associated periodic syndromes. Consensus guidelines, as reported in the American Society of Hematology, include Kineret as a viable treatment option in this clinical setting . Studies have demonstrated Kineret to be safe and effective in the treatment of patients with Erdheim-Chester disease. Therapies such as interferon alfa are not well tolerated and have variable efficacy. Given the support in the current medical guidelines and literature, Kineret is appropriate for treatment of this patients Erdheim-Chester disease. Therefore, Kineret 100 mg/0.67 mL syringe is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee surgery (arthroscopy with meniscectomy). Magnetic resonance imaging (MRI) of the left knee demonstrated tricompartmental osteoarthritis of the knee, particularly severe in the medial compartment, where a complex tear of the medial meniscus was also present. This is a typical degenerative tear that is usually not helped by a partial meniscectomy. Researchers noted a three-fold increase in the risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears. Researchers recommended against arthroscopic knee surgery for degenerative knee disease. The medical evidence does not support arthroscopy in the presence of a degenerative medial meniscal tear and osteoarthritis. Therefore, left knee surgery (arthroscopy with meniscectomy) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mitral valve repair with MitraClip and one day hospital stay.Findings:  Two of the three physician reviewers found percutaneous mitral valve repair using the MitraClip device has been approved by the U.S. Food and Drug Administration for high risk patients with degenerative or other primary mitral valve regurgitation. Researchers evaluated both functional and degenerative mitral regurgitation patients who were at high risk for surgical mitral valve repair. Excellent outcomes for the device were demonstrated. Per researchers, percutaneous mitral valve repair may be indicated for severely symptomatic patients with chronic severe primary mitral regurgitation who have favorable anatomy for the repair procedure but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal medical therapy. This patient does not exhibit severe symptoms. His symptoms would be considered only Class II. In addition, his Society of Thoracic Surgeons (STS) score does not classify him as prohibitive surgical risk. In sum, the requested mitral valve repair with MitraClip and one day hospital stay are not likely to be more effective than other treatment options. 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.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.