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

enrollee has requested authorization and coverage for acupuncture treatment within five miles of the enrollees residence. Based on the current medical literature, acupuncture has been demonstrated to be effective in well selected patients with migraine, tension and episodic headaches. The recommended acupuncture frequency and duration is an initial trial of five to six sessions. Additional sessions may be performed when supported by improvement in objective measures with evidence of progressively greater, incremental objective gains. The literature suggests that care may be discontinued due to a lack of measurable improvements. In this case, the patient has undergone numerous acupuncture sessions with temporary reduction in symptoms. However, the provider failed to document the number of sessions completed as well as the specific, measurable, sustained, significant, objective functional improvement obtained with each acupuncture session to support future services. Moreover, there is a paucity of data supporting the medical necessity of acupuncture treatment within five miles of the patients residence for treatment of her 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 for the right knee. Review of the submitted documentation supports the medical necessity of the requested Orthovisc injections in this case. The relevant literature reveals that hyaluronic acid (such as Orthovisc) 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. Further, nationally recognized evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines state that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronic acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. In sum, evidence-based peer-reviewed literature supports the use of viscosupplementation injections such as Orthovisc for the treatment of pain in patients with severe osteoarthritis of the knee. Viscosupplementation allows for delay of total knee replacement and is more efficacious than corticosteroid injections. In this case, the patient has been diagnosed with advanced (bone-on-bone) osteoarthritis of the right knee. The patient has current extreme right knee pain and functional impairment in activities of daily living that has failed to respond adequately to other conservative treatment. She wants to delay total knee replacement and has reported positive results with hyaluronic acid injections in the past. Therefore, the requested Orthovisc injections for the right knee are medically necessary for 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines state that in some patients with soft tissue sarcomas, PET imaging may be useful for prognostication and treatment planning. This was the case for this patient, as her primary tumor was only partially resected. PET imaging may be beneficial for evaluating the activity and size of the primary tumor. This modality has been shown to be more sensitive than conventional imaging in the diagnosis or detection of metastatic disease, often in unexpected locations.  Positron emission tomography/computed tomography (PET/CT) scans allow for such evaluation with one total body scan, whereas conventional imaging would have required multiple scans of various organ systems to achieve the same level of information. Therefore, PET scan was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 diagnostic radiology 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 balloon ostial dilation.  Findings:  Three physician reviewers found that the patients primary problem is recurrent bouts of sinus pressure/pain and drainage. Per the records, computed tomography (CT) of the sinuses was essentially normal, with no obstruction of the ostiomeatal complexes. Balloon ostial dilation has been used for many years for the treatment of specific sinus disease. In this case, the patients primary issues include poor sleep, fatigue and reduced productivity. The sinonasal symptoms are minimal, and there has been no medical therapy for treatment other than antibiotics. There is a lack of support for the requested services in this setting. Thus, balloon ostial dilation is not likely to be of greater benefit than other available 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 otolaryngology 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: A 34-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that the records provided for review document that this patient has been diagnosed with schizoaffective disorder, bipolar type, personality disorder, OCD, disorder social anxiety disorder, generalized anxiety disorder, panic disorder, anorexia, and psychotic symptoms. She has been tried on several antidepressants and mood stabilizers in the past. However, the records do not indicate whether the medication trials were adequate, taking into account the maximum tolerated dosage and duration of treatment with each medication trial. Overall, there is a lack of evidence regarding the failure of available standard therapy for treatment of this patients symptoms to support treatment with TMS. Thus, the requested TMS 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 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 psychiatry and is actively practicing. One Reviewer is board certified in psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry 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 a minor male enrollee has requested reimbursement for adolescent residential mental health treatment services. According to the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter on OCD, cognitive behavioral therapy (CBT) is considered the first-line of treatment for mild-to-moderate cases of OCD. For patients with moderate-to-severe cases of OCD, the AACAP recommends a combination of CBT and medication management. The AACAP noted that treatment resistance is considered when a patient has persistent OCD symptoms despite engaging in adequate treatment that has been demonstrated to be effective. A research study on residential treatment for adolescents with OCD noted that patients with complex comorbidity or previous unsuccessful treatment attempts may require more intensive monitoring, multimodal interventions, and greater intensity of treatment delivery than even intensive outpatient CBT provides. The authors further reported that residential treatment provides a greatly increased number of hours of CBT provided per week (Leonard, et al). The patient in this case has a history of failing treatment with medications as well as outpatient and IOP levels of care. The records indicate that discharge prior to 8/10/18 would have been premature and likely resulted in relapse. Overall, the current medical literature and practice parameters support that the treatment at the residential level of care was appropriate for continued management of this patients behavioral health issues. Thus, the adolescent residential mental health treatment services provided were medically necessary for treatment of this patients medical condition. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. In a systematic review of meta-analyses, researchers conducted a systematic review of overlapping meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. In addition, researchers noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. This patient reported consistent relief with hyaluronic acid injections. Given this support, the requested bilateral Synvisc One injections are medically necessary for treatment of this patients bilateral knee osteoarthritis. 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

enrollee has requested reimbursement and prospective authorization and coverage for onabotulinumtoxinA (Botox) injections in the pelvic floor muscle. The current medical literature does not support the utility of Botox as within the standard of care for treatment of myofascial pelvic floor pain. Although there are a few studies suggesting its efficacy, the available medical literature consists of small retrospective case series with a limited number of patients. In the absence of adequate data demonstrating improved health outcomes on long-term follow-up, the Botox injections in the pelvic floor muscle provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Enrollee has requested authorization and coverage for annual breast magnetic resonance imaging (MRI). As noted by the American College of Radiology (ACR) and the National Imaging Associates (NIA), mammography is the recommended method of breast cancer screening in the general population. However, for patients with dense breast parenchyma, the current data suggests that MRI is considered the most sensitive modality for breast cancer screening. This patient was found to have breast cancer at an early age, and the tumor was occult on mammography due to underlying dense breast tissue. She is at risk for recurrence due to her age at the time of initial diagnosis of breast cancer and mammography is of limited value due to dense breast parenchyma. Thus, the requested annual breast MRI is supported as medically necessary for evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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: A male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. This patient has been diagnosed with major depressive disorder. However, the records suggest that the patients condition may include an element of bipolarity, given the presence of mania-like symptoms. The provider reports the patient has been treated with several antidepressants and mood stabilizers in the past. However, the records provided for review do not indicate whether the medication trials were adequate trials in terms of dose and duration, or the outcome associated with the medication trials. All told, the patient does not fulfill the current criteria for the treatment with TMS. Thus, the requested TMS is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested TMS is 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 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 psychiatry and is actively practicing. One Reviewer is board certified in psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast lift and breast surgery to remove excess skin. This patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Per the records, this patient does not have macromastia. Rather, she has involutional ptosis following weight loss. There is a lack of evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The records do not include office notes that document longstanding musculoskeletal symptoms that have failed to respond to conservative treatments. There is a lack of support for the requested services in this clinical setting. Therefore, the medical necessity of the requested services has not been established.The requested services are not reconstructive in nature. The patients condition does not constitute an abnormal structure of the body. Breast ptosis is part of the normal spectrum of skin structure. Breast ptosis is a normal part of aging and is a normal finding in women who have been pregnant or have lost weight. This condition is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The peer-reviewed literature has not demonstrated that mastopexy is an effective treatment for musculoskeletal pain or is a superior treatment to dermatology management for rashes. Mastopexy will not improve health outcomes and is not clinically indicated. The records do not document a functional deficit which would be improved by this surgery. Mastopexy would not treat her symptom of back pain, even if the underlying problem was macromastia. The records noted that she had low volume, hanging breasts (mostly skin) that would not meet the criteria for breast reduction. Based on the documentation, the requested services are cosmetic in nature. In sum, the requested breast lift and breast surgery to remove excess skin are not medically necessary for the treatment of this patient and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) myelogram. Review of the submitted documentation supports the medical necessity of the requested MRI myelogram. The records indicate there are no signs of intracranial hypotension on the MRIs of the brain and these signs are generally present in cases of CSF leaks.  However, there are cases (approximately 25%) where no such finding is present and yet the individual has a CSF leak. Thus, it has been established that a CSF leak may be present despite a normal brain scan. Given the possibility that the patient may be experiencing a CSF leak despite her normal MRI results, a MRI myelogram is medically appropriate and reasonable in this case. As such, there is sufficient evidence to support the medical necessity of the requested MRI myelogram for further work-up and evaluation of the patients condition.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in radiology 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 temazepam 30 mg. The American Academy of Sleep Medicine (AASM) clinical practice guidelines for chronic insomnia note that there is weak evidence to support the effectiveness of temazepam as a treatment for sleep onset and sleep maintenance insomnia (Sateia, et al). Further, the AASM assert that cognitive behavioral therapy for insomnia (CBT-I), is a standard treatment with a reassuring safety profile. The guidelines further indicate that medications for chronic insomnia disorder should be considered mainly in patients who are unable to participate in CBT-I, who still have symptoms despite participation in such treatments, or, in select cases, as a temporary adjunct to CBT-I. This patients records do not document an adequate trial of CBT-I. In sum, based on current practice guidelines, the requested temazepam 30 mg is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 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.