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

The patients parent has requested authorization and coverage for hip to ankle scanogram/EOS imaging. The Health Plan denied the request and reported the requested services are not medically necessary for the evaluation of this patient. Researchers concluded that the identification of congenital and acquired etiologies causing alignment disorders and leg-length discrepancies (LLD) in children is important for management. Per the authors, LLD of greater than 1 cm can cause altered biomechanics, resulting in scoliosis, back and lower extremity joint pain, pelvic tilt, abnormal gait and premature degenerative joint disease. Medical literature states upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure. In addition, the ability of this technology to obtain images while subjects are standing upright makes this the ideal modality with which to assess limb alignment in the weight-bearing position. Researchers reported Russell-Silver syndrome is a rare condition associated with prenatal and postnatal growth retardation. Orthopedic problems associated with Russell-Silver syndrome include limb or body asymmetry, scoliosis, hip dysplasia and hand and/or foot anomalies. A limb asymmetry can affect the arms, legs or both. Limb lengthening surgery performed to equalize limb lengths in patients with Russell-Silver syndrome has shown positive results. In this case, the patient has been diagnosed with Russell-Silver syndrome and a right leg length discrepancy. He is being monitored on an annual basis to determine whether surgical invention is required to prevent permanent deformity and associated orthopedic problems. The medical evidence supports the requested services in this clinical setting. Therefore, hip to ankle scanogram/EOS imaging is medically necessary for the evaluation 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 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 patients parent has requested reimbursement and prospective authorization and coverage for weekly speech therapy and feeding therapy services co-administered in one session. Based on the available documentation, this patients condition warrants the requested speech and feeding therapy to improve the dysphagia, strengthen lingual movements, and improve jaw stabilization. Speech therapy will address the patients articulation, expression, and communication skills. He previously received treatment with slow progress. Since transitioning to his current provider, a speech and feeding specialist with expertise in treating Down syndrome, he has made progress. He has developed a bond with his current provider, which is also bilingual, which has facilitated treatment. Moreover, the combined speech and feeding therapy has been effective for this patients progress. Therefore, the weekly speech therapy and feeding therapy services co-administered in one session were and 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 physical medicine and rehabilitation with expertise 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for custom orthotic shoe inserts. The enrollee has diagnoses of plantar fasciitis, pain in the right foot, neuralgia, and pes cavus. Pain developed gradually several years prior and was rated a 7/10 in severity. Her pain had an aching, dull, sharp, shooting, stabbing, and throbbing quality, radiating into the right hand and to the bilateral feet and legs. Pain medication was partially effective in relieving the pain. The enrollees podiatrist is requesting custom foot orthotics. She indicates the foot pain has more than one cause and the shoe inserts could help to make her daily routine of working and driving more bearable. She is on her feet when she is at work, which is very painful for her. The enrollee indicates she would rather try inserts than add more medications to her routine. She has liver issues and worries about medication impacts. While many studies have been published regarding custom foot orthotics, the results are varied and are either inconclusive or negative.  The role of over-the-counter orthotics for pain relief has been extensively researched. Studies found they can be an effective treatment for pain relief.  There is insufficient evidence in the record of the enrollees trying any such measures. There is no evidence of the use of any conservative measures prior to the recommendation of the custom orthotics.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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

The patient has requested authorization and coverage for an ultrasound of the carotid arteries. Based on the records provided for review, the patient has coronary artery disease and a family history of carotid stenosis. The patient does not have a personal history of carotid stenosis or bruit, or symptoms concerning for transient ischemic attack such as focal neurologic deficits. In the absence of these conditions, the documentation does not support an indication for an ultrasound of the carotid arteries. Screening ultrasounds of the carotid arteries are not recommended by any guidelines for use in this clinical setting. Therefore, the requested ultrasound of the carotid arteries is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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 suction assisted protein lipectomy (SAPL). This patient presents with right leg lymphedema that has not improved despite conservative therapy. The patient previously underwent total hysterectomy and bilateral salpingo-oophorectomy with removal of 22 lymph nodes in 2009, with lymphedema since 2010. Treatment has included manual lymph drainage and custom compression garments. Due to the failure of conservative therapy, persistent pain and associated symptoms including cellulitis, the requested SAPL is medically necessary for treatment of this patient. Moreover, the requested procedure is reconstructive in nature. The SAPL will address the patients abnormal condition and improve function as well as provide a more than minimal improvement in the patients appearance. All told, the requested SAPL is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ZTlido 1.8% topical system. The U.S. Food and Drug Administration (FDA) has approved the ZTlido 1.8% topical system for the treatment of post-herpetic neuralgia. A review reported that there is a lack of evidence to support the use of lidocaine patches, such as ZTlido, for musculoskeletal pain. In this case, the patient has a known diagnosis of lumbar radiculopathy and lumbar stenosis. She was also diagnosed with arthritis, which is a musculoskeletal disease. The provider recommended treatment with ZTlido patches. However, the records do not document an indication for this medication. Based on the available medical records for review and the current medical literature, the requested ZTlido 1.8% topical system is not medically necessary for treatment of this patient.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar Intracept system (CPT code 22899, HCPCS C9752 and HCPCS C9753). The Intracept intraosseous nerve ablation system is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain. There should be documentation of symptoms that have not responded to at least six months of conservative care, accompanied by either Type 1 or Type 2 Modic changes on a magnetic resonance imaging (MRI). There is a paucity of published clinical data to support the use of this treatment modality in this clinical setting. One trial involving 17 patients treated for refractory chronic low back pain demonstrated improved patient reported outcomes for one year after treatment. Another study is a multicenter randomized control trial involving 225 patients with refractory low back pain and Modic changes in the treated vertebral bodies. The authors reported significantly greater improvement in patient reported outcomes at three months compared to a group of patients treated with sham intervention. However, findings on the long-term safety and efficacy beyond three months is lacking. Clinical conclusions on this procedures safety and efficacy, should be confirmed by additional investigators, and require longer-term safety and efficacy data prior to accepting the Intracept procedure as standard of care. Therefore, the requested lumbar Intracept system (CPT code 22899, HCPCS C9752 and HCPCS C9753) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested lumbar Intracept system (CPT code 22899, HCPCS C9752 and HCPCS C9753) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for inpatient chronic pain management program. The records provided for review document that this patients chronic migraines have persisted despite medical therapy and supplements for the treatment of migraines. The patient has also been treated with other forms of supportive care such as massage, acupuncture and biofeedback. However, there is no documentation that the patient has exhausted traditional medications for aborting acute migraine and prophylactic medications for the prevention of migraines. Acute treatment consists of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans. Among triptans, sumatriptan nasal spray has been demonstrated to be safe and effective for pediatric patients. Moreover, preventive therapies including propranolol, amitriptyline, levetiracetam, valproate, and topiramate are recommended for use in this clinical setting. All told, the requested inpatient chronic pain management program is 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 neurology with 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

The patient has requested authorization and coverage for Orthovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed other conservative treatments with the alternative being total knee arthroplasties. Furthermore, the patient reported excellent results from viscosupplementation provided in the past. All told, the requested Orthovisc injections in both knees 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has diagnoses of attention-deficit hyperactivity disorder, unspecified anxiety disorder, adjustment disorder with mixed disturbance of emotions and conduct, moderate cannabis use disorder, and parent-child relational problem. He had difficulty coping with his emotions and was reactive at times. Prior to his admission to the wilderness program, he was using marijuana daily and had tried other drugs. There were signs of heightened emotional stress, with periodic anxiety or brief depressive-like reactions. The enrollees parents reported his moods were unpredictable, which led to increasing defiance at home. His parents were concerned about his escalating drug use; especially marijuana. He entered the wilderness program. The enrollee participated in interventions and challenges specific to outdoor behavioral healthcare, designed to help him build skills related to self-confidence, assertive communication, interpersonal relationships and coping skill development. The enrollee learned and practiced dialectical behavioral therapy to develop skills focused on mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness. He participated in a substance use-counseling program. He learned how to identify and manage his emotions in healthier ways. He learned basic cognitive therapy strategies designed to help him identify and replace the unhealthy thought patterns that reinforce his feelings of depression and anxiety. The enrollees mother states the enrollee had already exhausted several outpatient resources; including therapy and academic interventions. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations was utilized in this review. The enrollees composite CALOCUS score correlates with high intensity community-based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 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

The enrollee is requesting authorization and coverage for placement in a skilled nursing facility. The enrollee has a history of severe obesity, diabetes mellitus, osteomyelitis, multiple toe amputations/partial ray amputation, and kidney disease. The enrollee currently has a wound at the right foot first ray amputation site. He would like to go back to a skilled nursing facility because the meals were prepared for him. He believes he would lose weight if he lived in a skilled nursing facility, versus preparing his own meals. The enrollee is currently receiving home health care for his surgical wounds.  Review of the record shows insufficient evidence of any skilled needs at this time.  Physical examination showed a warm and well-perfused foot, with loss of protective sensation to the 10-gram monofilament.  The enrollees reported blood glucose readings are well controlled and he is adhering to prescribed medications. The foot wound is slowly healing. The medical literature indicates skilled nursing facilities provide additional rehabilitation and recovery after hospital discharge before returning home. However, there is insufficient evidence in the record of complex care needs requiring placement in a skilled nursing facility. The enrollee is not considered homebound/bedbound and is able to receive care in his home. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.