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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for a Meerkat Dynamic Stander (CPT codes E0638 and E1399). Cerebral palsy has a functional diagnosis of inability to ambulate normally by two years of age. Based on the documentation provided for review, this patient sustained early brain injury with intraventricular hemorrhage (IVH) and Chiari malformation type 1. As noted in the medical literature, IVH frequently leads to damaged polysynaptic motor pathways that allow the normal development of corticospinal motor programs used in normal ambulation. The condition is associated with numerous orthopedic problems including decreased bone density and ligamentous injury. The Meerkat Dynamic Stander allows patients with cerebral palsy to circumvent some of these limitations. All told, this stander represents the standard of care for this patient to decrease orthopedic morbidity associated with cerebral palsy. Therefore, the requested Meerkat Dynamic Stander (CPT codes E0638 and E1399) is 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 that the requested Meerkat Dynamic Stander (CPT codes E0638 and E1399) is 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 device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is 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

  The enrollee is requesting reimbursement for anesthesia (CPT code 00731). The patient underwent laparoscopic cholecystectomy for upper abdominal pain. This did not relieve her symptoms. She was on proton pump inhibitors (PPIs) but symptoms persisted. The patient admitted to having dyspepsia, epigastric pain, nausea, early satiety and post-prandial fullness. An esophagogastroduodenoscopy (EGD) was recommended and she underwent the procedure under monitored anesthesia care (MAC). Results showed normal esophagus, gastritis, which was biopsied, and normal duodenum. A review of the records and nationally recognized guidelines indicates monitored anesthesia care (MAC) anesthesia was not medically necessary during the endoscopy. According to the procedure report, the patient received MAC sedation with propofol under the supervision of an anesthesiologist. As per guidelines by professional societies, MAC anesthesia with anesthesiology assistance during gastrointestinal (GI) endoscopy should be considered for prolonged or therapeutic endoscopic procedures, anticipated intolerance to standard sedatives,  American Society of Anesthesiologists (ASA) greater than class III, or increased risk for airway obstruction because of anatomic variant. A recent meta-analysis regarding administration of propofol during EGD concluded endoscopists may safely administer propofol without compromising procedural quality in patients classified as ASA I or II undergoing routine endoscopy. The patient was classified as ASA II and did not meet the other requirements for MAC anesthesia. The patient had no other known medical conditions other than her current workup for abdominal pain. She uses alcohol only socially. She has an ASA physical status of II. The physician reviewer found that the patient had neither the comorbidity nor the anatomic (airway) risk factors that require MAC. Additionally, there is no medical recommendation by the provider indicating this patients medical condition requires MAC over intravenous (IV) sedation with Propofol
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 56-year-old female who has been diagnosed with bilateral knee osteoarthritis. On 1/18/19, the patient received a third right knee Euflexxa injection. Physical examination findings included tenderness over the right knee joint line and retropatellar regions of the right knee. On 3/29/19, the provider noted that previous viscosupplementation injections provided good results. On 4/16/19, the patient received a third left knee Euflexxa injection. Physical examination findings included tenderness over the left knee joint line and retropatellar region of the left knee. The patient has requested authorization and coverage for Euflexxa injections in both knees. 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 Euflexxa injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. The physician reviewer found that  viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had an excellent response to prior viscosupplementation injections. Furthermore, her options are limited. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for the Helicobacter Pylori lab test. The patient has a Helicobacter Pylori (H. Pylori) infection. Progress notes from an office visit indicate the patient had finished a two-week treatment for H. Pylori and was still taking Prilosec. She had no complaints of nausea, vomiting, diarrhea, abdominal pain or blood in the stool. The physician ordered the H. Pylori test to check for a cure.  Lab testing revealed elevated H. Pylori antibodies levels of 15. The H. pylori antibody test would not help determine whether or not the patient had an active H. pylori infection. This test can only determine whether or not the patient had been exposed to H. pylori in the past and had produced antibodies. The medical literature indicates the accessibility of serology tests can result in their use by laboratories inexperienced in H. pylori diagnosis, which can result in misinterpretation of the data. Additionally, antibodies exist in the host even after eradication therapy; therefore, there can be a considerable amount of time between the administration of eradication therapy and the confirmation of a significant decline in antibody titers. This limits the utility of serology in confirming the eradication of infection. Most diagnostics do not perform well in situations with low bacterial density. Literature does not support the use of this test to determine the presence of an active H. pylori infection. The H. pylori antibody test is not appropriate in this clinical scenario.                                                      Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are 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

The patient has requested authorization and coverage for exploratory laparoscopic surgery. Applying the guidelines from the American Society of Colon and Rectal Surgeons, this patients records do not support a current indication for the requested exploratory laparoscopic surgery (Paquette, et al.). The patient has been diagnosed with chronic constipation and pelvic dyssynergia. The documentation provided for review does not include a work-up concerning for chronic small bowel obstruction, which could support the proposed surgery (Knowles, et al.). Exploratory surgery with laparoscopy and lysis of adhesions is not recommended for the treatment for pelvic dyssynergia. All told, the requested exploratory laparoscopic surgery 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 surgery with subspecialty certification in colon and rectal 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

An enrollee has requested authorization and coverage for hyaluronan injections in both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited, as he has tried and failed other conservative treatments, including repetitive corticosteroid injections, with the alternative being bilateral total knee arthroplasties. Under these circumstances, hyaluronan injections in both knees are medically necessary to treat 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

The patient has requested authorization and coverage for Botox injections in combination with Aimovig. This patients records document a history of migraine headaches. She has failed traditional migraine control treatments. The patient is currently being treated with Aimovig, which is a calcitonin gene-related peptide (CGRP) antagonist, and Botox, an acetylcholine-blocking agent. The current standard of care for the treatment of patients with chronic migraine is to use a multipronged therapeutic regimen involving different mechanisms of action. This is the reason why using Aimovig, a CGRP antagonist with Botox, an acetylcholine-blocking agent, is useful. Botox also reduces the release of inflammatory cytokines. Research by Dominguez and colleagues suggests that Botox might be more efficacious in patients with elevated serum CGRP levels. As such, using an agent that blocks CGRP such as Aimovig in patients who are good responders to Botox has been shown to have a synergistic effect. Given this support, the requested Botox injections in combination with Aimovig are 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 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 patient reportedly obtained lasting benefit from viscosupplementation in the past. Furthermore, the patients remaining treatment options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Additionally, the provider does not consider the patient to be an ideal candidate for surgery. For these reasons, the requested Orthovisc injections of both knees are medically necessary for management of this patients osteoarthritis of both knees.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 patient has requested authorization and coverage for a custom wrap around solid ankle foot orthosis (AFO). Based on the records provided for review, a custom wrap around solid AFO for the right ankle is not medically necessary for treatment of this patient. The documentation does not reveal objective evidence of osteoarthritis on imaging studies, weakness on a physical examination of the right ankle or foot, or objective findings of ligamentous instability on the right ankle or foot. There is no evidence that the patient has tried and failed a standard prefabricated AFO. A review of the literature reveals that prospective long-term studies are needed to evaluate the association between orthotic use and foot structure in the development of osteoarthritis. Given these findings, the requested custom wrap around solid AFO is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: 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 to total knee arthroplasties in the presence of mild tibiofemoral arthritis and severe patellofemoral arthritis. The provider does not recommend over-the-counter NSAIDs due to comorbid diabetes. 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Euflexxa injections for the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Under these circumstances, Euflexxa injections for the right knee are medically necessary to treat 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

The patient has requested reimbursement and prospective authorization and coverage for continuation of dual-diagnosis residential drug and alcohol treatment services. Per American Society of Addiction Medicine (ASAM) guidelines, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, intoxication and withdrawal potential, the patient has demonstrated ongoing withdrawal symptoms as per her Clinical Institute Withdrawal Assessment (CIWA) scores. Dimension 2 considers the presence of biomedical issues. This patient remains a fall risk, as she recently underwent femur repair surgery. For dimension 3, emotional, behavioral, and cognitive problems, the records report that the patients cognitive deficits have been impairing her ability to care for herself. Dimension 4 considers a patients readiness to change. The provider states that the patient expresses little or no interest in changing and considers use of alcohol part of her daily routine. For dimension 5, relapse and continued use problem potential, the patient admits that she craves alcohol and no has no plan in place to be sober, as she has not developed clear relapse prevention tools. Dimension 6 evaluates a patients recovery environment. The provider reports the patient isolates herself from her spouse and others when she drinks, so she does not avail herself of supportive resources. Given these findings, the patient meets the criteria for residential level of care services. Therefore, the continuation of dual-diagnosis residential drug and alcohol treatment services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 with expertise in addiction 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.