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

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement for partial hospitalization program services and prospective authorization and coverage for future partial hospitalization program services specializing in children with autism. This patient completed approximately six weeks of partial hospitalization program treatment. He has a confirmed diagnosis of autism and has been referred for ABA services. Progress notes from the partial hospitalization program indicate that the patient continued to have some potential aggression issues. The progress notes indicate that ABA therapy on an outpatient basis was recommended and was occurring. The progress notes do not indicate clinical reasons as to why partial hospital program would be necessary to treat the patient versus ABA therapy, which is routinely administered on an outpatient basis. The patient did not have active medical issues that were affecting his treatment. His family is actively engaged in treatment. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. The patient has a composite score of 15. This score correlates with intensive outpatient services. Therefore, partial hospitalization program services and future partial hospitalization program services specializing in children with autism were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 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 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 Orthovisc injections to both knees. A health technology assessment from the ECRI Institute concluded that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. However, there are questions remaining about the most effective formulations, which populations benefit most, and whether hyaluronic acid injections combined with other agents will increase effectiveness. The American Medical Society for Sports Medicine (AMSSM) supports hyaluronic acid injections in the knees for patients who have failed to respond to conservative treatment and to potentially delay total knee replacement in patients with severe osteoarthritis and pain that interferes with functional activity. This patient presents with chronic bilateral knee pain with intermittent giving way of the left knee. She is status post bilateral knee anteromedialization osteotomy and medial patellofemoral ligament reconstruction in 2017, with subsequent deep implant removal from both knees. She reports limited ability to participate in physical therapy due to pain. Clinical examination findings are consistent with reported imaging evidence of degenerative changes. Conservative treatment has included physical therapy, activity modification, home exercise, NSAIDs, and corticosteroid injections with limited relief. Prior treatment with hyaluronic acid injections over the past 10 years provided significant benefit for six to eight months. The records document pain and functional limitations in addition to failure of comprehensive conservative treatment. In an attempt to potentially delay total knee arthroplasty, the requested Orthovisc injections to 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total hip arthroplasty using the anterior approach. Findings:  The physician reviewer found that the choice between anterior approach and posterior approach in primary total hip arthroplasty remains controversial. In the first study referenced below, patients treated with the anterior approach reported less pain, consumed fewer narcotics, and reported better hip function. There were no statistical differences in complication rates between the anterior and posterior approach patients. According to the second study referenced below, the surgical procedure time is longer with the anterior approach, but the incision is shorter, pain is less, patients require less opioid medication, and the length of stay is shorter. The anterior approach goes between muscles, hastening the subsequent rehabilitation and preventing muscle atrophy. There is sufficient support for the requested services in this clinical setting. Therefore, a total hip arthroplasty using the anterior approach is medically necessary for the 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection to the left knee. 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 has a diagnosis of osteoarthritis of the left knee. She has reportedly obtained excellent benefit from hyaluronic acid injections in the past. The provider noted the patient is attempting to delay total knee replacement surgery and is a candidate for repeat injections. Therefore, the request for Synvisc One injection to the left knee is medically necessary for treatment of osteoarthritis of the patients left knee.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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for oxycodone and morphine. The Guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Guidelines also state that continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of evidence of the patients progress toward treatment objectives, and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.  This patient has chronic pain. The current medical evidence does not support the requested medications in this clinical setting. The risks of combining opioid therapy with sedatives and cannabis outweigh any potential benefit of chronic opioid therapy. Therefore, oxycodone and morphine are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Synvisc One injections to both knees. The enrollee has osteoarthritis of both knees that causes pain.She has tried over-the-counter medications and cortisone injections, which did not improve her symptoms.  She has been receiving hyaluronic injections and recently she had injections as prescribed by her orthopedist but had limited benefit from these. She has not had other treatment since and it is recommended she be evaluated for possible knee replacement surgery.  However, since she is young for knee replacement surgery, she would like to consider other options rather than a knee replacement. Findings:  Review of the record indicates the benefit to the enrollee from hyaluronic acid injections was mild and was wearing off in a short period of time.  The medical literature is summarized as not supportive regarding the use of hyaluronic acid. Most studies show that it does not show superiority over other treatments; including placebo.  In a study of hyaluronic injection for osteoarthritis of the knee, trials did not show clinically important differences of hyaluronic acid treatment to that of a placebo, which is a substance with no clinically beneficial effect. The use of any intra-articular hyaluronic acid formulation is not recommended due to the lack of robust evidence demonstrating benefit. There has been a longstanding debate and conflicting data across trials and analyses regarding the benefit of viscosupplementation (such as, intraarticular hyaluronic acid) for the treatment of symptomatic knee osteoarthritis. Further, intraarticular hyaluronic acid is associated with potential side effects such as pain flare-ups. The use of hyaluronic acid is not supported since studies have not shown clinically important benefits in the outcomes. A critical review of the safety and efficacy of hyaluronic injections indicated the evidence remains inconsistent and controversial for the use of intra-articular injections.  They concluded future trials are needed.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Injection Euflexxa for the left knee at a dosing once a week for three weeks. The enrollee has a history of left knee osteoarthritis and pain. Findings:  The physician reviewer found that a magnetic resonance imaging scan performed demonstrated a degenerative complex tear of the body and the posterior horn of the medial meniscus, tricompartmental diffuse degenerative cartilage erosions, and semi-membranous tendinopathy. A repeat MRI demonstrated the addition of a small joint effusion with evidence of synovitis.  Hyaluronic acid injections were prescribed which helped her pain. An x-ray of the left knee showed severe medial degenerative joint narrowing and moderate anterior compartment degenerative joint disease.  Her orthopedist notes she has failed extensive non-surgical treatment and has recommended possible arthroscopy and Euflexxa injections of the left knee.  The patient states she was told by her prior orthopedist that as long as the injections continue to work she can delay a knee replacement surgery. Medical literature does not recommend hyaluronic acid (Euflexxa) injections.  There is no evidence that hyaluronic acid injections result in a delay of knee replacement. Additionally, studies show that it does not show superiority over other treatments; including placebo.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 orthopedics and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injections to both knees for osteoarthritis. Findings:  The physician reviewer found that she has had bilateral knee pain, right worse than left, for the last few years. She received cortisone injections to her knees.  At a visit with her orthopedist she indicated the injections provided relief for many months but the pain had worsened over the last few months. An x-ray of the bilateral knees showed tricompartmental degenerative changes bilaterally, most pronounced in the patellofemoral compartments, right slightly greater than left, and small right and tiny left effusions.  The physician discussed conservative management options, including non-steroidal anti-inflammatory drugs, activity modifications, cortisone injections and viscosupplementation. She elected to proceed with cortisone injections. At the next visit, the enrollee reported continued pain and requested a trial of Orthovisc, which was administered then and at two subsequent visits. When she was seen again, she indicated significant knee pain was impacting her activities of daily living and activity.  The treatment plan included conservative treatment and cortisone injections. A study in the medical literature indicates the use of any intraarticular hyaluronic acid formulation is not recommended due to the lack of robust evidence demonstrating benefit. There has been a longstanding debate and conflicting data across trials and analyses regarding the benefit of viscosupplementation. Evidenced-based studies do not demonstrate that hyaluronic acid injections result in a delay of knee replacement. Additionally, studies show that it does not show superiority over other treatments; including placebo. Review of the record indicates the enrollee had previous benefit from hyaluronic acid injections, but the benefit was mild and was wearing off in a short time. Guidelines do not recommend the use of hyaluronic acid injections.  Final Result: The reviewer determined the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Otezla (apremilast) medication. The enrollee is diagnosed with moderate to severe plaque psoriasis. According to his provider, other medications have been avoided due to their immunosuppressive properties and side effects, and that disease-modifying antirheumatic drugs (DMARDs) and ultraviolet light have been avoided due to anxiety, depression, and the sensitive area of plaque. There are no head-to-head studies comparing the multiple medications available at this time to treat psoriasis.  In an enrollee such as this, they list apremilast as a first line agent along with multiple other agents. Otezla has been effective in treating this enrollees condition. There is a risk in changing medications at this time. Very recent data indicates that patients started on apremilast were as likely as patients started on a biologic agent to still be on the same medication after a year. These data suggest that the effectiveness of apremilast can be expected to continue. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for Easystand Zing Size 2 Multi-Position Stander. According to the medical record, the enrollee has spastic hemiplegic cerebral palsy and intractable epilepsy. She is unable to walk or stand on her own, unable to sit upright on her own, and uses a wheelchair for mobility. Her physician has prescribed an adaptive stander/walker (Easystand Zing Size 2 Multi-Position Stander) since the enrollee needs a gait trainer due to lack of balance and spasticity. The enrollee had a trial with the Zing Stander in two sessions with the ability to adduct 30 degrees. The physician requires the enrollee to be standing and weight bearing daily to promote healthy bone density and efficient digestive function. According to the medical literature, passive range of motion, bowel function, pain, activity, and participation may improve for some adolescents at gross motor function classification system (GMFCS) level V, through use of a stander. The intensive active stretching in a dynamic stander is an effective new conservative clinical treatment of ankle plantarflexor contracture in children with cerebral palsy (CP). Standing frames are beneficial for contracture management. Standing should occur thirty minutes, five times a week for a positive impact. Supporting standing devices allow the user to attain and maintain a standing up/partial standing position.  Literature details beneficial effects of standing devices on range of motion, as well as spasticity and bowel function for participants of all ages.  Within the submitted documentation it was noted the enrollee has trialed the requested device while in therapy with benefit.  Final Result: Three of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. Encephalitis is a neurological syndrome caused by inflammation of the brain parenchyma (Britton, et al.). Treatment is challenging due to rapid disease progression, a broad differential diagnosis, and a lack of definitive treatment. The records provided for review document that this patients providers determined that he was stable for transition to a less acute level of care. The records document that the patient had no further neurologic work-up planned that would have required continued hospitalization. The patients diagnoses included right ischium and heel pressure ulcer, urinary retention, hypertension, hyponatremia, and Clostridium difficile. The patient did not require acute care or the intensity of services provided at the inpatient hospitalization level of care. Therefore, the inpatient hospitalization services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.