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

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with right knee osteoarthritis. A right knee x-ray revealed mild to moderate tricompartmental osteoarthritis. The patient reported right knee pain. Physical examination findings included right knee medial and lateral joint line tenderness. The patient reported that prior cortisone injections were not beneficial. The patient has requested authorization and coverage for a Synvisc-One (hyaluronan) injection for the right knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One (hyaluronan) injection for the right knee is 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. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One (hyaluronan) injection for the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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

The patient has been diagnosed with left knee osteoarthritis. The patient reported benefit from prior Synvisc injections. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted that the patient has had a positive response to prior viscosupplementation injections. The provider also noted the patient had failed treatment with cortisone injections, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient requested authorization and coverage for a Synvisc-One injection in the left knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. 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 medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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

The patient has requested authorization and coverage for weekly 50-minute sessions with a mental health provider and nutritional counseling services. Researchers noted that, psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. This recommendation is consistent with the American Psychiatric Association (APA) guidelines, which state that, to prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended. Moreover, medical literature found that psychotherapy is a first-line intervention for patients with bulimia nervosa. Psychotherapy has been shown to help reduce patients symptoms, but needs to be continued for maintenance of bulimia nervosa and major depressive disorder. The standard of maintenance psychotherapy is weekly, which is appropriate to treat this patients bulimia nervosa, major depressive disorder, and generalized anxiety disorder. Given this support, the requested weekly 50-minute sessions with a mental health provider and nutritional counseling services 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 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

The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on LOCUS criteria, this patient met the criteria for RTC treatment. The patient has a composite score which is consistent with medically monitored residence based services, such as RTC. Given these findings, the RTC services were medically necessary for the treatment of this patient.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 subspecialty certification in geriatric 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for thighplasty and panniculectomy. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Medical literature noted that the criteria for treatment by panniculectomy are that the panniculus hangs below the level of the pubis and the medical records document that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of three months. This patients panniculus does not appear to hang below the level of the pubis. The patient complains of skin breakdown underneath her abdominal pannus, but there is no report of appropriate medical treatment of skin breakdown or of failure of appropriate medical treatment of skin breakdown. The patient does not have a functional problem with skin breakdown demonstrated to be resistant to appropriate medical treatment for more than three months. Based on the medical information received for review and evidence-based literature, the requested panniculectomy is not medically necessary for treatment of this patient. Moreover, the patients abdominal pannus following weight loss is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The abdominal pannus is not an abnormal structure of the body. The patients pannus is a normal structural change that is an accommodative response to loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested panniculectomy is not being requested to address a functional deficit and would not make a more than minimal improvement in the patients appearance. Accordingly, the requested panniculectomy is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. 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

The patient has requested authorization and coverage for Restasis, or in the alternative, Xiidra. Restasis is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of dry eye disease. Patients with underlying inflammation have been shown to benefit from treatment with Restasis. This patient has dry eye syndrome. The records document that he previously experienced positive response with Restasis for the treatment of his dry eye disease. Given this support, the requested Restasis is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 reimbursement for Crinone 8% gel. This patients records document a history of early pregnancy loss. Her provider recommended treatment with Crinone 8% gel. The use of Crinone has not been demonstrated to provide benefit in this clinical situation. According to the current medical literature and guidelines from the American College of Obstetricians and Gynecologists (ACOG), vaginal progesterone in any form oral, vaginal or intramuscular has not been shown to be beneficial in the prevention of recurrent early pregnancy loss. All told, the Crinone 8% gel was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 obstetrics and gynecology 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

An enrollee has requested reimbursement for left eye corneal collagen cross-linking procedure and the riboflavin 5-phosphate ophthalmic solution, up to 3 mL. Corneal cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for keratoconus and post-refractive ectasia. The primary purpose of cross-linking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. This patient meets the criteria for corneal cross-linking with documented evidence of progressive keratoconus. Therefore, the left eye corneal collagen cross-linking procedure and the riboflavin 5-phosphate ophthalmic solution, up to 3 mL was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found that the left eye corneal collagen cross-linking procedure and the riboflavin 5-phosphate ophthalmic solution, up to 3 mL was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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, 2, and 3 are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Euflexxa injections for the right knee and/or left knee. The enrollee has osteoarthritis of both knees that causes pain. She received viscosupplementation injections one-year prior that provided eight months of pain relief. Her knee pain was preventing her from engaging in her regular physical activities. X-rays and a physical examination were consistent with tricompartmental knee osteoarthritis. A sports medicine note indicated the enrollee had tried physical therapy without relief from pain, but Euflexxa injections had helped for about a year. A professional society recommends the use of hyaluronic acid injections for appropriate individuals with knee osteoarthritis; based on the results of clinical trials.  The documents indicate the enrollee has a long-standing history of bilateral knee pain. The enrollee has completed physical therapy for several years without improvement, but has demonstrated considerable improvement, with lasting resolution of symptoms, with prior injections. The use of hyaluronic acid injections is standard practice; part of the nonsurgical treatment options to address mild to moderate osteoarthritis. A literature review revealed that intra-articular hyaluronic acid can offer low-risk, symptomatic benefits to those with knee osteoarthritis. These outcomes are demonstrated as improved overall knee health and delays in time to total knee replacement.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for two epidural injections. The enrollee has lumbar disc degeneration, lumbar radicular pain, low back pain, pelvic pain, left hip pain, and sacroiliitis. At an office visit, she reported lumbar spine pain with radiation to her groin and legs and pain around her left hip. She reported weakness, which resulted in an inability to walk. The enrollee reports the injections relieved her back pain for about six months. She underwent two epidural injections. This enrollees physical exam reports motor weakness in the left leg knee extenders and flexors, as well as weakness in left ankle dorsiflexion. This enrollee has all of the evidence-based criteria for an epidural steroid injection. A randomized controlled trial studied lumbar transforaminal epidural steroid injection for radicular pain secondary to disc herniation. The authors found 54 percent of individuals treated with transforaminal injection of steroid achieved pain relief. Outcomes were similar for those with acute or chronic radicular pain. This study provides evidence that, for persons with lumbar disc herniation, lumbar transforaminal epidural steroid injection provides a greater than 50 percent relief of pain for 54 percent of recipients at one month after treatment, it is significantly more often effective than sham and other treatments, and lumbar transforaminal epidural steroid injection substantially reduces the need for surgery.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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

The enrollees parent is requesting reimbursement for residential treatment center (RTC) services. The enrollee has diagnoses of anxiety disorder, oppositional defiant disorder, and cannabis use disorder. The enrollees composite CALOCUS score correlates with Level IV, medically monitored, community-based services. However, the enrollee requires a higher level of care; Level V, non-secure, 24-hour services with psychiatric monitoring.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for residential treatment center (RTC) services. She entered a residential treatment center after a five-day inpatient stay for an overdose. At the time of discharge, she denied thoughts of suicide, homicide, or self-harm. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollee demonstrated a high risk of harm and a low ability to function. The enrollee had been unsuccessful with previous treatment attempts. The enrollee experienced difficulties with family or relationships, but did have a support system in place. The enrollees composite LOCUS score correlates with Level IV, a partial hospitalization program; however, the enrollees score of four on dimensions I, II and III requires a higher level of care.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 robotic unroofing surgery to repair the myocardial bridge.The medical literature does not support that the requested robotic unroofing surgery to repair the myocardial bridge is medically necessary. While surgical unroofing of a myocardial bridge is generally accepted as appropriate treatment in selected patients with refractory myocardial ischemic symptoms, there have been no outcomes data comparing standard open heart surgical approaches to robotically assisted off-pump procedures. In this case, the patient has sufficient symptoms and objective findings to justify surgery. However, there is insufficient data to recommend the robotic procedure, and she does not represent a prohibitive surgical risk for a standard surgical approach. Under these circumstances, robotic unroofing surgery to repair the myocardial bridge is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.