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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient has performed extensive prior treatment with nonsteroidal anti-inflammatory medications, gabapentin, physical therapy, bracing, corticosteroid injection and arthroscopy. He manages a family ranch and his relatively young age and high activity level are relative contraindications to total knee replacement surgery. The patient has had good relief with prior hyaluronic acid injection and repeat injections have been shown to be safe and effective. Thus, the Orthovisc injections were medically necessary for treatment of this patients osteoarthrosis.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 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: A enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). Findings:  The physician reviewer found that criteria does not support the clinical utility of breast MRI in this clinical setting. The recommendation that for patients with complaints of pain without a focal mass and lactating, that mammography is the first-line examination and then ultrasound as clinically appropriate. The guideline does not consider MRI in these clinical scenarios to be the appropriate examination of choice. Thus, the requested bilateral breast MRI is not supported as medically necessary for evaluation of this patients medical condition. 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Epclusa  The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus . The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases  and the Infectious Diseases Society of America  all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. For these reasons, Epclusa  is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 internal medicine with sub-specialty certification in gastroenterology 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). Adenocarcinoma of the lung should be evaluated for specific molecular abnormalities which have known clinical implications. Such testing is usually performed from the tissue biopsy, but can also be done from liquid assay with Guardant360. Tissue biopsy is preferable and more accurate. However, in this case, the tissue biopsy was reportedly not sufficient for such analysis. Therefore, it was elected to use the Guardant360 assay rather than attempt another tissue biopsy. Given these findings, the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the blood test (Guardant360 biopsy-free tumor sequencing test) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncologyand is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography scan provided on 2/07/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees concussion. A very common and widely researched issue confronted by emergency rooms nationwide is the over-utilization of CT scans for patients with relatively minor head trauma.  There are several programs available to help triage these patients. In an article written by Haydel in 2000, The authors concluded that CT was indicated in all patients with minor head injury. In subsequent prospective studies of patients with a score of 15 on the Glasgow Coma Scale, the rate of intracranial lesions on CT was much lower (6 to 9 percent). Various clinical presentations were found to warrant CT scans in the setting of minor trauma.  These include the presence of one or more of the following seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Since the original research, other models have become popular augmenting the Glasgow scale. These include the New Orleans Criteria and the Canadian CT Head Rule. In addition, The American College of Radiology (ACR) has established Appropriateness Criteria to help providers best utilize imaging modalities for various clinical presentations.  In the ACRs guidelines for Head Trauma imaging is not indicated for minor or mild acute closed head injury. In this patients case, the use of a CT scan was medically appropriate. On the patients initial presentation, the patient did not have a CT scan and was treated conservatively. However, her symptoms continued for 10 days. She then presented to her family physician with continuing symptoms of dizziness. While dizziness is a common ailment, one could surmise several post traumatic entities that could cause dizziness ranging from an acute disruption of the semicircular canals to temporal bone fractures. In this case, the CT was not performed acutely but 10 days following the incident due to continuing symptoms. As such, the CT scan after 10 days of persistent symptoms was medically necessary and appropriate for evaluation of the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of overactive bladder. Percutaneous tibial nerve stimulation (PTNS) as third-line therapy after failed physical therapy, medications and behavior modification has been clearly shown to have a benefit paralleling that of medical management and is recommended as a therapeutic intervention prior to more invasive techniques. The evidence suggests benefit in patients who have failed behavioral and/or medication therapies. Even in the context of post-surgical therapies, as is the case with this patient, PTNS has shown benefit if the other therapies have failed. The European Urological Association indicates PTNS has a Grade B recommendation, which is sufficient to support its use in this clinical setting. In sum, PTNS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found the requested percutaneous tibial nerve stimulation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  All three reviewers are board certified in urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Urgent PC (tibia neurostimulation). Findings:  Two of the three physician reviewers that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation (PTNS) in patients with urinary urgency and frequency. However, most trials have a small number of patients with short term follow-up. Current guidelines recommend that providers should offer behavioral therapies, including bladder training, bladder control strategies, pelvic floor muscle training, and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral anti-muscarinic therapy or oral 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. The guidelines rate PTNS as a third-line therapy. There are alternative treatments, including Botox injections and sacral neuromodulation. The use of PTNS has not been proven to be superior to other alternatives. Studies have compared PTNS to anticholinergics and have demonstrated comparable efficacy. There is a lack of head-to-head trials comparing sacral nerve stimulation to PTNS. Thus, PTNS has not been shown to be superior to sacral nerve stimulation. Therefore, the requested Urgent PC (tibia neurostimulation) is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: An enrollee has requested authorization and coverage for a spinal cord stimulator. The submitted documentation fails to demonstrate the medical necessity of the requested device. In an application for independent medical review, the patient reported that she has been diagnosed with complex regional pain syndrome. However, the notes submitted do not support the diagnosis of complex regional pain syndrome. The records do not include a physician generated history and physical examination supporting this diagnosis. There is no documentation of a diagnostic work-up performed or of past therapies trialed. The medical evidence does not support the requested device in this setting. Therefore, the requested spinal cord stimulator is not medically necessary for the 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for open treatments with rib fracture with internal fixation. Findings:  Two of the three physician reviewers found Rib fractures are common in patients with blunt chest trauma. Over the past decade, a renewed interest in rib fixation has occurred. Stabilization of the chest wall in this setting, particularly when a flail segment is present and when conservative treatment has failed, is associated with significant reductions in respiratory failure, pneumonia, and intensive care unit (ICU) stay. Non-united rib fractures are a known indication for internal fixation, particularly when multiple fractures are present. Plating is the surgical technique most commonly used. Internal fixation has been used for many years with documented good results. The two surgical procedures were necessitated by broken plates and nonunion with associated pain and clicking. All told, open treatments with rib fracture with internal fixation were likely to be more effective than other treatment options. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (rupture of membranes (ROM) testing in pregnancy). Findings:  Two of the three physician reviewers found qualitative immunochromatographic testing for ruptured membranes, such as AmniSure, has been approved by the U.S. Food and Drug Administration (FDA). These tests are alternatives to traditional testing for ruptured membranes. Traditional testing includes three elements from an evaluation of vaginal fluid: ferning, nitrazine positive and pooling. This traditional testing has been noted in the literature to be accurate with low false positive rate. On the other hand, tests such as AmniSure have been shown to have a higher false positive rates. The American College of Obstetricians and Gynecologists supports the use of these tests as a second option in cases where traditional testing is equivocal or the situation is high risk. In this case, the patient did not present with risk factors that would make using traditional testing to rule out rupture of membranes unsatisfactory. Thus, ROM testing in pregnancy was not likely to have been more efficacious than other modalities for evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 obstetrics and gynecology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for psychiatric emergency services. Findings:  The physician reviewer found that the records provided for review do not demonstrate that the services provided were for treatment of a psychiatric emergency medical condition. The patient was not in active or imminent withdrawals, was not a danger to herself or others, was cognitively intact, capable of caring for herself, and was not gravely disabled. She was medically and psychiatrically stable, and she had completed detoxification. The medication changes made during her stay were minor in nature. She did not require services at this high level of care, and could have returned to ambulatory care. She was appropriately evaluated and there was no evidence of a condition placing her health in serious jeopardy, there was no serious impairment to bodily functions, and there was no serious dysfunction of any bodily organ or part. There was no psychiatric emergency present. Although she was depressed, she was not a danger to herself or others, and was not gravely disabled. Thus, the services she received were not psychiatric emergency medical services. Final Result: The reviewer determined that the services at issue were not necessary for treatment of a psychiatric emergency medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 1.2 g. Based on the available documentation, this patient has normal stature which is not more than two standard deviations below the mean for age and gender, a normal bone age, and a normal adult height prediction that falls within two standard deviations of his genetic target height. He has no known morphological abnormalities of his pituitary gland. The fact that he had a suboptimal response to provocative GH testing does not support a diagnosis of GH deficiency, as such tests have poor specificity for the diagnosis of GH deficiency when performed with sex steroid priming in a child during the peri-pubertal period. Thus, the requested Nutropin AQ NuSpine 1.2 g is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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.