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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections for bilateral 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 has a history of osteoarthritis of both knees for many years. The available documentation reports bilateral knee pain, tenderness over the medial and lateral femoral condyles, and positive patellar grind test. The provider reported that the patient previously underwent viscosupplementation with excellent results. Furthermore, the options are limited with the alternative being bilateral total knee arthroplasties. Given these findings, the requested Euflexxa injections for bilateral knees are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 6-liter portable oxygen tank. This patient is currently receiving supplemental at 6 liters per minute (6L/min) continuously via oxygen tanks. The requested portable concentrator delivers oxygen on-demand in pulses during early inspiration, but not continuously throughout the respiratory cycle. Pulse delivery systems are lightweight and portable, and can improve the quality of life for patients with chronic lung disease. However, pulse systems are not effective in all patients. Marti and colleagues reported on a cross-sectional study that showed exercise desaturation occurred in nearly 40% of patients with interstitial lung disease using pulse delivery systems. Given the advanced nature of this patients interstitial lung disease, a portable concentrator will not likely deliver adequate oxygen to meet his cardiopulmonary needs during the day. There is an absence of documentation that a pulse-based oxygen delivery device would be safe in this patient, and yield adequate blood oxygenation. All told, the requested 6-liter portable oxygen tank is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 internal medicine with subspecialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the thoracic spine and of the lumbar spine.The submitted documentation does not support that the requested services are medically necessary. Joint guidelines from the American College of Physicians (ACP) and the American Pain Society explicitly recommend that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. The joint guidelines state that clinicians should reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.In this case, the patient has a history of degenerative disease affecting the neck and back. The submitted documentation reflects that the patient had MRI scans of his thoracic and lumbar spine as recently as 2017. This imaging demonstrated that the patient had some mild spinal stenosis of the lumbar spine, and no evidence of foraminal stenosis was noted. Records reflect that while the patient has subjective weakness, lack of mobility, and pain, no objective physical findings were noted that would indicate some deterioration of the back or legs. There are no objective findings on the physical examination or by history that would provide a clinical indication for the requested thoracic and lumbar MRI scans. Under these circumstances, the requested Magnetic Resonance Imaging (MRI) of the thoracic spine and of the lumbar spine  are not medically necessary for 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 denials should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen intravenous immunoglobulin (IVIG) (HCPCS J1459) 2 grams per kg infusions. EBV is an important pathogen in recipients of solid organ transplants. Infection with EBV manifests as a spectrum of diseases including PTLD. It is known that EBV infected B cells can cause PTLD. EBV disease and its associated PTLD is frequently seen when primary EBV infection occurs after transplant. Intensity of immunosuppressive therapies also influences the risk for PTLD. The use of EBV viral load monitoring facilitates the diagnosis and management of PTLD as well as to inform preemptive therapy with reduction of immunosuppression. There is limited data in the medical literature to support that IVIG is effective in the treatment of EBV viremia . The standard of care for treatment of PTLD is antiviral therapy, rituximab and possibly chemotherapy. All told, the requested Privigen IVIG (HCPCS J1459) 2 grams per kg infusions are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in transplant 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 enrollee is requesting authorization and coverage for transforaminal epidural steroid injection. The enrollee has lumbago, sciatica, and long term use of opiate analgesics. The enrollee received a right lumbar transforaminal nerve block. He later reported his pain has improved 60 percent since the nerve block, but the pain had returned three weeks prior. The enrollee described his pain as severe, affecting activities and sleep. He reported his pain rating as a nine on the one-to-ten pain scale. He was also experiencing numbness and a pins-and-needles sensation. He has tried non-steroidal anti-inflammatory drugs with no relief. He takes Norco every eight hours and Robaxin twice a day. His current pain medication regimen has not improved his pain. The enrollee received another right lumbar transforaminal nerve block. The enrollee has tried conservative therapy, including physical therapy and opiates, without substantial pain relief. He achieved symptom relief with two prior transforaminal epidural steroid injections. Literature shows epidural corticosteroid injections were associated with reductions in pain. A systematic review supports epidural steroid injection. Researchers report high-quality trials provide strong evidence for short-term benefit, and at least one high quality trial provided moderate evidence for long-term benefit of transforaminal epidural injections for managing lumbar disc herniation in terms of pain relief and functional improvement.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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser hair removal on the face and neck. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for some patients, interventions such as rhinoplasty or facial hair removal can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Facial hair removal is one of the most common treatments for gender dysphoria for transgender females, to reduce distress as well as to help with social functioning in living as a female. Coleman and colleagues noted that hair removal through electrolysis, laser treatment, or waxing is an effective treatment to help alleviate gender dysphoria. As this patient has documented distress related to the presence of masculine facial hair, the requested laser hair removal on the face and neck is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Factor V Leiden mutation testing (CPT 81241).  Although no DVT was identified on duplex imaging, the patient did have an episode of superficial venous thrombosis (SVT). In response to this, the work-up was appropriate, given the patients age and non-smoker status. Subsequent genetic testing was recommended to determine whether patient is Factor V Leiden heterozygous or homozygous. This genetic testing was appropriate because the homozygous state carries much high thrombotic risk compared to the heterozygous state. The homozygous state may require therapeutic anticoagulation. Additionally, genetic testing was appropriate to identify the specific mutation in order to enable testing of the patients daughter. All told, the Factor V Leiden mutation testing (CPT 81241) was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Factor V Leiden mutation testing (CPT 81241) was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in general vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Synvisc-One injections to the right knee. The enrollee has osteoarthritis of the right knee. He reportedly has tried cortisone injections without relief. An examination of the right knee showed restricted and painful range of motion. The provider noted medial and femoral condyle tenderness, and a positive patellar grind test. A Synvisc-One injection was administered to his right knee. At a follow up visit, the enrollee reported significant pain relief from the previous Synvisc-One injection. He also noted he was able to decrease his use of anti-inflammatory medications. A repeat Synvisc-One injection was recommended. A professional society reports the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who do not respond to other treatment options. Records show the enrollee has knee arthritis and has trialed previous nonsurgical treatment options, as well as surgical treatment, without resolution of symptoms. The use of viscosupplementation (Synvisc-One) injection to aid in the treatment of osteoarthritis is standard practice.Final Result: The reviewer determined that the requested services are 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 reimbursement for fertility preservation. The enrollee has breast cancer. Her treatment plan includes 12 weeks of chemotherapy followed by a double mastectomy. Her physician recommended that she freeze her eggs or embryos to protect her future fertility. She underwent fertility preservation. Literature indicates a professional society recommends that, as part of the education and consent process prior to cancer therapy, health care providers address the possibility of infertility with individuals treated during their reproductive years, or with parents or guardians of children, and be prepared to discuss fertility preservation options. Literature indicates sperm and embryo preservation, as well as egg preservation, are considered standard practice and are widely available. This enrollee is being treated for breast cancer and is at risk of developing ovarian failure. The standard of care is to proceed with egg or embryo cryopreservation.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 obstetrics 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

The enrollee requested reimbursement for transperineal placement of a hydrogel SpaceOAR. The enrollee underwent a prostate biopsy due to an elevated prostate specific antigen; it showed high-risk prostate cancer. A computed tomography scan was negative for metastasis. The enrollee elected radiation therapy, with placement of the hydrogel SpaceOAR in order to decrease the risk of rectal injury during radiation. A study reports hydrogel placement has a success rate of 99 percent. There were no device-related adverse events, rectal perforations, serious bleeding, or infections within either the treated or control group. Literature shows the hydrogel spacer application is a relatively safe procedure; well tolerated and with a high success rate. Spacer application significantly reduces radiation dosage and results in long-term reductions in rectal toxicity, as well as improvements in bowel, urinary, and sexual quality of life.Final Result: Two of the three reviewers determined that the requested services were likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology 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 enrollee is requesting reimbursement for residential treatment center (RTC) level of care. The enrollee has borderline personality disorder, major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, and alcohol use disorder. The enrollees composite LOCUS score correlates with Level IV, medically monitored non-residential services.Final Result: The reviewer determined that the requested service was not 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar dexamethasone sodium injections. Researchers concluded that the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. Researchers also found that the evidence for long-term improvement is Level II for therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. This patient presents with a longstanding history of chronic low back pain, significantly worsened over the past six months. The pain currently interferes with the patients ability to perform activities of daily living (ADLs) and sleep. She denied any radicular symptoms. Clinical examination findings are consistent with facet-mediated pain and imaging demonstrated bilateral facet arthropathy at the lower lumbar levels. The records document that the patient has failed several months of reasonable and comprehensive conservative treatment, including non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and a home exercise program. Current evidence-based medical literature supports the use of therapeutic facet joint injections in this patients clinical scenario. Therefore, the requested lumbar dexamethasone sodium facet joint injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medications Xanax (alprazolam) 0.5mg twice a day as needed and Norco (hydrocodone/acetaminophen) 5/325mg three times a day as needed.Federation of State Medical Boards guidelines for the Chronic Use of Opioid Analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a 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. CDC 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 escalationIn this case, the patient has not used either Xanax or Norco for two and one-half years. The patient was seen by her primary care provider recently, and she did not request or receive a prescription for either of these medications at that time. The patient was also seen by a pain management specialist, and after evaluating the patient, they did not conclude that the patient was a suitable candidate for Xanax or Norco due to her psychiatric comorbidities, including possible borderline personality disorder. The patients recent total body MRI demonstrated findings of degenerative disc disease of the neck and low back without significant canal or foraminal stenosis, therefore, these MRI findings did not reveal high grade stenosis that would be commensurate with the patients complaints. Under these circumstances, the requested medication Xanax (alprazolam) 0.5mg twice a day as needed is not medically necessary for treatment of the patients medical condition. In addition, the requested medication Norco (hydrocodone/acetaminophen) 5/325mg three times a day as needed is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denials should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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.