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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injection series in the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed conservative treatments. The alternative is a total knee arthroplasty, which the patient does not want because of her experience with the right knee. Therefore, the requested Supartz injection series for the left knee is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a bilateral knee magnetic resonance imaging (MRI). The American College of Radiology (ACR) appropriateness criteria for chronic knee pain notes that imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. While plain x-rays may be of limited value due to the menisci and ligaments not being visible, they may be used to assess the degree of degenerative disease and whether there are any acute bony structural abnormalities. In this case, plain x-rays demonstrated moderate-to-severe degenerative disease of the bilateral knees and described bone-on-bone osteoarthritis. In this clinical setting, while an MRI may demonstrate meniscal tears as well as ligamentous disruption, the status of the ligaments is irrelevant to the patients workup and management options, given that the plain x-rays demonstrated virtually complete loss of the menisci and severe arthritic change. Therefore, a bilateral knee MRI is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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 factor V Leiden and prothrombin gene testing services. Researchers note that venous thromboembolism (VTE) is a significant clinical event. Generally, patients with VTE with at least one first degree relative with documented VTE before age 45 have the highest risk of having an inheritable thrombophilia disorder and should be tested for the presence of all five inherited thrombophilia, of which factor V Leiden and prothrombin gene mutation are the most common. In this case, the patient reported that his mother had a history of massive blood clots. In this clinical setting, identification of an inheritable disorder would influence testing needs for other family members and affect future decision making for this patients course, given his higher risks for travel or surgery. Therefore, factor V Leiden and prothrombin gene testing services are 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 requested factor V Leiden and prothrombin gene testing services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician Reviewer 3 is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a home oxygen tank.Current standards-of-care and best practice guidelines support prescribing home oxygen for patients with hypoxemia at or below oxygen saturation level of 88%. In this case, the patient has no evidence of reproducible exertional hypoxemia. Although there are reports of oxygen saturation of 78% with ambulation, these findings could have been spurious, particularly in the setting of a poor quality plethysmograph. Moreover, repeat ambulatory oximetry on two separate occasions showed normal oxygen saturation during ambulation up to 200 feet. The submitted documentation fails to demonstrate the medical necessity of the requested equipment at this time. Therefore, a home oxygen tank is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that 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 sub-specialty 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 physical therapy three times a week or physical therapy two times a week. Findings:  The physician reviewer found that The importance of the acetabular labrum has been increasingly recognized, playing a critical role in both normal anatomy and abnormal pathology of the hip joint. The author further state, In the setting of femoroacetabular impingement (FAI) or dysplasia, bony biomechanics may cause labral injury, which may translate to patient symptoms. Long-term consequences of labral tears may include joint degeneration. Additionally, Freke and colleagues state, People with symptomatic FAI demonstrated some deficits in hip muscle strength and reduced balance on one leg when compared with control subjects. For hip joint ROM and hip muscle strength results for within-group differences between preintervention and postintervention time points were limited and inconclusive. Further, Mansell and colleagues conducted a study comparing the effectiveness of surgery with nonoperative management. The authors found no significant difference between treatment with surgery alone and physical therapy alone. In this case, the patient underwent surgery in 2020 to address her hip pathology. Following her hip surgery, the patient underwent physical therapy. There are no documented impairments that require any ongoing formal physical therapy. The patient reports she has core and hip weakness, for which she needs ongoing physical therapy. This issue, however, can be addressed with independent exercise. Therefore, physical therapy three times a week or physical therapy two times a week is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 a tension-free mesh technique procedure for hernia repair. Researchers note that there is no one standard repair technique for groin hernias. In this case, the patient has right chronic post inguinal herniorrhaphy groin pain. While he has been seen multiple times for right chronic post inguinal herniorrhaphy groin pain, the records do not document an indication for a second surgery, such as a recurrence of right inguinal hernia or signs of mesh infection. Although there is documentation that the patient declined injections due to the short duration of relief provided by cervical injections, it is unclear whether the processes of diagnostic injections and potential nerve ablation have been adequately described to the patient, as the potential for improvement is much different than with the cervical injections. Given that there are more conservative medical treatments for the patients symptoms, such as nerve block or ablation and non-steroidal anti-inflammatory medications, the requested service is not medically indicated. Therefore, a tension-free mesh technique procedure for hernia repair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 general 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

Findings:  The physician reviewer found that The patient has requested reimbursement for inpatient hospitalization services. Agrawal and colleagues note that hysterectomies may be performed as a  minimally invasive procedure, abdominally, or vaginally. Lee and colleagues note that same-day discharge after robotic-assisted hysterectomy for benign and malignant conditions is feasible and safe. Soto and colleagues note that total laparoscopic hysterectomy can be performed safely and in less operative time compared to robotic hysterectomy. A laparoscopic hysterectomy has multiple advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions, and are usually outpatient procedures unless a complication arises. In this case, the records did not document conditions for which inpatient admission may be indicated following a laparoscopic hysterectomy, including surgical complications such as bladder ureter or bowel injury or hemorrhage, conversion to abdominal hysterectomy, complex surgery such as the staging of endometrial cancer, wound complications, and comorbidities. There was no evidence of any injury to other organs. While the records noted significant blood loss during the surgery, the patient received blood transfusions and there was no evidence of postoperative bleeding. As a laparoscopic hysterectomy is an outpatient procedure, and as the submitted records did not suggest any serious problem warranting inpatient admission, the services at issue were not medically necessary. Therefore, inpatient hospitalization services were not medically necessary for the 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  Two of the three physician reviewers found that the requested PSMA PET scan is 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occipitocervical fusion. The records provided for review document that this patient has a history of occipital neuralgia secondary to post Chiari decompression procedures. Occipital neuralgia is characterized by severe pain in the distribution of the greater auricular nerve. Although patients with occipital neuralgia may require surgery, such as laminectomy and fusion, there is a lack of evidence to support the efficacy of occipitocervical fusion for this syndrome.  Researchers found that, minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. The authors cautioned that, Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options. There is adequate data demonstrating that occipitocervical instability may be treated with occipitocervical stabilization and fusion. However, this patients records do not document the presence of occipitocervical instability. Given these findings, the requested occipitocervical fusion is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 lumbar/sacral transforaminal epidural injection. The American Society of Interventional Pain Physicians (ASIPP) guidelines for epidural steroid injections addressed approaches to repeat injections in a series. ASIPP reported that, In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be two-and-a-half to three months or longer between each injection, provided that greater than 50% relief is obtained for two-and-a-half to three months, not exceeding four per year, per region (Manchikanti, et al.). In this case, the patient has lumbar radiculopathy affecting the left lower leg and heel. MRI has demonstrated multilevel degenerative disc disease and joint disease causing canal stenosis at the lower three lumbar levels and an additional 6 mm disc herniation at L5-S1 displacing the left S1 nerve root, which correlates with the patients symptoms. The patient has tried and failed conservative care and underwent an epidural steroid injection with 40% pain relief and ongoing symptoms. The records do not include documentation of improvement in functional capacity and the patients pain score was 5/10 on follow-up. According to the ASIPP guidelines, repeat injections may be considered when a patient reports at least 50% pain relief for at least three months. This patients response was less than 50% with ongoing symptoms. Given these findings, the requested lumbar/sacral transformational epidural injection is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 patients parent has requested authorization and coverage for (1) 15 hours per week of community applied behavior analysis (ABA) services, and (2) five hours per week of in-home with parent consultation ABA services. Findings:  The physician reviewer found that Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that the essential components of an individualized ABA treatment plan include a comprehensive evaluation to inform treatment goals, data based decision making, and establishing a learning environment that is conducive to treatment and that minimizes maladaptive behavior. In this case, the records note that the community setting is not conducive to the treatment of this patient due to significant maladaptive behaviors observed in the community setting. The patient is to be evaluated in the in-home setting to inform treatment modifications that would allow the patient to gradually resume treatment in a community setting. In this clinical setting, given that the providers recommendation against a community setting appears to be within established ABA guidelines, (1) 15 hours per week of community ABA services are not medically indicated. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research, and that they should be rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the home is currently the least restrictive environment that is appropriate for the delivery of ABA services. Therefore, (2) five hours per week of in-home with parent consultation ABA services are medically necessary to treat the patients condition to correct or ameliorate any physical or behavioral conditions. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OL1000 Bone Growth Stimulator (E0747). Although electrical bone stimulation may be a helpful adjunct to promote bone healing, its efficacy remains unclear. Quality studies have reported mixed results in determining whether bone growth stimulator devices successfully promote bone healing. There are data supporting the use of electrical stimulation in promoting bone healing for cases involving spinal fusions and certain long bone fractures, but there is a lack of evidence supporting bone healing for other applications. Haglin and colleagues concluded that substantial evidence is lacking for the treatment of acute high-risk fractures or delayed union and nonunion after fractures with bone growth stimulation. Given the uncertain benefit of electrical stimulation, particularly in foot and ankle cases, the utility of a bone growth stimulator is not likely to be more beneficial for this patients fracture nonunion. For these reasons, the requested OL1000 Bone Growth Stimulator (E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested OL1000 Bone Growth Stimulator (E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.