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 Euflexxa injection series in the right 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 options are limited. The patient has failed other conservative treatment, including a corticosteroid injection. Therefore, the requested Euflexxa injection series in the right knee is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in the left knee.Findings: 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, there is a history of relief with viscosupplementation using Monovisc. Furthermore, the options are limited. The patient has tried and failed other treatments, including physical therapy and platelet rich plasma injections. Therefore, the requested Monovisc injection in the left knee is medically necessary for the 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a microsurgery lymphovenous bypass procedure. Garza and colleagues describe lymphaticovenular anastomosis or lymphovenous bypass as, A surgical procedure where lymphatic vessels in a lymphedematous limb are connected to nearby small veins and venules using microsurgical and super-microsurgical techniques. This allows the clearance of lymphatic fluid from the affected limb, by utilizing the venous system, which has the capacity to easily accommodate the extra fluid volume, as an outflow. A direct surgical connection is created between the overloaded lymphatic channels, proximal to the site of the lymphatic obstruction, and nearby venules. The authors further note, Numerous studies have been published which show improved symptoms and as much as 61% reduction in volume difference of the affected limb after lymphaticovenular anastomosis at one year. Schaverien and Coroneos note, Observational case-control and cohort studies support the efficacy of lymphovenous bypass and vascularized lymph node transplantation for lymphedema in reduction of limb volume and episodes of cellulitis. The available literature supports favorable limb volume reduction outcomes for both orthotopic and heterotopic lymph node flap transfer in both the upper and lower extremities. Pereira and colleagues report that lymphovenous anastomosis is an effective treatment option to reduce the volume in the affected limb and to improve symptoms involved. In this clinical setting, the use of the requested service is supported by current medical literature in treating this patients condition. Therefore, the requested microsurgery lymphovenous bypass procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested microsurgery lymphovenous bypass procedure 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 service is 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 reviewer 1 is board certified in plastic surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in general surgery and in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a stem cell injection to the right knee. Current medical literature does not support the use of injection of stem cells or hyaluronic acid following total knee arthroplasty as an effective method of diminishing residual pain. In this case, the patient underwent right total knee arthroplasty for painful end-stage osteoarthrosis the previous year. Visit notes reported that the patient received a PalinGen SportFlow injection, described by the manufacturer as an amniotic tissue allograft containing cellular components, cytokines, growth factors and extracellular matrix proteins that are naturally found in amniotic tissues. Amniotic fluid derived injections do not contain live cells. There is a lack of scientific evidence on the efficacy of hyaluronic acid and/or of amniotic tissue allografts for the treatment of residual pain in this clinical setting. Therefore, the stem cell injection to the right knee was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the stem cell injection to the right knee  at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Supartz injections to the right 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 options are limited. The patient has undergone a right total knee replacement with the exception that the patella was not replaced. The provider has tried a cortisone injection without success. Thus, the Supartz injections to the right knee were medically necessary to treat the patients medical 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the pacemaker provided on 12/15/20. Findings:  The physician reviewer found that  use of an accelerometer based leadless device in a younger patient who requires only single chamber sensing/pacing with complete heart block is a reasonable choice of pacemaker in this clinical setting. In this case, the patient required a permanent pacemaker after surgery with a persistent complete heart block. A Micra accelerometer leadless device was selected given the patients young age and the possible likelihood of multiple revisions and/or lead fracture in a young, active patient over a long lifetime. Additionally, the patients sinus node function was intact, and a single chamber device was all that was necessary for the management of a complete heart block. There was also a small chance that over several weeks/months after healing from surgery the AV block may have resolved, obviating the need for the pacemaker and making a leadless device a more attractive option as well. Therefore, the pacemaker provided on 12/15/20 was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the device at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a knee magnetic resonance imaging (MRI). The submitted documentation does not support the medical necessity of the service at issue. The American College of Radiology (ACR) appropriateness criteria for chronic knee pain note an MRI may be indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. The guidelines further note an MRI is not indicated before completing a physical examination and radiography, or for the conditions of severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. A study reports  the management of patients with knee pain is nonoperative both for degenerative meniscal tears and degenerative joint disease in its initial stages, and MRI studies add little value in the management of middle-aged and elderly patients with degenerative disease. The study further notes failure to respond to nonoperative measures warrants orthopedic assessment with radiographic studies and counseling on managing degenerative joint disease both nonoperatively and operatively. In this case, the patient was being treated for a medial meniscus root tear. The records reported knee pain with swelling and pain on ambulation and stair negotiation, and on examination, the knee was swollen and painful on mobilization. However, the submitted records did not include a recent knee x-ray or documentation of the trial and failure of conservative care measures. Therefore, the knee MRI was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined the service at issue was 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 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 Hill-Rom Envella Micro Bead Sand Bed. Arnold and colleagues note that multiple case series suggest that air fluidized therapy/continuous low-pressure pressure redistributing beds in long-term acute care hospitals facilitate the healing of advanced wounds in medically complex patients when included as part of a wound care program. However, VanWyhe and Willer note that air-fluidized therapy beds were associated with user dissatisfaction and staff injuries. McInnes and colleagues report that based on the current evidence, it is unclear whether any particular type of low or high tech support surface, such as low air loss beds, air suspension beds, and alternating pressure surfaces, is more effective at healing pressure ulcers than standard support surfaces. In this case, while the patient remains at risk for pressure injuries. The records document intact skin. Given that pressure injury prevention may be accomplished using routine repositioning and one of many different bedding surfaces or overlays, including a gel overlay, a low air loss mattress, or a foam mattress, the requested equipment is not medically indicated. Therefore, a Hill-Rom Envella Micro Bead Sand Bed is not medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Findings: The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; when there are four or more attacks per month; or when there is a contraindication to, failure, or overuse of acute treatment. Currently, Botox is approved for chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages of injectable therapies. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. A 2018 review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine by a study noted that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has a history of chronic migraines that did not respond to oral preventative medications, including Aimovig, Topamax, phenytoin, and sumatriptan. Based on the AHS statement, AAN guideline, and study noted above, the patient is an appropriate candidate for prophylactic treatment with botulinum toxin therapy. Therefore, the requested Botox injections are medically necessary for the treatment of the patients medical condition.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 medication Vasculera. The mainstay of pharmacologic treatment for POTS is beta-blocker therapy. Nonpharmacologic treatments include optimizing hydration, exercise, elevating the head of the bed, and lower body compression stockings. Patients are also advised to avoid precipitating causes such as dehydration and to withdraw medications that might predispose to tachycardia. A study found failing beta-blockers, additional medications utilized for POTS include fludrocortisone, midodrine, pyridostigmine, clonidine and ivabradine. In this case, the patient has a history of POTS and is reported to have been unsuccessfully treated with metoprolol. The patient has requested authorization for the medication Vasculera, which is categorized as a medical food and is purported to help with chronic venous insufficiency disorders. There is a paucity of literature support for the safe and effective use of Vasculera for the treatment of POTS. Under these circumstances, the requested medication, Vasculera, is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. The first step in the evaluation of a palpable mass is imaging, which then determines the need for biopsy to rule out cancer. Per the American College of Radiology (ACR), Ultrasound should be the first imaging study in a patient younger than 30 who presents with a palpable mass. This patient presented to her provider with a palpable left breast mass. The provider noted that the patient also has an extensive family history of cancer. Consistent with the ACR recommendations, the ultrasound of the left breast performed in September of 2020 was appropriately chosen as the first imaging modality for evaluation. The ultrasound performed in September of 2020 was indicated to prevent serious deterioration of the patients health resulting from unforeseen illness for which treatment could not have been delayed until the patient returned to the plans service area. Given these findings, the left breast ultrasound performed was provided for evaluation and treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the services at issue were urgent care services as defined by California law. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in surgical oncology 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.