Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services provided. The Health Plan has denied this request indicating that the services at issue were not emergency medical services. A review of the record indicates that the enrollee was evaluated by a plastic surgeon for bilateral congenital ear anomalies. Following evaluation, the enrollee proceeded to have EarWell devices placed bilaterally. The devices were replaced every two weeks, with follow-up treatments. The patient reponded well to the treatments without incident.In this case, the patient had a congenital deformity that was not addressed immediately. There is only a 3 month window to initiate EarWell System treatment in order to avoid future reconstructive surgery. Because of the limited treatment time, the evaluation of this infant was emergent, as was initiating and replacing the EarWell treatment. Treatment of the patients bilateral malformations of the ears was required to address and relieve serious dysfunction of a bodily part. Accordingly, the services at issue were necessary for treatment of an emergency medical condition, and the patient received emergency medical services. Final Result: The reviewer determined that the requested emergency 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 otolaryngology, and in plastic surgery within the head and neck 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 Orthovisc injection. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee's osteoarthritis. The submitted documentation supports the medical necessity of the requested service.  Given the history of significant benefit from prior injections, the current literature supports the use of viscosupplementation in this clinical setting.  There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The researchers noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use 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. Therefore, the requested Orthovisc injection is medically necessary for the 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 Otezla 30 mg, twice daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The American College of Rheumatology does not currently have national guidelines on the recommendations for the treatment of psoriatic arthritis. The European League Against Rheumatism has recently released national guidelines for the treatment of psoriatic arthritis. The guidelines recommend conventional synthetic disease-modifying antirheumatic drugs as an initial therapy after failure of nonsteroidal anti-inflammatory drugs and local therapy for active disease. If additional treatment is necessary, a biologic disease-modifying antirheumatic drug or a targeted synthetic disease-modifying antirheumatic drug is recommended. The initial biologic disease-modifying antirheumatic drug is generally a tumor necrosis factor inhibitor. In this patients case, the records do not document failure or U.S. Food and Drug Administration (FDA) approved package insert contraindication to biological disease-modifying antirheumatic drugs. Anti-tumor necrosis factor agents have been proven very effective for psoriatic arthritis and are disease modifying agents. They prevent progression of disease, erosions and disability and are thus the preferred agent for psoriatic arthritis. The current literature supports the use of conventional and biologic agents (anti-tumor necrosis factor agents)over the use of targeted synthetic biologic (Otezla) for the treatment of psoriatic arthritis.  Although there is some literature to suggest that use of Otezla with other biologic agents may be safe, there is currently no national guidelines or large randomized controlled studies demonstrating this.  As such, Otezla 30 mg, twice daily is not medically necessary for the 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 internal medicine with sub-specialty certification in rheumatology 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 Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis vulgaris.  The submitted documentation supports the medical necessity of the requested medication. Otezla was approved by the U.S. Food and Drug Administration in 2014 and became standard of care around that time.  National guidelines in the United States are not up to date on the treatment of psoriasis, especially given the new discoveries and treatments over the last few years. There are more recently published guidelines in Canada that recommend use of Otezla as first line treatment. This is based on trials which have shown safety and efficacy of Otezla in treating chronic plaque psoriasis. Thus, the medication is currently FDA approved and is safe and effective. There are no step therapy guidelines in existence in the United States, and the choice regarding which systemic treatment a patient is prescribed is based on comorbidities and individual response at this time. The requested medication is medically appropriate in this clinical setting. Therefore, Otezla is medically necessary for the 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 dermatology 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 review of the records indicates that the enrollee was admitted to a partial hospitalization program. After an initial period of authorized services, the Health Plan indicated that, the enrollee did not require more intensive evaluation and treatment than from a lower level of care. The submitted documentation does not support the medical necessity of partial hospitalization program. The patient was not in severe withdrawals. She had moderate cravings for THC and reported moderate fatigue. She denied suicidal or homicidal ideation. There were no emotional, behavioral, cognitive, or impulsive barriers to stepping down to a lower level of care at that point, as she did not require frequent medical and nursing supervision. The patient was medically and psychiatrically stable, and she was medication compliant. The patient was highly motivated, actively participating, and residing in a sober living environment which she experienced as not stressful. All of these factors lessened her chances of relapse. She had support at home. There was no evidence that stepping down to a lower level of care would lead to deterioration in the patients clinical status. Under these circumstances, partial hospitalization program services provided were not medically necessary for treatment of the patients behavioral health conditions.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase in tramadol dose. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees medical condition. Nationally recognized evidence based medical guidelines recommend tramadol as an option for pain treatment. Tramadol is indicated for treatment of moderate to severe pain. There is limited information to recommend this drug for neuropathic pain. The immediate release formulation is recommended at a dose of 50 to 100 mg by mouth every four to six hours (not to exceed 400 mg per day). Opioids appear to be efficacious, but should be limited for short-term pain relief in patients with acute low back pain. Long-term efficacy is unclear (greater than 16 weeks), and there is also limited evidence for the use of opioids for chronic low back pain. Failure of activity level to respond to a time-limited course of opioids has led to the suggestion of reassessment and consideration of alternative therapy. Overall, the safety of long-term use has not been adequately studied, and some non-randomized prospective studies suggest opioid treatment may actually impede functional recovery.  Researchers concluded that the evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms. Medical literature shows chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events. This patient presents with chronic pain relative to lumbar degenerative disc disease and arthritis, status post back surgery. There is no indication provided to support the medical necessity of an additional increase in tramadol dose. The records do not support an escalation in dose or that the patient is achieving pain reduction and functional improvement with the use of this medication, and there are no side effects or aberrant behaviors. Therefore, the request for an increase in tramadol dose is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy (CPT code 15830). This patient presents with documented evidence of an overlapping symptomatic lower abdominal pannus. She is reported to have functional impairment with painful rashes and fissures from the overlying pannus. Further, her condition has been documented to affect her ability to complete her activities of daily living (ADLs). The provider noted the patient has been treated with adequate conservative modalities including topical dermatologic treatment, antibiotics, creams, and ointments for over one year. The photographs provided for review show evidence of a mild to moderate condition. In addition, the providers notes document evidence of functional impairment related to the presence of excess abdominal tissue. Therefore, a panniculectomy is supported and expedited to significantly improve the patients functional impairment related to the overlying pannus. All told, the requested panniculectomy (CPT code 15830) is medically necessary for treatment of this patients adiposity secondary to Cushings disease. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested authorization and coverage for Euflexxa shots series of three for the left knee every six months. In the current peer-reviewed medical literature, the authors conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee. The authors concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Further, the researchers found that repeated cycles of intra-articular sodium hyaluronate in patients with knee osteoarthritis was found efficacious during a 54-month follow-up period. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. This patient presents recurrent left knee pain and stiffness. She had reportedly failed to improve with NSAIDs and analgesics. Prior viscosupplementation has been performed with good benefit and 50% pain reduction for at least six months. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Given this patients previous response, repeat viscosupplementation injections are indicated. However, there is a paucity of data supporting a clinical indication for a series of Euflexxa injections to be repeated every six months. Therefore, current Euflexxa injections, one series of three injections, to the left knee is likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. One reviewer found that Euflexxa shots series of three for the left knee every six months are not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Final Result: Two of the three reviewers determined that a portion of the requested services 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a repeat biopsy. The 2018 NCCN guidelines on prostate cancer indicate that a repeat biopsy should be considered if the prostate exam changes, if a multiparametric MRI (mpMRI) indicates a more aggressive disease or if the PSA value changes. The guidelines further recommend monitoring of diagnosed prostate cancer with PSA testing every 3-6 months accompanied by digital rectal exams. If there is new or worsening bone pain, additionally a bone scan is recommended at detection and every 6-12 months. Here, the patient was diagnosed with relatively low-risk (Gleason 3+3) prostate cancer. Documentation does not indicate an increase in PSA that might warrant a biopsy. Records do not show that the patient has had an mpMRI, nor are there any other indicators that this patient has an aggressive form of prostate cancer. There are no recent prostate exam findings that indicate a noteworthy change in the patients condition. Lastly, there is no isolated mass that might be targeted for a second biopsy. Therefore, a repeat biopsy is not medically necessary for this patient at this time.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 urology 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 a podiatry referral. Per the reviewer, it is well documented in the progress notes that this patient suffers with bilateral foot pain that is unresponsive to cortisone injections, NSAIDS, orthopedic footwear and Icy Hot gel. The patient is unable to ambulate comfortably. An x-ray confirmed plantar calcaneal spur along with bilateral osteoarthritis of the foot. The patients primary care providers have been unable to treat this patients foot conditions. A podiatrist may have different insight into the patients foot pain which would allow for further treatment. Therefore, the requested podiatry referral is medically necessary.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 a board-certified podiatrist 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 microwave ablation. Findings: Two out of three physician reviewers found that microwave ablation is likely to be more beneficial for treatment of this patients condition than any available standard therapy. In this case, due to the solitary recurrence with no evidence of distant disease on her most recent restaging studies, it is reasonable to consider local therapy to her liver lesion. Due to the hepatic location of the lesion, ablation can be considered as an alternative to surgical resection as it is associated with equivalent local control and less side effects than surgery. Available studies have shown that microwave ablation results in a wide range of complete tissue ablation depending on tumor size, with complete ablation common and nearing 100% with smaller tumors. Tumor recurrence rate at ablated sites are very low. Intraoperative and postoperative complications are low. Newer microwave technology demonstrated shorter ablation time and fewer complications. Complications from microwave ablation are minimal. Microwave ablation has a short recovery time, short hospital stay, less morbidity and less cost compared to surgery.Final Result: The reviewers determined that the service at issue 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 reviewers 1 and 3 are board certified in radiation oncology, and physician reviewer 2 is board certified in interventional radiology; all three reviewers 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.