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

The patient has requested reimbursement for inpatient hospital level of care. The records document that this patient had a history of left knee trauma with persistent moderate to severe pain and mechanical symptoms. Magnetic resonance imaging (MRI) showed a lateral meniscal tear with parameniscal cyst. The patients condition failed to improve despite reasonable and comprehensive conservative treatment. The patient underwent a meniscectomy and cyst excision and was discharged from the hospital on the same day. Evidence based medical literature supports full inpatient admission given that the ambulatory care center was unable to manage patients with markedly elevated BMIs, and the increased risk factors associated with obesity and hypertension in this patients case. Given these findings, the inpatient hospital level of care was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Orthovisc injections to the right knee. The enrollee has a medical history of osteoarthritis and chronic pain in his right knee. The enrollee has tried non-steroidal anti-inflammatories, physical therapy, and platelet-rich plasma injection with little relief. He has been receiving Orthovisc injections, which have provided significant pain relief. The enrollees treating physician reports the enrollee is not a surgical candidate for knee replacement, nor are there any other surgeries that can be offered which would provide any benefit. Literature shows intra-articular injections of hyaluronic acid, among other medications, are being used as an alternative therapy in osteoarthritis in order to maximize the topical effect and minimize adverse effects. Hyaluronic acid injections appear to be the safest and longest-lasting of the injectable alternatives. Researchers report on a systematic review which shows hyaluronic acid injections for knee osteoarthritis provide a small, but significant, benefit with respect to function. Because this enrollee is not a candidate for total knee replacement surgery, and he has responded positively to hyaluronic acid in the past, it is reasonable that a repeat set of hyaluronic acid injections would be appropriate for this enrollee.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 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for bilateral mastopexy and belt lipectomy. The enrollee has excess skin as the result of a 200-pound weight loss. The enrollees surgeon reports the enrollee would have a deformed appearance without the breast lift and reports the enrollee has excess skin hanging below her pubic line. Literature indicates mastopexy is designed to elevate breast tissue and to correct sagging breasts. Mastopexy will not improve health outcomes and is not clinically appropriate from a functional or medically necessary standpoint. It is being performed for appearance and enrollee convenience. The medical records do not demonstrate that ongoing, clinically significant abdominal skin problems have not responded to topical therapy, or, despite initial response, have recurred and caused significant problems. Supervised medical management for rashes is not documented in the progress notes. The enrollee is not sick because of her excess skin, and has not experienced ulcerations, panniculitis or sepsis from her infections.  A dermatologist has not evaluated the rashes.  The enrollee has not required hospitalization or treatment with antifungal or antibiotic medications. The alleged abnormality does not constitute an abnormal structure of the body because abdominal and hip skin redundancy is a normal anatomic occurrence associated with weight loss and aging.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for the Femring vaginal ring. The patient has tried and failed multiple estrogen treatment options including the patch, gel, and creams. She has had allergic reactions and unscheduled vaginal bleeding from these treatments. She has tried alternatives, and has responded well to Femring. Given the patients clinical situation of her history of response to therapy and Femring's treatment of systemic symptoms, it is appropriate and medically necessary for the patient to continue treatment with Femring. Final Result: The reviewer determined that the requested medication 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 obstetrics and gynecology 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

The enrollee requested authorization and coverage for prolotherapy at the right sternoclavicular joint. An x-ray showed right sternoclavicular joint subluxation. The enrollee reported pain across his trapezius and anterior chest wall. Records show the enrollee tried one session of physical therapy, and taping, without benefit. The physician recommended the continuation of exercise and taping, and the enrollee was referred to a sports medicine clinic. If the enrollees pain did not improve, the plan was for a steroid injection or prolotherapy at the sternoclavicular joint. The enrollee states he has been diligent in his attempts towards treating his condition using conventional means and prolotherapy is now his only available option. Data on the effectiveness of dextrose prolotherapy for temporomandibular dysfunction are promising, but insufficient for recommendations. A governmental agencys report on prolotherapy showed that, compared to no-injection controls, prolotherapy injections produced an inflammatory response; however, the response was similar to that seen with needle-stick and saline-injection controls.  Other researchers indicate the efficacy of dextrose prolotherapy, in acute pain, as first-line therapy, and in myofascial pain, cannot be determined from the literature. Medical records do not support attempts at appropriate conservative care, as the records show only one session of physical therapy was attempted.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery 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 authorization and coverage for the medication Trulicity. This enrollee has a medical history of type II diabetes mellitus, for which she has been taking oral medications; however, her diabetes was not well controlled. She also has a history of hyperlipidemia and a high body mass index. She was provided with samples of Trulicity, which gave her better control of her diabetes. The enrollees physician reports the enrollee has tried and failed other treatment options, but has been improving with the Trulicity. The use of a glucagon-like peptide 1 agonist is clearly indicated in this enrollee because of their body mass index, and literature shows a glucagon-like peptide 1 agonist can result in weight loss. However, studies provided comparative data for the various glucagon-like peptide 1 agonists and showed Liraglutide (Victoza) offers the best benefits in terms of A1C control and weight reduction. A separate study found no clinically meaningful differences in weight loss, blood pressure reduction or hypoglycemia risk when the glucagon-like peptide 1 agonists were compared with each other. There was no difference among the long acting agents, including dulaglutide and once-weekly exenatide, on A1C values.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 endocrinology, diabetes and metabolism 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 authorization and coverage for Monovisc injection to the right knee. The enrollee has osteoarthritis of the right knee. He has a history of anterior cruciate ligament repair. The enrollee received two corticosteroid injections in the past and reported the first one helped, but the second one did not. The plan was for a magnetic resonance imaging scan of the right knee, physical therapy for two to three months, and a referral to sports medicine for Monovisc. The enrollee is requesting Monovisc injection to his right knee. The enrollee reports he has exhausted all other treatment except for surgery, and physical therapy has achieved very limited results. Research showed intra-articular hyaluronic acid (Monovisc) provides a moderate symptomatic benefit to knee osteoarthritis enrollees, and without major safety concerns. Literature shows intra-articular hyaluronic acid (Monovisc) may offer a better benefit-to-risk ratio, compared to other pharmacologic options, as measured by improvements in outcomes and substantial delays in time to total knee replacement. A literature review by a professional society showed those subjects who received hyaluronic acid were 15 percent and 11 percent more likely to respond than were those who received intra-articular corticosteroid and intra-articular placebo.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 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: Upheld Decision of Health Plan

The enrollee is requesting reimbursement for residential treatment center services. The enrollee has a history of bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety, attention deficit disorder, substance abuse, and insulin-dependent diabetes mellitus. He entered a residential treatment center and received individual therapy, group therapy, and medication management. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level IV care, a partial hospitalization program.Final Result: The reviewer determined that the requested services were 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: Upheld Decision of Health Plan

The enrollees parent is requesting authorization and coverage, and reimbursement, for intensive outpatient program (IOP) level of care services. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This enrollee did not display a serious risk of harm or serious functional impairment. His family is willing and able to assist in his recovery. The enrollee has shown progress with recovery and is collaborating on his treatment plan. His composite CALOCUS score correlates with Level 1, Recovery Maintenance and Health Management, which is a lower level of care than intensive outpatient program (IOP).Final Result: The reviewer determined that the requested services were not, and are not, medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in child and adolescent 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollees parent requested reimbursement for lab work. The enrollee has neuro-immune syndrome, emotional dysregulation, mood lability, acute onset of cognitive dysfunctions and memory lapses. There is also concern for seizures as she had a previously abnormal electroencephalogram. The enrollees pediatric neurologist ordered laboratory tests and a prolonged, ambulatory video electroencephalogram to evaluate for seizures and encephalopathy. Research shows there is no evidence to support the usefulness of the requested tests for the evaluation of new seizures or behavioral changes. The medical records do not provide any clinical indication for these tests. The appropriate and evidence-based recommendations for evaluating possible immune encephalopathy do not include these laboratory studies. There is no literature to support these tests in the evaluation of children with suspected auto-immune encephalitis. In addition, researchers noted that while antibody positive and negative enrollees had similar clinical features, the response to treatment was unrelated to antibody status.Final Result: Two of the three reviewers determined that the requested services were not 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 neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. A magnetic resonance imaging (MRI) of the left knee revealed severe osteoarthritis of the medial compartment. An MRI of the right knee revealed moderate osteoarthritis of the medial compartment. The patient reported knee pain, and physical examination findings included tenderness over bilateral knees. The patient has been treated with bilateral knee steroid injections, bilateral knee viscosupplementation injections, and oral and topical medications. The provider noted an x-ray of the knees obtained, revealed severe bilateral medial compartment osteoarthritis. The patient did not want to undergo bilateral knee replacement surgery. The provider noted Euflexxa injections administered and a Supartz injection administered provided 50% pain relief. The patient has requested authorization and coverage for Euflexxa injections to both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue is this case is whether Euflexxa injections to both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties which she does not want. Furthermore, there is a history of 50% pain relief from prior viscosupplementation injections. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections to both knees are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthofix bone growth stimulator (HCPCS E0748).The current medical literature supports that the requested device is medically necessary. Researchers recommended the use of electrical bone growth stimulation as an option for patients younger than 60 years of age, since a positive effect on fusion has been observed. The same, however, could not be stated for patients over 60, because electrical bone growth stimulation did not appear to have an impact on fusion rates in this population. In another review, Morone and Feuer concluded that cases in which a spine surgeon may want to consider adjunctive electrical stimulation include patients undergoing multilevel fusion or reoperation, those who use tobacco, and those with disorders of low bone mineral density (that is, osteoporosis). Morone and Feuer found that the overall fusion rate of the electrical stimulation treated patients (84%) compared with the non-electrical stimulation treated patients (64%) was statistically significant.In this case, the patient was diagnosed with grade 2 spondylolisthesis at L5/S1, spinal and foraminal stenosis due to spondylosis and disc degeneration, and lumbar radiculopathy. The patient underwent a staged lumbar fusion procedure including L5/S1 discectomy, bilateral foraminotomies, insertion of an interbody device, arthrodesis, and insertion of an anterior plate in the first stage of surgery, followed by pedicle screw placement, posterolateral fusion with autograft and allograft bone, and arthrodesis at L5/S1 in the second stage of surgery. Current evidence based medical literature indicates that bone growth stimulation has a positive effect on fusion for patients at high risk for pseudoarthrosis. The present request is also supported by the combination of risk factors including large surface area to fuse. Under these circumstances, the requested Orthofix bone growth stimulator (E0748) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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.