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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gloves (HCPCS code A4927).Urinary incontinence is a common problem that can have a considerable effect on an individuals quality of life, but can be significantly improved with correct assessment, treatment and management (Bardsley, A.). Functional incontinence is a type of incontinence that is caused by cognitive or mobility impairments, and not a failure in bladder function or in the neurological control of urination (Khandelwal, C., and Kistler, C.). This condition may require interventions such as timed voids, incontinence briefs, routine perineal cleansing, and application of various dermatological products (e.g., moisturizers, protectants, no-rinse cleansers, and antifungals) for prevention and/or treatment of incontinence-associated dermatitis (Gray, M.).In this case, the patient has a history of functional urinary incontinence, and records reflect that the patient receives and uses incontinence briefs and bed liners on a regular basis. There is no documentation, however, that indicates the intended use for the requested gloves or specifies the reason for their prescription. There is also no indication in the submitted records that the patient is able to don the gloves and use them for any medically related purpose, including for any bowel-related care. Under these circumstances, the requested gloves (HCPCS code A4927) are not medically necessary to assist with the patients condition.Final Result: The reviewer determined that the requested equipment is not medically necessary to assist with the patient's 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: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the knee. Researchers noted that that a systematic approach to examination of the knee includes inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and provocative tests. The American College of Radiology (ACR) recommends radiography as the initial imaging examination for nontraumatic knee pain is radiography. Radiographic imaging is appropriate when knee pain persists for more than six weeks or for acute traumatic pain in patients who meet specific evidence-based criteria. An MRI examination for nontraumatic knee pain is indicated when the pain is persistent and conventional radiographs are nondiagnostic or when additional information is needed before instituting treatment. MRI is reserved for patients when surgery is considered or a patient experiences persistent pain despite adequate conservative treatment. This patient presented with a history of chronic right knee pain with associated mechanical symptoms. Functional limitations were noted in activities of daily living. Clinical examination findings were suggestive of meniscal pathology and she was diagnosed with arthralgia. An x-ray of the right knee did not reveal any significant abnormality. She failed to improve despite four months of conservative treatment including activity modification, medications, bracing, and strengthening exercises. Current evidence based medical guidelines and literature support the use of MRI as the next imaging study for this patients medical condition. Therefore, the MRI of the knee was medically necessary for 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

Nature of Statutory Criteria/Case Summary: The patient has requested Synvisc One injection to the knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining treatment options are limited. In this patients case, the medical records document a history of osteoarthritis with pain and swelling and prior corticosteroid injections were not effective, but the patient reported good relief from prior viscosupplementation. Furthermore, the patients remaining treatment options were limited with the alternative being a total knee arthroplasty for moderate degenerative changes. For these reasons, the Synvisc One injection in the knee was medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient had requested authorization and coverage for (1) acupuncture treatments three (3) times, or (2) acupuncture treatments two (2) times a month. Vickers and colleagues note that, Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Yin and colleagues report, Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. In this case, the patient reported benefits from prior acupuncture, but without documentation of pre-acupuncture and post-acupuncture baselines for comparison purposes, the total number of acupuncture sessions completed, and measurable, progressive, significant, or objective functional improvement. The records did not indicate a flare-up of the condition, or a re-injury. There is no indication that the patient is currently undergoing an independent conditioning-aerobic program. The documentation did not demonstrate significant symptom reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. Given that measurable, progressive, significant, objective functional improvement has not been documented,  the requested services are not medically indicated. Therefore, (1) acupuncture treatments three (3) times, or (2) acupuncture treatments two (2) times a month are 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 licensed acupuncturist, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the injection of 100 Units of Botox (CPT J0585). Findings:  The physician reviewer found that Luvisetto and colleagues performed a review of available evidence in favor or against the use of botulinum neurotoxin A (BoNT/A) for the treatment of headaches. They concluded that there is much basic science evidence for an analgesic effect of BoNT/A, and clinical trials confirmed the efficacy, safety and tolerability of the toxin in the prophylactic treatment of certain headaches in adults, such as chronic migraine and trigeminal neuralgia. Botox has received FDA approval for the treatment of migraine headaches in patients who have more than 14 headache days per month. Kutuk and colleagues conducted a randomized controlled trial to compare the efficacies of botulinum toxin-A injection and dry needling methods in the treatment of patients with myofascial pain syndrome (MPS) in the temporomandibular joint (TMJ). They concluded that abobotulinum toxin-A injection and dry needling yield satisfactory therapeutic outcomes regarding pain relief and restoration of function in patients with MPS involving TMJ. In this case, the patient has been diagnosed with migraines and MPS. Records demonstrate that the patient suffers from chronic headaches. The patient is noted to have received Botox for the treatment of pain in the past, and the patient reported that Botox injections have been the only treatment to help relieve her pain and jaw locking. Under these circumstances, the 100 units of Botox (CPT J0585) injected on the date of service were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a myoelectric upper extremity orthosis (HCPCS code L8702). Findings:  The physician reviewer found that a review of 45 trials, Mehrholz and colleagues noted that electromechanical and robot-assisted arm training improved activities of daily living scores, arm function, and arm muscle strength with 95% confidence interval. Peters and colleagues found that for patients with upper extremity impairment, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Willigenburg and colleagues found that myoelectric orthosis increased patient perceptual improvement over the use of no orthosis. Given current medical literature and as the patient has exhausted traditional therapies, the requested device is medically indicated. Therefore, a myoelectric upper extremity orthosis (HCPCS code L8702) is medically necessary for the treatment of this patient.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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine.The first appropriate imaging for the evaluation of low back pain with radicular symptoms is lumbar radiographs. According to American College of Radiology (ACR) Appropriateness Criteria for low back pain, if pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next exam. In this case, there is no documentation of four to six weeks of conservative management, which would include physical therapy, NSAIDs or exercise. The patient's initial physical therapy consultation was less than three weeks ago. There is also no documentation of radiographs of the lumbar spine. Under these circumstances, the requested magnetic resonance imaging (MRI) of the lumbar spine is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar spine computed tomography (CT) scan. The American College of Radiology (ACR) Appropriateness Criteria note that CT of the lumbar spine may be appropriate for acute, subacute, or chronic lower back pain or radiculopathy if the patient is a surgical or interventional candidate with persistent or progressive symptoms during or following six weeks of conservative management, or if the patient has a history of prior lumbar surgery and new or progressing symptoms or clinical findings, and magnetic resonance imaging (MRI) is contraindicated, unavailable, or nondiagnostic. In this case, the patient is status post multiple spinal surgeries, and has failed to improve with activity modification, medications, sacroiliac joint injection, and home exercise. He has progressively worsening severe lower back, buttock, and sciatic pain that are limiting his activities of daily living. Clinical examination findings are consistent with right sacroiliac joint pain and dysfunction. The documentation does not reflect focal neurologic deficits. Given that a MRI is standard of care, and there is no documentation showing that a MRI is contraindicated or would be nondiagnostic, the requested service is not medically indicated. Therefore, a lumbar spine CT scan is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for (1) platelet-rich plasma (PRP) injections two times in a six-month period (every three months) for each knee, or (2) a PRP injection in each knee. Researchers note, Currently, the literature remains divided regarding the overall effectiveness of leukocyte-rich PRP for the treatment of orthopedic diseases, namely osteoarthritis. There is still no general consensus on this subject since leukocyte-rich PRP has shown both positive and negative results according to different animal studies. There are no clinical studies specifically evaluating the use of leukocyte-rich PRP alone for knee osteoarthritis. The use of PRP is not currently included in specific recommendation per the American Academy of Orthopaedic Surgeons for the treatment of knee osteoarthritis. Therefore, (1) PRP injections two times in a six-month period (every three months) for each knee, or (2) a PRP injection in each knee are not 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 (1) PRP injections two times in a six-month period (every three months) for each knee, or (2) a PRP injection in each knee are 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 services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for relationship development intervention treatment services. There is a lack of evidence in current medical literature on the effectiveness of relationship development intervention (RDI). Applied behavioral analysis (ABA) services are currently the most evidence-based strategy for treating autism, with some evidence supporting other interventions such as cognitive behavioral therapy and exercise. In this case, the records do not reflect specific information what concerns will be targeted during RDI treatment, how they will be targeted, and at what intensity. Given the lack of evidence supporting the effectiveness of RDI, and lack of documentation to determine the type, frequency, and duration of RDI in this case, the requested services are not medically indicated. Therefore, relationship development intervention treatment services are 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Duexis. The reviewed records state that this patient presents with medial right knee pain and instability due to a partially torn medial collateral ligament and patellofemoral arthritis. There is a history of gastrointestinal side effects from ibuprofen in the past, which prompted her provider to recommend Duexis, which is a combination of ibuprofen and famotidine. Duexis is a well-tolerated, effective non-opioid analgesic (Deeks). Researchers noted, there is a significant protective effect and the rate of upper gastrointestinal ulcers was significantly reduced with Duexis when compared to treatment with ibuprofen alone. The protective effect of famotidine is beneficial for patients with a history of gastrointestinal upset with ibuprofen, as in this patients case. For these reasons, the requested Duexis is medically necessary for treatment of this patient. 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 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: The patient has requested authorization and coverage for a hyaluronic acid injection. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a hyaluronic acid injection is medically necessary for the treatment of this patient.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.