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 an additional two (2) units of sedation.Considering that deep sedation requires titration of medications, monitoring of vital, and postoperative observation, 30 minutes of sedation time are not enough, making the additional 30 minutes of sedation medically necessary in order to carry out the procedure and allow for the patient to not undergo stress during the procedure. Anxiety is a known trigger for asthmatic patients. Ogle and Hertz state, Sedation offers a method of alleviating the fear, and for some it is the only way they will have their dental needs treated. Moreover, the authors noted, Oral sedation with benzodiazepines and anxiolysis with nitrous oxide are two effective methods to help alleviate anxiety and fear of dental procedures. For patients who are susceptible to complications from anxiety, anxiolysis and anesthesia for the entire duration of the procedure may be necessary. In this case, the patient presented with four impacted wisdom teeth, which is complicated by asthma. Considering the extent of hard and soft tissue impaction, the proximity to the inferior alveolar nerve and the maxillary sinuses, all of the third molars are complicated extractions, which will require time for their safe and efficacious removal. As such, time for the procedure and thus time for the sedation are necessary beyond a total time of 30 minutes. In this setting, one hour is a common amount of time required to carry out all of the therapy. Therefore, the requested additional two (2) units of sedation 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 dentistry 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 cervical spine MRI and lumbar spine MRI.Findings: According to the American College of Radiology (ACR) appropriateness criteria for cervical neck pain, increasing nontraumatic neck pain without red flags would indicate radiographs as an initial imaging study. If the pain does not resolve despite conservative management after six weeks, then MRI may be indicated to evaluate for disc or neurologic abnormality. Conservative management includes physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the patient has bilateral numbness extensively evaluated and due to ulnar entrapment. The patient does not have a history of cancer or prior spine surgery, and infection is not suspected. Additionally, there is no documentation of an NSAID trial, and the patient did not complete an adequate course of physical therapy. The patient also had a cervical MRI approximately nine months ago. Therefore, repeat cervical  MRI is not currently indicated. Thus, the requested cervical spine MRI is not medically necessary for evaluation of the patients medical condition.According to the ACR, a lumbar spine radiograph is the initial imaging study for low back pain. If the 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 imaging modality. In this case, there has not been a lumbar spine radiograph, nonsteroidal anti-inflammatory drug (NSAID) trial, or physical therapy related to the lumbar spine. Although there is a reported history of prior compression fracture, mid-thoracic pain is thought to be chronic in nature. Presently, there are no discrete guidelines for the management and evaluation of thoracic pain. The current practice guidelines are based upon the guidelines for low back pain. Therefore, the requested lumbar spine MRI is not medically necessary for the evaluation of 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Orthovisc (hyaluronic acid) injection, once weekly for four weeks, in the left knee. 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 is unable to take NSAIDs or corticosteroid injections due to a cardiovascular condition and has failed treatment with acetaminophen. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested services are medically indicated. Therefore, an Orthovisc (hyaluronic acid) injection, once weekly for four weeks, in the left knee, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for arthroscopy right knee, debridement/shaving of articular cartilage and meniscectomy. Findings:  The physician reviewer found that clinical trials have shown that arthroscopy of the knee is not an effective treatment for osteoarthritis. However, patients who have displaced meniscal tears or loose bodies in a knee with pre-existing arthritis can benefit from this procedure. Arthroscopy can have a role in arthritic knees if there is clinical and imaging evidence of symptomatic meniscal tear causing mechanical symptoms such as painful, disabling catching, locking and popping. Karpinski and colleagues conclude that results of randomized controlled trials comparing arthroscopic treatment of arthritic knees with other treatment options are inconsistent; however, there is evidence that a subgroup of arthritic patients with meniscal flap tears can benefit from arthroscopy. In this case, the MRI of the right knee showed a significant tear with a folded, displaced meniscal fragment posterior horn lateral meniscus. Two of the knee compartments were relatively healthy. The patient ran five to seven miles a day and is not considering total knee replacement. Therefore, the requested arthroscopy right knee, debridement/shaving of articular cartilage and meniscectomy is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. The records reviewed document that this patient presented status post fall from 20 feet onto a concrete floor. The patient was determined to have comminution of L1 vertebral body with retropulsion of the fragments into the spinal canal up to more than 50% of the canal. She underwent an open corpectomy of L1 through a thoracolumbar approach and T12 to L2 fusion with cage fixation. As noted in the medical literature, the average length of stay following a mini-open thoracolumbar corpectomy is 7.2 days versus 12.2 days for an open thoracolumbar corpectomy (Sulaiman, et al.). This patient was hospitalized for 14 days following the surgical intervention. It is acknowledged that this is 1.8 days longer than the average stay. However, in this case, due to the complexity of the injury including retropulsion of fragments into more than 50% of the spinal canal requiring two-level fusion, length of stay slightly beyond the expected average would be reasonable. Furthermore, the patient demonstrated acute psychosis during this hospitalization. In light of the foregoing, the inpatient hospitalization services were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a colonoscopy for polyp removal. She did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented in the submitted records. The patient had an ASA classification score of 2 and there is no evidence that she presented with a difficult airway. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest that there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, anesthesia services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: The patient has requested authorization and coverage for gradient compression stockings. The records provided for review report a history of bilateral lower extremity weakness, pain, and intermittent swelling, as well as dizziness with standing, neck pain, and back pain. Magnetic resonance imaging (MRI) did not show any neural compression and repetitive stimulation studies on nerve conduction testing have been negative. Overall, the patients records do not provide adequate documentation of a medical condition for which compression stockings are indicated. Compression stockings are helpful for patients with conditions such as venous insufficiency conditions, lymphedema, congestive heart failure, and orthostatic hypotension (Tzani, et al.; Logan, et al.). In addition, compression stockings can play a role in preventing blood clots in patients who are severely immobile (Golemi, et al.). This patients physical examinations have revealed normal orthostatic vital signs and no evidence of leg swelling. The patient has symptoms of possible radiculitis or radiculopathy. However, compression stockings are not recommended for treatment of radiculitis or radiculopathy (Jensen, et al.; Lewis, et al.). The records do not support a diagnosis of myasthenia gravis since repetitive nerve stimulation tests have been negative and there are also no documented antibody test results consistent with myasthenia gravis. Based on the current medical literature and the records provided for review, the requested gradient compression stockings are not medically necessary for 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 acupuncture services (12 sessions).Acupuncture is effective for the treatment of chronic musculoskeletal and osteoarthritis pain. A referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. In this patients case, she continues to be symptomatic despite treatment with physical therapy and medication. There is sufficient support for an acupuncture trial in this clinical setting. Three to six sessions are generally required to produce functional improvement. Therefore, an initial six sessions of acupuncture are medically necessary. Objective functional improvement should be established if additional treatment is requested. Significant objective improvement includes decreased pain, increased endurance, increased ability to perform activities of daily living, and improved sleep. Therefore, six sessions of acupuncture are medically necessary for the treatment of this patient. Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sensory integration therapy. There is insufficient evidence in current medical literature to support the use of sensory integration therapy in this clinical setting over any standard available therapy. In a systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders, Sharp and colleagues conclude, Intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Marshall and colleagues note that multidisciplinary intervention for childhood feeding difficulties may involve operant conditioning or systematic desensitization intervention, which help children improve in dietary variety/intake, and more reductions in difficult mealtime behaviors in children with autism spectrum disorder. The American Academy of Pediatrics notes that, while sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in the treatment of children with developmental and behavioral disorders, Parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In a review of sensory integration therapy for people with autism spectrum disorder, Watling and Hauer found moderate evidence to support the use of Ayres Sensory Integration within the scope of occupational therapy to improve performance, that the results for sensory-based methods were mixed and recommended further research with higher level studies and larger samples. Leong and colleagues describe sensory integration therapy as a controversial treatment method that is widely used for people with disabilities without convincing evidence regarding its effectiveness. In this clinical setting, there is insufficient evidence in current medical literature supporting the use of sensory integration therapy. Therefore, sensory integration therapy is 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 (sensory integration therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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 neurology with special qualification in child neurology 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 authorization and coverage for Tibsovo 250 mg (60 per month). The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of oligodendroglioma note that ideally, all or almost all of the tumor should be surgically removed. The guidelines further note for high risk patients who are over 40 or who have had a partial resection, the best treatment choice may be a clinical trial, radiation followed by chemotherapy with procarbazine/lomustine/vincristine (PCV) or temozolomide, or radiation in conjunction with chemotherapy. Mellinghoff and colleagues note that among 35 patients with progressive nonenhancing gliomas treated with ivosidenib, 85.7% (or 30 patients), achieved stable disease. However, these results are based on a phase 1 trial. Given that the use of ivosidenib is not supported by NCCN guidelines, and as only phase I safety data is available, there is a lack of support in current medical literature for the use of the requested medication over standard treatment. Therefore, Tibsovo 250 mg (60 per month) is 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 Tibsovo 250 mg (60 per month) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.