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

Nature of Statutory Criteria/Case Summary: The patient is a 62-year-old female with a history of osteoarthritis of the right knee. The records noted a history of infection after a Synvisc injection for which arthroscopic debridement and intravenous antibiotics were utilized. Cultures from that procedure were negative. The patients current treatment includes Naproxen and cold packs. Corticosteroid injections have provided short-term relief. The provider has recommended viscosupplementation with Euflexxa for pain relief. The patient has requested coverage for Euflexxa injections. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. Current literature supports the use of viscosupplementation for osteoarthritis of the knees. According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit for patients with knee osteoarthritis.  Viscosupplementation may allow for substantial delay in time to total knee replacement. Medical evidence indicates that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting when compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The patient has knee osteoarthritis, and had short-term pain relief with corticosteroids.  Therefore, Euflexxa injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested injections 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee has requested reimbursement for occipital nerve injections that were provided. Two out of three physician reviewers found that medical literature supports that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Researchers performed a meta-analysis in 2017 and found that when compared to control intervention, greater occipital nerve (GON) block intervention can significantly alleviate pain, reduce the number of headache days and medication consumption, but have no significant influence on the duration of headache per four weeks for migraine patients. In this case, the patients pain complaints are corroborated by medical history and physical examination. In particular, the patient has well-documented occipital neuralgia. In addition, the records indicate that the patients pain has been non-responsive to multiple rounds of conservative measures including non-steroidal anti-inflammatory drugs (NSAIDs), neuropathic agents and activity modification. The use of occipital nerve blocks is well supported by medical literature, and the patient experienced documented efficacy and improved function from the first occipital nerve block to substantiate repeat injections. Thus, the occipital nerve injections that were likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Final Result: The reviewers determined that the services at issue were 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, 2 and 3 are board certified in anesthesiology with subspecialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: When there is concern about a patients inability to return home from the acute setting, SNF care can be considered. SNF services are supervised by a physician and nursing is provided 24-hours per day. In addition, physical therapy and occupational therapy are available. As noted in the medical literature, SNF care is supported as medically necessary when the patient requires skilled nursing or rehabilitation services at least five days a week. These services require the expertise of trained professional health care providers. This patient is status post severe motorcycle trauma with multiple fractures of the lower extremities. He continues to be non-weight bearing, and requires two to three people to assist his transfer to a wheelchair. He is noted to be unable to move his right foot and needs high dose opioids for pain. Frequent repositioning in bed is also indicated in order to avoid ulcer formation. Moreover, the patient has significant functional impairments which limit ambulation and his ability to perform activities of daily living. The providers reported that his wife is unable to physically care for the patient alone, monitor the high doses of opioids, and position his extensively traumatized body in order to avoid ulcers. Given these findings, the requested SNF services are medically necessary for treatment of this 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 internal medicine with expertise in skilled nursing facilities 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 nad coverage for obinutuzumab (Gazyva). The submitted documentation supports the medical necessity of the requested medication. This patient is requesting continuation of treatment with obinutuzumab (Gazyva) to be used in combination with ibrutinib. He received this treatment in a clinical trial. This combination was recently approved by the U.S. Food and Drug Administration as a first-line therapy for patients with chronic lymphocytic leukemia. As this patient was enrolled in the trial that lead to approval and is requesting continuation of this recently approved therapy, the requested medication is medically appropriate. There is sufficient support for the requested medication in this clinical setting. Therefore, obinutuzumab (Gazyva) is medically necessary for the 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 49-year-old female with psoriasis that is complicated by psoriatic arthritis.  Per the records, her symptoms have not been controlled by first-line topical treatments. Her scalp lesions cannot be treated with light therapy, and acitretin, methotrexate and cyclosporine were not considered due to potential liver/renal toxicity. The patient has requested coverage for Humira. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Humira is medically necessary for the treatment of this patients medical condition. Psoriasis is a chronic inflammatory skin disease that presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis can have a negative impact on the quality of life, especially in patients with moderate or severe disease. Humira is Food and Drug Administration approved for the treatment of rheumatoid arthritis and is also used in treating other conditions, including psoriasis and psoriatic arthritis. Clinical studies and randomized controlled trials have shown the short-term efficacy of Humira in psoriatic arthritis and psoriasis. Humira has been shown to be effective therapy when used either continuously or intermittently at 40mg subcutaneous injections every other week. In patients resistant to conventional doses, the efficacy of Humira can be increased by dose escalation, such as shortening the dosing interval and increasing the amount of medication per single dose. Medical evidence supports the requested medication in this clinical setting. Therefore, Humira is medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient received extensive outpatient psychotherapy, medication management and school counseling prior to time of admission. Findings:  The physician reviewer found that he patient expressed a suicidal plan to his friends and their parents, a marked decline in his academic performance, and a decreased interest in social activities. The plan of care was for a higher level of care in a controlled inpatient residential environment to have a sober place to recover safely from his depression with intent to harm self. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. This patient had an adequate outpatient treatment plan that included psychiatric care, psychotherapy and school counseling. He was unable to be safe as an outpatient and had severe depression, passive and active suicidal ideation with a plan. The outpatient providers plan was a higher level of care to assure a sober environment, appropriate medication management, psychotherapy and family therapy, as well as an overall integrative well-being plan. During his stay in residential treatment, it was noted that he had severe depression and weekly thoughts of suicide. The titration of Zoloft to 150mg and addition of Abilify 5mg and melatonin for insomnia, in combination with a multidisciplinary therapy approach, made a critical impact on the patient. He gained tools for emotional expression and abstinence strategies. In reviewing the ASAM worksheet, this patients inability to control substance abuse without 24-hour support and functional deficits support the medical necessity of the RTC services at issue.Final Result: The reviewer determined that the requested services 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 psychiatry with subspecialty certification 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  A patient is requesting reimbursement for MTHFR mutation genetic testing that was provided due to a diagnosis of colorectal cancer. The providers letter of medical necessity states that Methylenetetrahydrofolate Reductase (MTHFR) mutation testing was performed for screening diagnosis and clinical management. The Health Plan has denied the requested reimbursement for this procedure and reported that the procedure is investigational and not medically necessary for the enrollees medical condition.Findings:  Three physician reviewers found that National Comprehensive Cancer Network (NCCN) Guidelines for colon and rectal cancers do not support testing for methylenetetrahydrofolate reductase (MTHFR). Support from observational studies for folate as a factor in cancer protection have shown that lower levels of MTHFR, an enzyme involved in folate metabolism, have a reduced risk of colon cancer. In this case, however, the patient already has advanced colorectal cancer and it is unclear how testing would change her management. Under these circumstances, MTHFR Genetic Testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested MTHFR Genetic Testing provided is not likely to be more beneficial for evaluation 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 in internal medicine with a subspecialty certification in medical oncology and physician reviewer 3 is board certified in internal medicine with a subspecialty certification in medical oncology and hematology and are all three actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scans. Findings:  The physician reviewer found that this patient underwent treatment for cancer. However, he remains at high risk for recurrence. According to the National Comprehensive Cancer Network (NCCN) guidelines for mantle cell lymphoma, follow-up is recommended every three to six months for the first five years. This follow-up should include diagnostic tests and imaging using the same modalities performed during work-up. This patients last reported CT scan was over six months ago. Given his risk for recurrence, the requested CT scans are medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 Prolastin-C therapy. Clinical practice guidelines published in 2016 by the Alpha-1 Foundation updated the American Thoracic Society (ATS) and European Respiratory Society (ERS) recommendations. These guidelines noted that intravenous augmentation therapy is not recommended for individuals with the MZ genotype with chronic obstructive pulmonary disease. Overall, there is a lack of data that intravenous augmentation therapy improves outcomes in those with the MZ or other heterozygote genotype that includes a normal M gene. This patient does not meet the criteria for use of augmentation or replacement therapy given the presence of the MZ genotype and a mildly deficient alpha-1 antitrypsin (AAT) level. All told, Prolastin-C therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings: Three physician reviewers found Prolastin-C therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Prolastin-C therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and are actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in pulmonary disease 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the matrix-induced autologous chondrocyte implantation (MACI) procedure. There is current peer-reviewed evidence that (MACI) is safe and effective for treatment of full thickness cartilage defects in the knee. The U.S. Food and Drug Administration (FDA) indications for MACI states that this autologous cellularized scaffold product is appropriate for the repair of symptomatic, full thickness cartilage defects of the knee, with or without bone involvement. In the medical literature, colleagues performed a systematic review that showed statistically significant improvements in patients undergoing MACI alone, and MACI combined with osteotomy, for patellofemoral chondral defects. This patients condition is severe and disabling. She reports significant locking and catching sensations. She is status post bilateral knee arthroscopy, debridement, chondroplasty, and synovectomy. She is not a candidate for total knee replacement due to her young age. She is not a candidate for osteochondral autograft or allograft transplant or microfracture surgery based on the size of chondral lesions. Given these findings, the requested MACI procedure is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Findings:  Two of three physician reviewers found the requested MACI procedure is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested MACI procedure is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for buttock liposuction. The submitted documentation fails to demonstrate the medical necessity of the requested services. Lipomas are generally treated with surgical excision because of the possibility of complete removal and minimal risk of recurrence. This patient had a recurrence of a lipoma after liposuction. The removal was possibly incomplete because of the presence of asymmetry post liposuction. Per the records, the provider recommended imaging prior to proceeding with surgery. The records do not document that this has been performed. The recommended MRI is appropriate prior to proceeding with the requested services. Therefore, the requested buttock liposuction is not medically necessary for the treatment of this patient. In this patients case, the patients condition constitutes an abnormal structure of the body. The lipoma is an abnormal structure of the body which is caused by a tumor. The records document an abnormal appearance. Additionally, the requested services will be performed to improve function and to create a normal appearance. The requested buttock liposuction is likely to provide more than a minimal improvement in the appearance of the patient. Therefore, the requested buttock liposuction is reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition but are reconstructive in nature. 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.