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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic services. Findings:  The physician reviewer found that there is a lack of evidence in current medical literature to support spinal manipulation for a diagnosis of hip pain. While the patient reported diagnoses of cervical disc disorder with radiculopathy and lumbago with sciatica on the left side, the submitted records did not include  documentation from a medical provider supporting these diagnoses. The patient reported undergoing chiropractic services, however, notes from these sessions were not included for review. Given that current medical literature does not support the use of chiropractic manipulation of the spine for the treatment of hip pain, the requested services are not medically indicated. Therefore, chiropractic 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 chiropractic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral outlet reduction revision (transoral revision of gastric bypass via endoscopy) surgery. Findings:  The physician reviewer found that Tsai and colleagues note that weight regain and dumping after Roux-en-Y gastric bypass (RYGB) are long-term challenges thought to be due to dilation of the gastrojejunal anastomosis. The authors further noted that endoscopic gastrojejunal revisions are feasible and safe and may stabilize weight regain and improve dumping symptoms. Hedberg and colleagues note that weight regain after bariatric RYBG affects up to 30% of individuals, and that endoscopic gastrojejunostomy revision is a low-morbidity, outpatient procedure that, in a retrospective study, provided significantly greater weight loss compared to medical management alone. In this case, the patient is morbidly obese with multiple comorbidities. The transoral approach to revision RYGB is associated with shorter hospitalization times and faster recoveries than an open approach. Therefore, transoral outlet reduction revision (transoral revision of gastric bypass via endoscopy) surgery is 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 (transoral outlet reduction revision (transoral revision of gastric bypass via endoscopy) surgery is 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 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1and 3 are board certified in surgery and are actively practicing. Physician reviewers 2 is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, bilateral Euflexxa injections are medically necessary for the treatment of the patients medical condition.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 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 a Synvisc-One injection in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate 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 options are limited. The patient has tried and failed other conservative treatments. Frequent corticosteroid injections are not helping, with the alternative being bilateral total knee arthroplasties. Thus, a Synvisc-One injection in both knees is medically necessary for the treatment of the patients medical condition. 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 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 reimbursement for Orthovisc injection series in both knees provided on 2/17/21, 2/24/21, and 3/03/21 and prospective authorization and coverage for Orthovisc injection series in both knees in six months.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of lasting benefit from prior injections. Furthermore, the options are limited. The patient has tried other conservative treatments, with the option being surgery. Therefore, the Orthovisc injection series provided into both knees on 2/17/21, 2/24/21, and 3/03/21 was medically necessary for the treatment of this patient. Additionally, the requested Orthovisc injection series into both knees in six months is medically necessary to treat the patients medical condition.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 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 bilateral lumbar transforaminal epidural steroid injections. Findings:  The physician reviewer found that records provided for review document that this patient has a history of chronic low back pain and bilateral radicular pain in the lower extremities. The provider documented that the patient previously benefitted from epidural steroid injections with over 50% improvement in pain for three months. Low back pain with bilateral radicular pain is commonly attributed to a combination of mechanical, inflammatory, and immunological causes. Epidural injections of steroids have been shown to reduce the inflammatory component of this process, with improvement in reports of pain and function. Although the caudal, interlaminar, and transforaminal approaches have been tried, the transforaminal approach under fluoroscopic guidance makes a targeted delivery of the steroid to the inflamed nerve root to achieve a superior result. Viswanathan and colleagues performed a literature review of 108 publications. The authors found that the overall success rate of the transforaminal lumbar epidural steroid injections ranged from 76% to 88% in the management of lumbar radicular syndrome. Given these findings, the requested bilateral lumbar transforaminal epidural steroid injections are medically necessary for 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: The parent of an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the upper right extremity.According to the American College of Radiology Appropriateness Criteria for chronic elbow pain, an MRI of elbow without intravenous (IV) contrast is usually appropriate when there is elbow pain and x-rays are non-diagnostic in the setting of (1) suspected occult fracture or other bone abnormality, (2) suspected nerve abnormality or (3) suspected collateral ligament tear. In this case, the patient had persistent pain, tingling in fingers, stiffness, swelling, lack of ability to perform certain activities of daily life, along with objectively limited flexion, extension, supination, and pronation elbow movements. This was reportedly despite treatment including splinting, analgesic medications, and anti-inflammatories. Additionally, radiographic studies were inconclusive. The combination of patients lack of detailed-definitive clinical and imaging-corroborative diagnosis led to plausible suspected differential diagnoses including occult bony injury, osteochondral lesion, ligamentous tear and/or nerve injury. There are multiple plausible elbow injuries in this case. Each has significant potential for highly adverse sequelae if not expeditiously fully detected, diagnosed, and treated with an injury-specific protocol. Therefore, an MRI of the upper right extremity is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the evaluation 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 authorization and coverage for stand-alone anterior lumbar interbody fusion procedure at L5-S1. Treatment of low back pain with lumbar fusion, in the absence of instability, trauma, tumor, or fracture is a common practice but remains controversial in terms of efficacy and safety over nonsurgical management. In a systematic review of the safety and efficacy of lumbar fusion for the treatment of degenerative disease, Yavin and colleagues report that positive clinical change was greatest in patients with spondylolisthesis, while complications and the risk of reoperation limited the benefit of fusion for patients with spinal stenosis. In a meta-analysis, Xu and colleagues concluded that spinal fusion surgery was no better than nonoperative treatment in terms of pain and disability outcomes for patients with degenerative disc disease. In this case, the patient has symptoms of chronic lower back pain. An examination did not show meaningful stenosis. The submitted documentation did not reflect that the patient had exhausted non-operative treatment. In this clinical setting, the requested service is not medically indicated. Therefore, stand-alone anterior lumbar interbody fusion procedure at L5-S1 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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 authorization and coverage for a power standing system and power seat elevation system for the approved power wheelchair. The submitted documentation does not support the medical necessity of the requested equipment. Toro and colleagues note that there is little data available to support standards development related to independent wheelchair transports. While power seat elevation may assist a user to independently transfer to and from a power wheelchair, the available records do not indicate that this patient would be able to safely perform independent transfers using this feature. The records do not include documentation of any transfer trials. Given that the patients environment may be adjusted to optimize his independence, such as with respect to reach, the requested power seat elevation is not medically indicated. There is a lack of evidence in current medical literature that regular passive standing, such as that achieved with a standing frame, provides clinically significant benefits with respect to muscle function, skin integrity, bone health, respiratory function, digestive function, urinary function or other organ system functions in the setting of severe neurological weakness. In a systematic review of 17 studies, Newman and Barker concluded that while supported standing could prevent small losses of ankle mobility, the clinical importance of these effects was uncertain and low-dose standing was unlikely to protect bone health. A standing frame may mitigate the risk of pressure injuries and wounds but may introduce new areas to the risk of pressure ulcer development, resulting in no clinically significant net gain. While a standing frame may allow the user to interact with nonwheelchair users at eye level, such interaction is not a medical necessity to accomplish mobility-related activities of daily living. Given the lack of evidence showing that the requested equipment results in clinically significant improvement to health and functional outcomes, the requested power standing system is not medically indicated. Therefore, the requested power standing system and power seat elevation system for the approved power wheelchair are not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.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 Supartz injection series in the left knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being surgery. Thus, Supartz injections for the left knee are medically necessary for treatment of the patients medical condition.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 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 reimbursement for anesthesia services received in late of 2019.There is sufficient support for the services at issue in this clinical setting. Researchers noted, We recommend 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. Additionally, the guidelines state, We recommend anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. Researchers concluded, From the viewpoint of endoscopists, sedation is useful for improving the completion rate, quality of endoscopic examination and treatment outcomes of therapeutic endoscopy. In this case, the patient has severe central sleep apnea and history of intolerance to endoscopy that caused the procedure to be discontinued in the past. The current guidelines suggest that the presence of severe sleep apnea and previous procedural intolerance make the patient an appropriate candidate for MAC. Thus, anesthesia services received on in late of 2019 were medically necessary for the treatment of the patients medical condition.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 anesthesiology 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.