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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested health plan coverage for dental anesthesia for his impacted third molar/wisdom tooth extraction. Findings:  The physician reviewer found that the enrollee has a history of asthma and a current diagnosis of impacted wisdom teeth. He was referred to a dental surgeon due to possible complications of wisdom tooth extractions. Due to the severity of extractions, the enrollee is unable to tolerate treatment at a local setting. The literature describes the circumstances under which general anesthesia for third molar extraction is deemed necessary. However, the vast majority are uncomplicated extractions that can be performed under local anesthesia in the outpatient setting. The literature does not support choosing general anesthesia over local anesthesia for third molar surgery. It may be an option for complex and longer procedures; but, it is associated with higher nerve injury and mortality risks in respect to local anesthesia.  Therefore, dental decisions on anesthesia modality are based on careful and thorough evaluation of enrollees dental condition and risk factors. As per the medical literature, this includes the use of panoramic radiography, which is the standard imaging technique for evaluating third molars, to determine the complexity of the enrollees tooth impaction relative to the enrollees dental anatomy. Studies show that even for enrollees who have anatomical risk factors, the procedure with local anesthesia can be modified in a way that it can still be used effectively for third molar surgery. Literature in support for general anesthesia for dental procedures is thus, limited to few, very complicated cases, usually after local anesthesia is attempted. There is insufficient objective documentation in the medical record to substantiate the necessity of performing this enrollees extractions under general anesthesia. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for Follicular Extraction Transplantation (FUE) Hair Transplantation Surgery for alopecia. Findings:  The physician reviewer found that a referral was made for a dermatology consult for hair transplantation, as the enrollee believes his lack of hair and resultant anxiety is causing his high blood pressure. The enrollee has androgenic alopecia, which is the most common cause of hair loss. Although literature supports the distressing effects of alopecia on health, such as anxiety and low self-esteem, literature does not support hair transplantation as the first-line therapy. Alopecia management involves a thorough assessment of an enrollees history, including nutritional status and risk factors, as well as physical exam including description and scalp biopsy. This is because malnutrition, vitamin deficiency, and risk factors, such as hair trauma are reversible causes of alopecia. Physical exam will also identify whether alopecia is solely due to androgenic alopecia or is exacerbated by a fungal infection. While literature supports hair transplantation as a more aesthetically pleasing, definitive treatment for severe alopecia, studies support non-surgical therapeutic modalities as a primary means of therapy in the early phases of hair loss. Non-surgical therapy includes medication and laser phototherapy. Studies support that advances in non-surgical medical management have allowed for stabilization of the hair loss process and partial re-growth. Review of the records indicates insufficient evidence of a comprehensive evaluation and work-up for the enrollees alopecia before considering hair implantation as a medical treatment option. Considering that surgical intervention is not the first-line therapy for treating this enrollees alopecia, Follicular Extraction Transplantation (FUE) Hair Transplantation Surgery is not medically necessary to treat the enrollees alopecia.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for partial hospitalization program (PHP) level of care services She was admitted to a residential treatment center (RTC). She stepped down to a partial hospitalization program (PHP) from a residential treatment center. The enrollee began to binge as a way of coping. She used laxatives and diet pills as part of purging behavior. . She reports symptoms of anxiety with shortness of breath and tightening of the chest, and depressed mood, nightmares and feelings of hopelessness. Findings:Her diagnoses on admission were bulimia nervosa and adjustment disorder with mixed anxiety and depression. She stepped down to a PHP program. She reported moderate anxiety, depression and frustration. She denied suicidal ideation or homicidal ideation or psychotic symptoms. She met her treatment goals during her time at PHP and maintained a stable weight with a fluctuation of 1-2 pounds.  She was able to gain some coping skills to deal with distress and started attending meetings to address her difficulties with co-dependency in relationships. Her condition at discharge included frequent eating disorder symptoms, and obsessive thoughts related to her eating disorder behaviors 80% of the time. Utilizing LOCUS criteria, the enrollees risk of self-harm score is 1.  There was no indication of suicidal or homicidal thoughts or impulses, and no history of suicidal or homicidal ideation. She had the clear ability to care for herself now and in the past. Functional status score is 2. She was experiencing some deterioration in interpersonal interactions. However, she is demonstrating significant improvement in function following a period of deterioration. Medical, addictive and psychiatric co-morbidities score is 2. She may occasionally experience psychiatric symptoms, related to stress, and medical illness. Recovery environment  level of stress score is 3 due to significant discord or difficulties in family or other important relationships or alienation from social interaction. Recovery environment  level of support score is 2; professional supports are available and effectively engaged. Treatment and recovery history score is 2. Recovery has been managed for moderate periods of time with limited support or structure.  Engagement and recovery status score is 2. The enrollee has significant understanding and acceptance of illness. The enrollees composite score is 14 which correlates to low intensity community based services.  Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections of bilateral knees. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence indicate 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. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when other treatments have been tried and options are limited. In this case, the patient has a history of lasting benefit from viscosupplementation. The patients options are also limited, as she was deemed not a surgical candidate for total knee arthroplasties. Under these circumstances, the requested Orthovisc injections of bilateral knees are medically necessary for 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 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: An enrollee has requested authorization and coverage for the human papilloma virus (HPV) vaccine, Gardasil 9. The current medical evidence does not support the requested services in this clinical setting. The patient has a history of HIV and recent low CD4 counts. The Centers for Disease Control (CDC) currently recommends the HPV vaccine series to protect against human papillomavirus for men and women who are 26 years of age or younger. There are studies that demonstrate the efficacy and safety of this vaccination in patients with HIV. Most of the studies are in women. Researchers evaluated the safety and immunogenicity of the quadrivalent HPV vaccine in men who were HIV positive. Of note, this was a small study of only 162 patients, and the authors recommended further studies. In sum, there is a lack of support for the HPV vaccine in men with HIV who are older than 26 years of age. Although the U.S. Food and Drug Administration (FDA) has recently approved this vaccine for use in older individuals, there is a lack of guidelines to recommend its use. There is a paucity of literature supporting the use of the HPV vaccine in males who are HIV positive and older than 26 years of age. Therefore, the HPV vaccine, Gardasil 9, 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 internal 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 transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach.Findings:  Two out of three physician reviewers found that the medical evidence supports the requested services in this clinical setting. The medical records demonstrate that the patient has symptomatic aortic stenosis, based on recent onset symptoms of dyspnea with limited (1 block or incline) exertion, fatigue and dizziness, and she therefore has Class II heart failure symptoms. The patient had a recent transthoracic echocardiogram (TTE) which revealed moderately severe to severe aortic stenosis secondary to a bicuspid valve. Records indicate that although the valve area itself is in the borderline severe range, the patients valve area index, adjusted for BSA, is severely stenosed (0.6 cm2/m2) and the peak velocity of flow across the valve (4.6m/sec) puts her in the severe range for aortic stenosis. While the patients Society of Thoracic Surgeons (STS) score is not extremely high, she does have the additional risk factors of autoimmune disease, and she is being treated with chronic methotrexate and steroid treatment, which puts her at much higher risk for poor surgical wound healing. In addition, the patient has been evaluated by a cardiac surgeon and a cardiologist (the recommended heart team approach prior to TAVR) who are of the opinion that the patient would benefit from TAVR, as opposed to open chest surgery AVR, given her additional risks of surgery. Requiring two different surgeons to certify that the patient would benefit from TAVR is not part of recent standard of care for this procedure, or guidelines, and should not be necessary. TAVR is an effective FDA approved therapy for the patients indication and is both reasonable and indicated in this clinical situation. Accordingly, the requested transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach, is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and clinical cardiac electrophysiology. Physician reviewer 2 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and interventional cardiology. Physician reviewer 3 is board certified in thoracic and cardiac surgery. All three physician reviewers 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: An enrollee has requested authorization and coverage for Euflexxa injections into the right knee. Findings:  The physician reviewer found that the records document a history of chronic right knee pain associated with stiffness due to advanced arthritis. The current medical literature pertaining to viscosupplementation reveals mixed results. 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 does not support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected patients with limited treatment options. This patient has benefitted from viscosupplementation in the past, and the alternative is a total knee arthroplasty. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa injections into the right knee are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing, Oncotype DX Genomic Prostate Score. Findings:  Three physician reviewers found that per the National Comprehensive Cancer Network (NCCN), men with low or favorable intermediate risk prostate cancer may consider Oncotype DX Genomic Prostate Score. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, the likelihood of biochemical progression after radical prostatectomy or external beam therapy and the likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. Therefore, genetic testing, Oncotype DX Genomic Prostate Score was likely to have been superior over other options for evaluating this patient.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation 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 internal medicine with sub-specialty certification in medical oncology 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 patient has requested authorization and coverage for surgery with a Cartiva implant synthetic of the right first metatarsophalangeal (MTP) joint. While the medical literature does show some early promising results with the use of the Cartiva implant for the treatment of hallux rigidus, there is a lack of high-quality studies demonstrating long-term safety and efficacy. The gold standard for treatment of hallux rigidus remains arthrodesis. This patients records do not include radiology studies that grade the severity of the patients degenerative changes of the great toe MTP joint. Therefore, the requested surgery with a Cartiva implant synthetic of the right first MTP joint is not likely to be more beneficial for the treatment of the patients medical condition and any available standard therapy.Final Result: Two of the three 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:  Reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) services. She has a history of substance and alcohol abuse. She has no history of prior treatment and abstinence attempts have been unsuccessful. She was admitted to a chemical dependency unit for observation and transferred to a residential facility. She attended groups and individual meetings with a therapist. She reported experiencing anxiety, overeating, and thoughts/desires to use. The discharge summary described a positive response to treatment. She was motivated and receptive. She continued to attend meetings and adhered to her medication regimen. Despite wanting to leave treatment prematurely on occasion, she remained and continued treatment. The enrollees composite LOCUS score is 11, which correlates with recovery maintenance and health management. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. This patient fell and sustained injuries to both lower extremities. She was unable to ambulate. Therefore, she was admitted to an acute inpatient level of care. She was found to have a sprain of the left knee with a fractured right fibula and avulsion injury to the right anterior cruciate ligament. She was treated conservatively with pain medications and placed in a controlled ankle movement (CAM) walker. Her pain was under control with oral medications, and she was hemodynamically stable. Laboratory studies were unremarkable, and there were no acute exacerbations of chronic medical problems. She did not have any parental medications or complex wounds. The patient was medically stable and no longer required care at an acute inpatient level of care. She could have been treated at a lower level of care. Therefore, the services at issue 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 internal 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.