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 Orthovisc injections. The 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 cases where options are limited. In this case, the patient reported an excellent response to prior viscosupplementation, with pain relief and improved function. Furthermore, his options are limited, with the alternative being a total knee arthroplasty. Therefore, Orthovisc injections 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for CT colonoscopy. She has a history of hypothyroidism, migraines, basal cell skin cancer, pre-diabetes mellitus, osteopenia, and appendectomy. She had a sigmoidoscopy that was negative and the plan was for a repeat procedure in five years.  The enrollee had a gastroenterology consult for screening colonoscopy and reported a bad reaction to anesthesia in the past with nausea, agitation and not feeling normal for more than a day.  Computed tomographic (CT) colonography (also virtual colonoscopy or CT colography) is an option for colorectal cancer (CRC) screening in asymptomatic average-risk individuals, over the age of 50 years. Other indications for CT colonography include the evaluation of the proximal colon in patients with an obstructing CRC or evaluation of signs or symptoms of CRC in whom a colonoscopy cannot be performed due to intolerance, technical difficulty, or in whom a colonoscopy is contraindicated. Recent guidelines were issued for Colorectal Cancer (CRC) screening.  A strong recommendation was made for screening, starting at age 50 years for average-risk adults.  There was not a preference for any one of seven screening test strategies over another in this guideline. Pateints should be actively engaged in informed decision-making about the screening options and be encouraged to select a screening option based on their preferences, personal circumstances, and disease risk.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology 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 is requesting authorization and coverage for a custom right foot orthotic. Findings:  The physician reviewer found that according to the medical record, the enrollee has a history of scoliosis and leg length discrepancy with her left leg reportedly one cm shorter than her right leg. Podiatry notes indicate right knee, hip, and foot pain. She has hammertoe of the second toe with rubbing against her shoe and talar spur. In addition to a built in heel lift on the left, a custom right foot orthotic to assist with reducing pronation, pain, impact on the soft tissues and bones of the feet, reducing strain on the soft tissue, off-load deformities, prevent or delay surgery, and prevent ulceration was prescribed by her podiatrist. There is insufficient evidence in the record of the actual documented assessment of the limb length discrepancy. Although there is an estimate of a one cm difference for this enrollee, in actuality this number could be higher or lower; which could change the treatment options.  Per the medical literature, measurements performed by a clinician rather than imaging modalities, are not accurate as there can be a high level of inter-observer variability. Further, there is no evidence in the record of a trial of a simple over-the-counter heel lift on the left, which, literature indicates may resolve right knee and hip pain related to limb length discrepancy. Studies demonstrate that a limb length discrepancy of less than two cm seldom causes any issues and may addressed with an internal heel lift. Final Result: The reviewer determined the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 is requesting reimbursement for wilderness therapy. The enrollee has a history of mental health disorder and substance abuse.  He entered into the intermediate outdoor behavioral health program. Findings: according to group session note summaries, the enrollee participated in group therapy sessions, which included outdoor activities, mindfulness exercises, vulnerabilities, daily reflections and readings from 12-step program handbooks. In current literature, wilderness therapy is an identified treatment modality for a wide range of populations and client problems.  The medical literature indicates therapeutic approaches, including nature as a therapeutic tool, need to embrace evidence-based practice so that clinicians may continue to utilize treatment and interventions based on the best available science.  Wilderness therapy is described as an eclectic framework for working with at-risk youth within the commonality of the natural setting, reliance on group interactions, and the perception of risk in activities.  However, the lack of standardization, lack of clear evidence-based practices, inconsistencies in treatment intervention, and wide range of treated populations causes wilderness therapy to appear to be an ambiguous treatment modality. Results are not clearly delineated. Youth with clinical diagnoses or substance use problems can use this technique to address a range of adolescent problems, including rebellion, self-doubt, and substance use.  The typical stay for this type of treatment has some variance as the treatment is to be customized based on the enrollees needs; however, average stay is eight to ten weeks. The record notes the enrollees history of substance abuse and mental health disorder, unspecified diagnoses, and the review of notes regarding the enrollees treatment interventions at this level of care. He primarily engaged in group therapy sessions. There is no evidence in the record that the enrollee obtained services above and beyond those available to him at a lower level of care.  Notes indicate the enrollee only participated in group therapies; most of which were focused on his emotional status, mindfulness, coping skills, and the 12-step program regimen. The record did not indicate the enrollee had a crisis or exacerbation of symptomology warranting this level of care an above-average length of stay beyond standard treatment guidelines for this type of treatment.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in psychology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 methylphenidate HCL 5 mg tablets, twice daily. The submitted documentation supports the requested medication in this clinical setting. Researchers evaluated the efficacy of methylphenidate for adults with attention deficit/hyperactivity disorder. The researchers noted methylphenidate improves attention deficit/hyperactivity disorder symptoms in adults in a dose-dependent fashion. In this patients case, the records document attention deficit/hyperactivity disorder, predominantly inattentive type. Methylphenidate is a standard treatment for attention deficit/hyperactivity disorder. The requested medication is appropriate to treat the patients condition and is consistent with standards of good medical practice. This patient has benefited from the use of methylphenidate. Therefore, methylphenidate HCL 5 mg tablets, twice daily, are 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. Findings:  The physician reviewer found that the patients provider noted the patient has severe gender dysphoria related to her appearance and voice.  In a letter, the provider noted that the patient had been living as a female for more than one year and was being treated with hormone therapy. The patient has requested coverage for any or all facial feminization surgeries (forehead lift, hairline lowering, orbital bony contouring, rhinoplasty closed with Weirs and cartilage grafts, cheek implants-small combined, subnasal lip lift with fat augmentation, thyroid cartilage shave, and voice feminization-local). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether any or all facial feminization surgeries (forehead lift, hairline lowering, orbital bony contouring, rhinoplasty closed with Weirs and cartilage grafts, cheek implants-small combined, subnasal lip lift with fat augmentation, thyroid cartilage shave, and voice feminization-local) are medically necessary for the treatment of the patients medical condition. The World Professional Association for Transgender Health (WPATH) states that facial plastic reconstruction, voice therapy and/or surgery are medically necessary gender affirming procedures. These procedures are medically indicated treatments for gender dysphoria.  In this patients case, the records document gender dysphoria related to her appearance and voice. Facial feminization surgery is associated with improved mental health quality of life in transgender patients. Medical evidence supports the requested services in this clinical setting. Therefore, facial feminization surgeries (forehead lift, hairline lowering, orbital bony contouring, rhinoplasty closed with Weirs and cartilage grafts, cheek implants-small combined, subnasal lip lift with fat augmentation, thyroid cartilage shave, and voice feminization-local) 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for arthroscopic osteochondral allograft surgery. The patient has a history of right knee pain. A magnetic resonance imaging (MRI) many years ago showed a meniscal injury, but the patient declined surgery at that time. During a more recent routine office visit, she described her knee pain as increasing in severity and frequency to seven to eight on a scale of one to ten over the previous two months. The pain is sharp and stabbing; waking her at night. She tried ibuprofen and Tylenol without relief. A repeat MRI of the right knee showed flattening and deformity of the lateral femoral condyle. The orthopedic surgeon prescribed osteochondral allograft surgery because the patients condition is not a simple chondral defect. The patient has a big crater in the bone with no support for the overlying cartilage, which is causing the pain and she has failed an extensive course of conservative management. He asserts that the patient meets guidelines for osteochondral transplantation. She has either failed or is ineligible for all other recommended treatment as she is too young for arthroplasty and aligned too well for osteotomy. In a recent study in the medical literature of 149 patients with femoral allograft transplantation, 71% of the patients reported having very good to excellent function, and 79% were able to participate in a high level of activity (moderate, strenuous, or very strenuous) six years after the procedure. Another group reviewed the results from five studies involving 291 patients.  While they noted differences in technique and patient characteristics among the studies, they found significant clinical improvement using standard knee society scores and good durability in 75% of the patients at over 12 years of follow-up. The treatment options for this patient are relatively limited. Knee arthroscopy and debridement is not effective in these cases, nor is microfracture because the patients underlying bone is not thought to be healthy. Cartilage restoration, such as autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI) is not indicated in the setting of bony changes such as condyle flattening.  Therefore, the most reasonable treatment is an osteochondral allograft transplant. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and Sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for circumcision. On a visit with the urologist, the enrollee indicated he wanted a circumcision due to irritation from pubic hair.  He denied issues with urinating or sexual intercourse and stated he desired to keep his pubic hair instead of shaving. On examination, the urologist documented easily retractable foreskin and normal genitalia. He did not recommend circumcision; however, the enrollee wanted the surgery.  Complications were discussed with the enrollee and the procedure was scheduled. Per the medical literature, some commonly accepted indications for circumcision include failure of medical management for recurrent balanoposthitis (inflammation of the glans and foreskin); non-retractable foreskin at the age of sexual activity; lichen sclerosis et atrophicus, BXO; neoplasm of prepuce; traumatic injury to foreskin, voiding obstruction, pam phimosis and phimosis. There is insufficient evidence in the record of these or any other conditions that would necessitate a circumcision in this enrollee.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 urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for serological antibody testing for Helicobacter pylori.Findings:  Two out of three physician reviewers found that this patient reported a history of Helicobacter pylori infection. Medical literatures noted Helicobacter pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available. Consistent with standard of care, the researchers noted 13C urea breath test or the stool antigen test can be used for noninvasive screening for Helicobacter pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms and without the need for endoscopic prelude to therapy or re-treatment. The medical evidence does not support serologic testing for the evaluation of this patient. The Helicobacter pylori immunoglobulin G (IgG) antibody assayed in this patients case is not beneficial in distinguishing between active disease and previous exposure. Further, antibodies to Helicobacter pylori can remain elevated for a long time after treatment, potentially increasing the number of false-positive results. This patients records do not specify whether she received treatment upon Helicobacter pylori detection in previous years, or whether it was her desire to be retested to assess efficacy of past eradication efforts. Serologic testing for re-documentation of a previously positive Helicobacter pylori status was not likely to have been more beneficial in achieving a positive outcome than standard testing with detection of active infection with stool antigen or urea breath assays. In sum, serological testing for Helicobacter pylori was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not 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 upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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:  The enrollee is requesting authorization and coverage for high frequency chest wall oscillation air-pulse generator HCPCS Code E0483.The enrollee has a history of bronchiectasis secondary to tuberculosis.  Findings:Her bronchiectasis was diagnosed by a computerized tomography scan (CT) scan.  Bronchoscopy showed pseudomonas in the washings but was negative for acid-fast bacilli.  She was treated with ciprofloxacin for the pseudomonas.  A high frequency chest wall oscillation device along with nebulized therapy was prescribed.  Notes indicate her sputum had decreased with Cipro on the same visit.  She was seen again and her lung exam was clear. She was placed on Zithromax three times a week.  A pulmonary function test showed restrictive lung disease.  The pulmonologist indicates conventional means of chest therapy would not be effective as the enrollee does not have a caregiver to provide manual chest physiotherapy.  The enrollees  assessment score shows she breathes easier and sleeps better when using high frequency chest wall oscillation air-pulse generator. Review of the record indicates the enrollee has had multiple episodes of exacerbations of bronchiectasis, which required treatment with antibiotics.  On exam, she had vesicular breath sounds with bilateral rales and rhonchi.  Based on the enrollees history and pulmonary function tests that are suboptimal, high frequency chest wall oscillation air-pulse generator is appropriate to assist with her mucociliary clearance.  According to the medical literature, high frequency airway clearance assist devices provide an improvement both in pulmonary function and quality of life related parameters in enrollees with chronic hypersecretive disease. Final Result: The reviewer determined the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pulmonary 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 similar medical condition.