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 bilateral, ultrasound-guided Supartz injections to the elbows.Viscosupplementation is an effective therapeutic strategy in early stages of arthropathy, with no complications and long-term good clinical results. In a study of hemophilic patients by Carulli and colleagues, 10 patients with arthritic elbows were treated with viscosupplementation with a good result. Clegg and colleagues report that, A multimodal approach for the treatment of osteoarthritis of the knee with viscosupplementation provides good efficacy for pain relief and return to function when used in an active population. In this case, prior injections of Supartz in both elbows produced good results. Furthermore, the patient has tried and failed other conservative treatments, including activity modification, home exercise program, and corticosteroid injections. As such, the patients options are limited. Additionally, ultrasound guidance provides accurate delivery of viscosupplementation injections. Therefore, bilateral, ultrasound-guided Supartz injections to the elbows are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 hyaluronan injections (Synvisc or Euflexxa) 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 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 good lasting benefit from multiple prior injections since 2013. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, hyaluronan injections (Synvisc or Euflexxa) in both knees are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 acute rehabilitation services. Findings:  The physician reviewer found that noxic brain injury, including due to cerebral hypoperfusion during cardiac arrest, has a challenging clinical course and guarded outcomes. The patient in this case sustained an anoxic brain injury due to cardiac arrest. The provider charted that the patient has experienced a protracted convalescence following multiple cardiac arrests. The patient recently started to emerge from a state of poor cognitive function. However, the patients cognitive status remains severely impaired. The records do not demonstrate that the patient is able to carryover information from one therapy session to the next. The patient has behavioral impairments, is severely physically deconditioned, and he has continued to require near total assistance for his self-care. Overall, the patient has a guarded prognosis for significant functional recovery. In this clinical setting, it is not expected that an intensive rehabilitation program will significantly improve the patients course or outcomes. The patient is not currently able to consistently participate in, tolerate, or meaningfully benefit from intensive acute rehabilitation services. Given these findings, the requested acute rehabilitation services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 solifenacin succinate 10 mg.Oxybutynin and solifenacin succinate are both oral antimuscarinics or anticholinergics and are used to treat overactive bladder. According to the American Urological Association (AUA), if a patient experiences unacceptable adverse drug events with one antimuscarinic medication, then a different antimuscarinic medication may be tried. In this case, the patient has tried and failed oxybutynin. The patient had dry mouth that made the medication intolerable. Therefore, solifenacin succinate 10 mg is medically necessary for the treatment of the patients medical condition.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 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 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 positron emission tomography (PET) scan (CPT code 78815 and HCPCS code A9552). This patients records document a history of stage IIA moderately differentiated adenocarcinoma of the ascending colon status post right hemicolectomy in July 2019 and subtotal hemicolectomy in July 2020. The patients provider has recommended follow-up imaging with a PET scan. Per the National Comprehensive Cancer Network (NCCN) guidelines, PET scans are not recommended for routine surveillance of patients with colon cancer (Benson, et al.). Furthermore, the additional major professional guidelines for colon cancer do not support the clinical utility of PET imaging for use in this clinical setting (Meyerhardt, et al.; El-Shami, et al.; Kahi, et al.). All told, the requested PET scan (CPT code 78815 and HCPCS code A9552) is not medically necessary for 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade. Findings:  The physician reviewer found that this patients records document a history of rheumatoid arthritis with persistent disease symptoms despite treatment with multiple medical therapies. The patient is breastfeeding, and her provider has recommended treatment with Remicade. The American College of Rheumatology (ACR) guidelines do not require concomitant treatment of methotrexate with Remicade therapy for patients with rheumatoid arthritis. Earlier guidelines from the ACR state that methotrexate is not recommended for nursing mothers. The ACR does support treatment with Remicade in nursing mothers with rheumatoid arthritis. Given these findings, the requested Remicade is medically necessary for 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 rheumatology 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 Euflexxa injection series in both knees.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 patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Thus, Euflexxa injection series in both knees are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 Otezla.The U.S. Food and Drug Administration (FDA) approved Otezla in 2014. Otezla (apremilast) is recommended for the treatment of moderate-to-severe psoriasis in adults. It receives an 'A' grade from the joint National Psoriasis/American Academy of Dermatology guidelines for its safety and efficacy and is recommended as first-line treatment of chronic plaque psoriasis. In this case, the patient has severe psoriasis with a BSA of 10%. The patient has tried and failed other conservative therapies. Further, according to the medical literature, Otezla has been demonstrated to be safe and efficacious for the treatment of psoriasis. Thus, Otezla is medically necessary for the treatment of the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services provided during upper and lower gastrointestinal endoscopic procedures. The current American Society of Anesthesiologists (ASA) guidelines for sedation and anesthesia in gastrointestinal endoscopy 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. The ASA states that, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. A review by Wernli and colleagues concluded that, Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days. In this case, the patient presented for upper and lower endoscopy. The patient does not have any documentation of significant heart, lung, kidney, or liver disease. There is a lack of detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies. The patient was given an ASA classification score of 2 and airway score of 1 without evidence that they presented with a difficult airway. The ASA guidelines for sedation and anesthesia in gastrointestinal endoscopy do not support the use of MAC services in this patient in the absence of significant health conditions or airway concerns. The ASA guidelines state that there is high quality evidence to support the use of mild to moderate sedation in uncomplicated endoscopy procedures, such as in this patients clinical setting. All told, the MAC services provided during upper and lower gastrointestinal endoscopic procedures were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 reimbursement for the laboratory testing (CPT 83520) provided by Athena Diagnostics, Inc. Findings:  The physician reviewer found that evaluating data on the current status of biomarkers for Alzheimers disease, Blennow and colleagues report that while a large number of clinical studies very consistently show that these biomarkers contribute with diagnostically relevant information, also in the early disease stages,  future studies are warranted to validate these promising results further. In this case, the patient presented with complaints related to memory deficits. While the use of biomarker testing may be helpful, their results have not been demonstrated to be diagnostic, as diagnosis of cognitive disorders remain based on clinical evaluations including a patients history and neuropsychological studies. Therefore, the laboratory testing provided by Athena Diagnostics, Inc. was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory testing  provided by Athena Diagnostics, Inc. at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 3 are board certified in neurology and are actively practicing. Physician reviewer 2 is board certified in board certified in neurology with sub-specialty certification in vascular neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for laboratory lipoprotein testing (CPT 83704) provided 3/09/21. Findings:  The physician reviewer found that According to published guidelines by the American Heart Association and American College of Cardiology (AHA/ACC), advanced lipoprotein testing may be indicated in patients at intermediate or borderline ten-year risk to further refine their risk when statin medication is being considered or intensified. In this case, the patient has multiple risk factors for atherosclerotic coronary artery disease and is already being appropriately treated with moderate dose statin therapy for risk reduction per AHA/ACC guidelines. Given her underlying diabetes and other risk factors, treatment with moderate to high intensity statin therapy is appropriate. Additionally, for patients treated with moderate to high dose statin medication, the nuclear magnetic resonance lipoprotein LDL particle testing is not recommended as a risk enhancer according to the AHA/ACC guideline approach. Therefore, laboratory lipoprotein testing provided 3/09/21 was not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition.Findings: Three out of three physician reviewers found that laboratory lipoprotein testing (CPT 83704) provided 3/09/21 was not likely to be more beneficial for you than any available standard therapyFinal Result: The reviewer determined that the service at issue was not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hysterectomy and removal of a cyst procedure sooner than the scheduled appointment. The records provided for review document that this patient has a history of pelvic pain and menorrhagia. However, the patients hematocrit is within normal limits and is not suggestive of excessive blood loss. In addition, there is no report that the patient has been assessed with endometrial biopsy to assess her bleeding, or laparoscopy to rule out endometriosis and pelvic adhesions. Moreover, there is no indication that the patient has undergone attempts to treat her heavy bleeding with hormonal treatment in the form of combined estrogen-progesterone pills, progestin, tranexamic acid, or endometrial ablation. The provider noted that the patient has refused hormone therapy. Treatment with either tranexamic acid or endometrial ablation is hormone-free. Similarly, a gonadotropin-releasing hormone (GnRH) agonist such as Lupron or antagonist with Orilissa are also hormone-free. This patient does not have a life-threatening condition that requires immediate surgery. For these reasons, the requested hysterectomy and removal of a cyst procedure sooner than the scheduled appointment on 6/24/21 is not medically necessary for 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology 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.