Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for the Regeneten Patch. This patient presents with complaints of grade 5/10 right shoulder pain with a history of prior rotator cuff repair 20 years ago. The patient has documented functional limitations and clinical examination findings are consistent with imaging evidence of a partial-thickness infraspinatus tear. The records include detailed evidence of trial and failure of a recent, reasonable and comprehensive non-operative treatment protocol. Her treatment plan includes rotator cuff repair with the Regeneten Patch. Overall, there is a paucity of large volume, long-term peer-reviewed outcome studies to support the use of the Regeneten Patch for revision rotator cuff repair. Schlegel and colleagues evaluated 33 patients and reported that arthroscopic implantation of a bioinductive collagen scaffold is a safe and effective treatment for intermediate- to high-grade partial-thickness rotator cuff tears of the supraspinatus tendon. Bokor and colleagues found that their study on 13 patients demonstrated the ability of a highly porous collagen implant to induce new tendon-like tissue formation and create an environment conductive to the healing of partial-thickness cuff tear. The physician reviewer found that the current data supporting the clinical utility of the Regeneten Patch include small patient sample sizes without randomization. A clinical trial is underway to demonstrate arthroscopic surgical treatment of high-grade partial-thickness tears using Regeneten yields statistically superior patient postoperative recovery outcomes, faster return to activities of daily living, and less health care utilization versus standard surgical repair techniques. These data will help determine whether the Regeneten Patch has a role in revision rotator cuff repair. All told, the requested Regeneten Patch is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Regeneten Patch is not 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 medical device is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The American Psychiatric Association (APA) guidelines state that the acute phase of treatment for depression may include TMS. TMS is U.S. Food and Drug Administration (FDA) approved for the treatment of treatment-resistant major depressive disorder. George and colleagues found that TMS is significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Connolly and colleagues reported that TMS was safe and effective in both acute and maintenance treatment of patients with treatment resistant depression. Tarhan and colleagues reported that TMS was well tolerated and found to be statistically and clinically effective in patients with treatment resistant depression. The physician reviewer found that records provided for review support that this patients depression is treatment resistant. He has failed treatment with multiple antidepressants and augmentation strategies, as well as psychotherapy. Given these findings, the requested TMS is 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 The patient has requested authorization and coverage for a lift recliner chair, or in the alternative, a semi-electric adjustable hospital bed with remote. Based on the available documentation, the requested lift recliner chair, or in the alternative, a semi-electric adjustable hospital bed with remote is not medically necessary for this patient. The records do not demonstrate that the patient is unable to elevate his legs in a standard recliner or that he has upper or lower extremity weakness with limited ability to go from a seated to a standing position. There is a lack of evidence in current medical literature that there is a relationship between sleep posture and spinal symptoms (Cary, et al.). In addition, a semi-electric adjustable hospital bed with remote is not medically necessary for this patient. This patient has a normal gait, normal upper and lower body strength without evidence of a frequent need to change positions. The physician reviewer found that  there is no evidence that the patient is unable to position his body in ways not feasible with an ordinary bed or that he requires traction equipment. The provider noted that the patient is currently independent with bed mobility. The physical therapy DME evaluation indicated that a semi-electric adjustable hospital bed is not appropriate for this patients condition. All told, the requested lift recliner chair, or in the alternative, a semi-electric adjustable hospital bed with remote, is not medically necessary for this patient.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.
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 for the left knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate 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. 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 everything else has been tried and the options are limited. In this case, the patients options are clearly limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty in the presence of mild osteoarthritis. Under these circumstances, Euflexxa injections for the left knee are medically necessary to treat 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. Researchers state that MRI is appropriate as the next study after x-rays for patients following a fall or twisting injury when no fracture seen on a radiograph and there is suspected internal derangement. In patients with a fall or twisting injury who have focal tenderness, effusion, or inability to bear weight, radiographs should be the first imaging study obtained. If the radiograph shows no fracture, MRI is best for evaluating for a suspected meniscus or ligament tear, or the injuries from a reduced patellar dislocation. Parent and colleagues concluded that it is essential that the role of MRI be reconsidered in older patients and in those with osteoarthritis. This patient presents with persistent severe left knee pain following a twisting injury. The records document significant swelling, functional limitation with activities of daily living, and inability to bear weight on the left leg. Clinical examination findings have documented effusion, limited active range of motion, medial joint line and patellar tendon tenderness to palpation, and positive crepitus. X-rays of the left knee showed moderate degenerative joint disease. Patient has failed to improve despite reasonable conservative treatment, including activity modification, NSAIDs, corticosteroid injections, and bracing. Given the patients history of injury, persistent left knee pain and dysfunction, radiographic evidence of moderate osteoarthritis, and failure of conservative treatment, current evidence based medical literature and guidelines supports a left knee MRI. Therefore, the requested MRI of the left knee is medically necessary for evaluation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient rehabilitation. Spinal cord injury can result in profound functional impairments generally requiring complex, individualized rehabilitative measures. The patient in this case sustained severe trauma to her spine, with clear clinical indications of paraplegia, as well as trauma to right lower extremity, due to a fall. There is ongoing loss of volitional motor function in the lower limbs, which is acute in nature. The patient is in need of rehabilitation to address functional deficits in light of this development. There is also a question of whether the patient has control of bowels and bladder. The patients course has been significantly complicated by psychiatric condition and cognitive impairments, including poor insight into patients condition. The patient has had paranoid ideations and has been uncooperative with medical, nursing and therapy assessments, and interventions. Patient has refused to wear the spinal orthosis ordered to be worn when out of bed. Limited participation has persisted despite ongoing psychiatric management, with adjustments to her psychotropic pharmacotherapy. At this stage, the patient is not a candidate for acute inpatient rehabilitation as there is an absence of documentation supporting that she would be expected to participate and benefit from intensive rehabilitation. According to the American Academy of Physical Medicine and Rehabilitation, acute inpatient rehabilitation is not indicated if a patient is unable to participate in and benefit from an intensive rehabilitation program. Despite the patients impairments and clinical issues, acute inpatient rehabilitation is not medically necessary. The patient has a guarded to poor prognosis due to the nature of the pathologies following her trauma, as well as her pre-existing psychiatric comorbidity. All told, the requested inpatient rehabilitation 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 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

The enrollee is requesting authorization and coverage for an injection, Synvisc One, for the left knee. The enrollee has moderate left knee osteoarthritis. A magnetic resonance imaging (MRI) scan was ordered due to acute pain. The enrollee was status-post arthroscopic surgery and the documentation noted there was concern for another tear. The MRI results showed osteoarthritis with no new tears. His range of motion is restricted and painful. There is no effusion. There is medial femoral condyle tenderness. His patellar grind test is positive. There is no instability. The enrollee has received cortisone injections multiple times with good benefit in the beginning. However, they are no longer effective. The enrollee reported receiving less than one week of benefit from the last cortisone injection. He has received Synvisc One injections twice; one year ago and six months ago. The enrollee reported it had been beneficial. Now the pain has returned and the enrollees orthopedic surgeon is requesting approval of Synvisc One injections. According to the literature, viscosupplementation therapy is indicated for enrollees who suffer from symptomatic osteoarthritis and have not adequately responded to conservative, non-pharmacologic therapy and simple analgesics (e.g. acetaminophen). Some specialty societies do not recommend the use of hyaluronic acid injections in those with symptomatic osteoarthritis of the knee unless a clear and compelling rationale for an alternative approach is present. The documentation noted this enrollee had previously undergone multiple cortisone injections, as well as Synvisc injections.  This enrollee no longer receives benefit from corticosteroids. However, he has received approximately six months of pain relief with each hyaluronic acid injection.  He is an appropriate  candidate for Synvisc One injection as there is no documentation of end stage disease. Given the return of symptoms, the requested Synvisc One injection is medically necessary.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 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

The patient is a 33-year-old male who has been diagnosed with bipolar depression and post-traumatic stress disorder. In an undated report, the patient reported symptoms of depressed mood, anxiety attacks, impulsivity, increased risky behavior, racing thoughts, excessive energy, erratic behavior, loss of interest, and constant worrying. The patient denied current suicidal ideation. He had a history of two prior suicide attempts. The patient has been treated with therapy, a four-day psychiatric hospitalization in April 2016, and medications that included Effexor, Seroquel, Wellbutrin, Zoloft, and Lamictal. In a letter dated 4/23/19, the provider noted the patient has had manic episodes. On 7/2/19, the patients Beck Depression Inventory score was 42. A Generalized Anxiety Disorder 7-item (GAD-7) score was 18, and a Patient Health Questionnaire-9 (PHQ-9) score was 21. The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. 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 TMS services are medically necessary for the treatment of the patients medical condition. TMS therapy has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of major depressive disorder in adults who have not responded to antidepressant medications. The physician reviewer found that patients with bipolar affective disorder (BPAD) may have a severely depressed mood and other impairments seen in major depressive disorder (MDD), they also have episodes of mania. A clinical trial by Sampaio-Junior and colleagues found no statistically significant remission rates in the use of TMS for the treatment of bipolar disorder. In this case, the patient has had prior manic episodes and meets the criteria for BPAD. BPAD and MDD are seen as two distinct disorders with different treatment algorithms. The medical evidence does not support the requested services in this clinical setting. Therefore, TMS 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for bilateral breast reduction surgery (CPT 19318, modifier 50). The World Professional Association for Transgender Health (WPATH) states that chest surgery can be carried out earlier than age 18 in order to give adolescents an opportunity to experience and adjust to a more masculine gender role. The WPATH recommendations also state that refusing timely medical interventions might prolong gender dysphoria and contribute to stigmatization. In this case, the patient already has significant emotional distress due to the presence of breasts, which has led to social and developmental limitations. Current studies report that the quality of life and satisfaction after masculinizing breast reduction are significantly improved in adolescents with gender dysphoria, including in non-binary individuals, such as this patient (Mahfouda, et al.). The physician reviewer found that  improved quality of life and comfort with physical appearance for transgender female-to-male patients, as well as patients who identify as agender, such as this patient. This patient has a diagnosis of gender dysphoria persisting over the last four years, which has significantly affected education and social development. Consideration of the evidence and recommendations show that preventing or delaying the requested services may prolong or worsen the patients gender dysphoria. All told, the requested bilateral breast reduction surgery (CPT 19318, modifier 50) is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with morphea of the right breast. The patient initially developed a lesion on the right breast. A biopsy performed revealed an inflamed sinus tract. The physical examination findings included a large geometric plaque with scarring and lichenification on the right breast. No areas of erythema, drainage, nodules, or open ulcers were noted. The provider noted that there were no signs of infection or inflammation.The patient has requested authorization and coverage for tacrolimus 0.1% ointment. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus 0.1% ointment is medically necessary for treatment of the patients medical condition. Cantisani and colleagues reported that morphea, also known as localized scleroderma, is a fibrosing disorder of the skin that may also affect the underlying muscle and connective tissue. The authors noted that even when spontaneous remission occurs, the residual damage created by previously active disease (pigment change, atrophy, contracture, limb length discrepancy) may be severe. Researchers reported that no consistent recommendations exist for the treatment of morphea. The authors noted that phototherapy, methotrexate/systemic corticosteroids, calcipotriene, and topical tacrolimus have the most evidence for efficacy in morphea. Topical treatment with tacrolimus 0.1% is effective for superficial dermal or dermal-limited (single plaque) lesions. In this case, physical examination findings included a large geometric plaque with scarring and lichenification on the patients right breast. No areas of erythema, drainage, nodules, or open ulcers were noted. Per the records, there were no signs of infection or inflammation. The medical evidence supports the requested medication in this clinical setting. Therefore, tacrolimus 0.1% ointment 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mammoplasty augmentation with prosthetic implants. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) lists breast augmentation as a treatment for patients with persistent, well-documented gender dysphoria, capacity to consent, and reasonable control over significant medical or mental health conditions. The WPATH acknowledges that for some patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The guidelines further report, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The requested bilateral mammoplasty augmentation with prosthetic implants is medically necessary to help alleviate this patients well-documented gender dysphoria and related distress. Therefore, the requested bilateral mammoplasty augmentation with prosthetic implants is 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 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.