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 Monovisc injection in the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where 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 for mild to moderate osteoarthritis. Under these circumstances, the requested Monovisc injection in the right knee is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 an Orthovisc injection series in the right knee now and repeated in six (6) months.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, the patient has a long history of benefit from prior injections which lasted 6 months each time. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, the requested Orthovisc injection series in the right knee now and repeated in six (6) months is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 reimbursement for a Monovisc injection (CPT J7327) of the left knee provided.Findings:  The physician reviewer found that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient has tried and failed arthroscopic surgery, corticosteroid injection, and other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Monovisc injection (CPT J7327) of the left knee was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer-assisted navigation during right hip replacement. Findings:  The physician reviewer found that Jacofsky and Allen report that while early results on the use of robotic-assisted orthopedic surgery as applied to total hip arthroplasty have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications, further studies are needed. Wasterlain and colleagues note that the primary benefits of navigation are a reduction in outliers during acetabular cup positioning and improved accuracy when quantifying limp-length and offset measurements. However, it remains to be seen whether these benefits translate into meaningful improvements in clinical outcomes. Montgomery and colleagues report that data failed to demonstrate any clinically significant reduction in short-term adverse events with computer-assisted surgery applied to total hip arthroplasty and that further study was warranted. In this case, there is a lack of evidence that the use of computer-assisted navigation would have improved patient outcomes over standard arthroplasty without navigation. Therefore, computer-assisted navigation (CPT 0054T) during right hip replacement was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the computer-assisted navigation (CPT 0054T) during right hip replacement 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 service at issue was not likely to have been more beneficial for treatment 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 orthopedic surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Tempus Gene Panel. This patient presents with a history of grade IV glioblastoma multiforme. Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics. Glioblastoma multiforme is a high-grade tumor that is best treated with resection, radiation therapy, and chemotherapy. On temozolomide treatment concomitant with radiation therapy, one randomized clinical trial showed a 26.5% two-year survival compared to 10.4% in the cohort receiving only radiation (Zhang, et al.). In this case, the patients tumor was submitted to Tempus for molecular testing to identify mutations that allow enrollment in appropriate clinical trials. Given the support in the medical literature and National Comprehensive Cancer Network (NCCN) guidelines, the Tempus Gene Panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Tempus Gene Panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be 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 reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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 magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology (ACR) appropriateness criteria for the evaluation of low back pain note that most patients presenting with uncomplicated acute low back pain or radiculopathy do not require imaging. Established criteria for chronic neck and low back pain note that MRI is generally not appropriate in the management of chronic pain absent other red flags, such as persistent symptoms following four to six weeks of conservative management, a suspicion of serious underlying conditions, or if the patient is a surgical or interventional candidate. In this case, while the patient reports chronic back pain, the documents do not reflect evidence of radiculopathy, numbness, loss of reflexes, or weakness. The records indicate that the patient received physical therapy in 2018. Per the submitted documentation, he received conservative therapy in the remote past. The documents do not show recent attempts at conservative management, such as physical therapy. While MRI may be appropriate following documented recent conservative treatment, it is not currently medically indicated. Therefore, MRI of the lumbar spine is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Keytruda infusions. This patient presents with metastatic breast cancer to liver status post tumor ablation. The provider noted concern for lymphangitic spread on recent computed tomography (CT) imaging. The patients provider has recommended treatment with carboplatin, gemcitabine, and Keytruda. The U.S. Food and Drug Administration (FDA) has approved Keytruda for the treatment of locally recurrent unresectable or metastatic triple-negative breast cancer in combination with chemotherapy in patients whose tumors express PD-L1, defined as having a combined positive score (CPS) of 10 on testing. The records provided for review do not include documentation of PD-L1 for this patient. Moreover, there is no report of the microsatellite instability (MSI), mismatch repair (MMR), or tumor mutational burden (TMB) status to support treatment with Keytruda. Without these markers, there is a lack of support for treatment with Keytruda. Therefore, the requested Keytruda infusions are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Researchers note that while many older adults require skilled nursing care following hospitalization, the overuse of institution-based skilled nursing care may be associated with various adverse medical consequences, and thus the transition of appropriate candidates to community-based living and care should be encouraged. Researchers report that inpatient skilled nursing facility level of care is indicated when a patient has an ongoing medical need for skilled nursing or skilled therapy services. In this case, the patient has multiple chronic conditions, including chronic pain in her left foot and mental health diagnoses. The records note that she is stable with pharmacotherapy. She is noted as independent and capable of living in the community. Given that the records do not demonstrate an ongoing need for skilled nursing services, the services at issue were not and are not medically indicated. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyFast 5 mg/5 mL (3,000 mL total), Dilaudid 8 mg (180 mg total), and Ketamine 150 mg/mL (60 mL total). This patient presents with a history of chronic pain related to CRPS and cyclic vomiting syndrome. He has attempted several forms of conservative non-opioid treatment modalities including plexus block injections, physical therapy, appendectomy, and cholecystectomy. The provider documented that the patients regimen of OxyFast, Dilaudid, and Ketamine has been managing his symptoms as a bridge to more sustainable treatment in the form of an intrathecal pain pump. The patients urine toxicology screens and Controlled Substance Utilization Evaluation System (CURES) reports have been consistent with therapy. In addition, there has been no evidence of adverse drug reactions or aberrant behavior identified. The Centers for Disease Control and Prevention (CDC) guidelines state that, nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. The American Society of Regional Anesthesia and Pain Medicine state that, For CRPS, there is moderate evidence supporting ketamine infusions to provide improvements in pain for up to 12 weeks. This patients treatment plan includes weaning off of high-dose narcotic therapy with placement of an intrathecal pain pump. In the interim, continuation of his medication regimen is supported for treatment of his CRPS and cyclic vomiting syndrome. For these reasons, the requested OxyFast 5 mg/5 mL (3,000 mL total), Dilaudid 8 mg (180 mg total), and Ketamine 150 mg/mL (60 mL total) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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 authorization and coverage for prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan with Gallium 68 PSMA-11. Findings:  The physician reviewer found that Gallium-68 PSMA-11 PET has been increasingly studied for the evaluation of patients with biochemical recurrence after primary treatment of prostate cancer. However, the test is not considered a generally accepted standard of care for routine use in all patients with biochemical recurrence after prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines cautioned that Gallium-68 PSMA PET imaging has been associated with high rates of false-positive results. The American Urological Association (AUA) guidelines reported that there are limited data available to support an indication for PSMA in patients with possible metastases. All told, the requested PSMA PET scan with Gallium 68 PSMA-11 is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested PSMA PET scan with Gallium 68 PSMA-11 is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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, 2, and 3 are board certified in urology 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 patient has requested authorization and coverage for a Hyalgan injection series in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient has a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Hyalgan injection series in both knees is 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 patient has requested authorization and coverage for Euflexxa injections in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient has a history of relief from prior injections received. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections in both knees 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.