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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for use of Mako robotic system (CPT 27447) for a right knee arthroplasty procedure. While it is recognized that radiographic parameters can be optimized compared to conventional instrumentation, there is a lack of data in current medical literature showing that midterm outcomes from such procedures are superior to standard instrumentation. In a network meta-analysis, Bouche and colleagues recommend against the use of navigation and other new approaches due to the risks associated with the uncertainties of novel surgical approaches. Shatrov and Parker report that while early clinical outcomes show promising results for computer-assisted total knee arthroplasty, longer-term data is still to come. Therefore, use of Mako robotic system (CPT 27447) for the patients right knee arthroplasty procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapyFindings:  Three of the three physician reviewers found the requested use of Mako robotic system (CPT 27447) for a right knee arthroplasty procedure 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 service 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. 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 placement of SpaceOAR Hydrogel. The records provided for review document that this patient presents with Gleason 4+3 prostate cancer. The patient was treated with radiation therapy with placement of SpaceOAR Hydrogel. As noted in the medical literature, SpaceOAR Hydrogel spacer placement can be utilized during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum. In a randomized phase 3 study in patients undergoing radiation for prostate cancer, the risk of adverse events grade 2 or higher at three-year follow-up was improved in hydrogel space group as compared to the control group. The patients treated with SpaceOAR Hydrogel also experienced a significant improvement in bowel quality of life. Results of a secondary analysis suggest that use of a SpaceOAR Hydrogel in this clinical setting can decrease sexual side effects and as well. The current National Comprehensive Cancer Network (NCCN) guidelines now endorse the use of a hydrogel space in patients undergoing radiotherapy for prostate cancer. Therefore, placement of SpaceOAR Hydrogel was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the placement of SpaceOAR Hydrogel was likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation 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 reimbursement for air and associated ground ambulance transportation services. Researchers notes that rehabilitation is an important aspect of the continuum of care in strokes resulting in functional deficits. In this case, the patient received inpatient rehabilitation after her stroke and made significant improvements. At discharge, the records noted supervision to contact guard assistance level of assistance for most functions. The records did not document clinically significant cognitive deficits or behavioral impairments. The patient was eating a regular oral diet and did not require critical care or other continuous, hands-on medical or nursing care. The patients family members, including her spouse and daughter, were present at the facility and learning to provide support and care.  The patient had the option of continuing rehabilitation locally until she could be cleared to fly home commercially, or otherwise return home via ground transportation to northern California. Given that this was an elective, non-emergent transfer for the convenience of the patient and her family, the services at issue were not medically indicated. Therefore, air and associated ground ambulance transportation services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 patients parent has requested authorization and coverage for an Orthovisc injection series 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. 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 lasting benefit from Orthovisc injections. The records document pain relief and functional improvement of both knees from viscosupplementation. The medical evidence supports the requested services in this clinical setting. Therefore, an Orthovisc 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 evaluation 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for breast augmentation surgery. The World Professional Association for Transgender Health (WPATH) lists breast augmentation surgery as a medically necessary treatment for gender dysphoria. WPATH notes that surgical procedures such as breast augmentation are often of great practical significance in the patients daily life and are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the gender dysphoria. In this case, given that the patient has a diagnosis of gender dysphoria, and as the provider has recommended breast augmentation surgery, the requested services are medically indicated. In this patients case, breast augmentation surgery is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, breast augmentation surgery is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MyoPro Motion G (upper extremity myoelectric orthosis  CPT L8702). Findings:  The physician reviewer found that MyoPro Motion G upper extremity myoelectric orthosis has not been demonstrated to help patients with arm weakness due to a stroke to perform self-care tasks or activities of daily living better than without the device. In addition, the MyoPro Motion G device has not been shown to improve any health outcomes following a stroke, such as reducing the incidence of overuse injury of the opposite, unaffected limb. Moreover, the MyoPro Motion G is relatively heavy compared to the anatomical weight of the arm, which makes it difficult for the patient to place the affected upper extremity into positions where she can use the device in a purposeful manner (Harrison and Field). The device may also cause a patient with a hemiparetic gait to have greater instability while ambulating due to an unfavorable displacement of the center of gravity caused by wearing the device. Overall, the requested MyoPro Motion G device is not expected to provide any clinically or functionally significant marginal benefits over conventional orthotic therapy for the treatment of this patients stroke related functional deficits. For these reasons, the requested MyoPro Motion G (upper extremity myoelectric orthosis  CPT L8702) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) of the heart without contrast, and with quantitative evaluation of coronary calcium. In this case, notes reported that the patient had a marked elevation of low-density lipoprotein (LDL) cholesterol. CT calcium scoring results reported that the patient had undergone prior coronary calcium scoring. In this clinical setting, current American College of Cardiology (ACC) guidelines recommend maximally tolerated statin therapy, and a repeat coronary artery calcium scoring was not reasonably expected to alter that recommendation. Therefore, CT of the heart without contrast, and with quantitative evaluation of coronary calcium, was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the computed tomography (CT) of the heart without contrast, and with quantitative evaluation of coronary calcium, 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 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 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart 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 magnetic resonance imaging (MRI) of the left knee. The American College of Radiology (ACR) criteria state that MRI is indicated for non-traumatic knee pain when pain is persistent, and radiographs are non-diagnostic. However, MRI is not recommended before a thorough physical examination and radiography, or for severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. Researchers concluded that the management of patients with knee pain for degenerative meniscal tears and degenerative joint disease in its initial stages remains nonoperative. Currently, MRI has not been shown to add substantial value in the management of patients with degenerative disease. Failure to respond to nonoperative measures warrants orthopedic assessment with radiographic studies and counselling on managing degenerative joint disease. This patient is being treated for left knee pain. The patients left knee pain has been worsening recently and is interfering with his ability to sleep. He presented to the emergency department and x-rays showed no visible acute osseous injury, with evidence of tiny patellofemoral osteophytes. The patient underwent treatment with a cortisone injection and medications. On 10/6/21, he presented with continued severe pain rated at 9/10 with clicking and popping. Physical examination findings demonstrated slight trace of effusion and medial joint line tenderness. There is a lack of documentation of any formal physical therapy or completion of physician-directed exercises to support an indication for MRI of the left knee. For these reasons, the requested MRI of the left knee is not medically necessary for 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 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 proton beam radiation therapy services, 28 fractions with hydrogel placement. This patient presents with a history of Gleason 3+3 prostatic adenocarcinoma. The patient is planned to undergo treatment with proton beam radiation therapy with placement of hydrogel to reduce exposure to normal surrounding health tissue. However, there is a paucity of high quality prospective clinical outcomes published in the peer-reviewed medical literature to support the efficacy of proton beam radiotherapy in the treatment of prostate cancer as compared to active surveillance, prostatectomy, intensity modulated radiation therapy (IMRT) with photons, stereotactic body radiation therapy (SBRT), or brachytherapy. Moreover, the American Society for Radiation Oncology (ASTRO) does not recommend treatment with proton beam radiation therapy for treatment of this patients prostate cancer outside the context of a clinical trial. The records provided for review do not document prior receipt of pelvic radiation or presence of a genetic condition that increases the patients risk for normal tissue toxicity to support an indication for use of proton beam radiation with hydrogel placement. For these reasons, the requested proton beam radiation therapy services, 28 fractions with hydrogel placement, 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 radiation oncology 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 a continuous positive airway pressure (CPAP) device. The submitted documentation supports the medical necessity of the requested device. The patient reported symptoms of fatigue and sleepiness during the day. Additionally, he has a history of depression and insomnia. Medical literature defines obstructive sleep apnea as a polysomnogram-determined obstructive respiratory disturbance index (RDI) of at least five events per hour associated with the typical symptoms of obstructive sleep apnea (e.g., unrefreshing sleep, daytime sleepiness, fatigue or insomnia, awakening with a gasping or choking sensation, loud snoring, or witnessed apneas), or an obstructive RDI of at least 15 events per hour (even in the absence of symptoms). Home sleep studies usually underestimate the severity of obstructive sleep apnea. Untreated obstructive sleep apnea could lead to medical complications. This patient meets the criteria for obstructive sleep apnea. CPAP is considered first-line treatment for obstructive sleep apnea. Therefore, the requested CPAP device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 internal medicine with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections. There is mixed evidence in the current medical literature on the effect of PRP when compared to corticosteroids or alternative well-accepted treatments. Han and colleagues report that a meta-analysis supported the use of steroids and hyaluronic acid for appropriate patients with knee osteoarthritis. The authors further found steroids as most likely the best treatment for pain relief, followed by hyaluronic acid, and noted that PRP interventions did not result in a relevant reduction of joint pain nor improvement of joint function compared with placebo. Given that the current medical literature does not support the benefit of PRP over standard treatment with steroids and hyaluronic acid, the requested services are not likely to be more beneficial for the treatment of this patient. Therefore, PRP injections are not likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PRP injections are 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 service 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. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa. The submitted documentation supports the requested medication in this clinical setting. Researchers noted, Randomized trials, medications that reduce triglyceride levels, such as extended-release niacin and fibrates, have not reduced the rates of cardiovascular events when administered in addition to appropriate medical therapy, including statins. Per the authors, Contemporary trials and recent meta-analyses of n-3 fatty acid products have not shown a benefit in patients receiving statin therapy. In the REDUCE-IT trial, the risk of ischemic events, including cardiovascular death, was significantly lower among those who received 2 g of icosapent ethyl (Vascepa) twice daily than among those who received placebo. The requested medication is medically indicated in this patients case. Therefore, Vascepa is 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 internal medicine with sub-specialty certification in cardiovascular disease 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.