Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injections. The ERCI Institutes Health Technology Assessment for Viscosupplementation for Treating Osteoarthritic Knee Pain concluded that evidence remains inconclusive on which patient populations are likely to benefit most from hyaluronic acid injections. Evaluation of eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations and whether hyaluronic acid injections should be combined with other agents to increase effectiveness. Peer-reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports-related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. This patient presents with a history of chronic left knee pain. He is status post left knee arthroscopy, partial lateral meniscectomy, and chondroplasty of the lateral tibial plateau in 2017. He had a return of left lateral knee pain with an increase in his activity level. Conservative treatment has included physical therapy, home exercise program, NSAIDs, platelet-rich plasma injection, corticosteroid injection, and stem cell injection without adequate relief of symptoms. He underwent Monovisc injection on 11/27/18 with the most significant relief to date, but his pain was reported grade 8/10 after only five months. Based on the records provided for review, there is a lack of documentation that this patient has significant moderate to severe osteoarthritis of the left knee. There is no current left knee examination or post-operative imaging reports supporting a diagnosis of moderate to severe osteoarthritis. Additionally, the records suggest the patient did not achieve six months of sustained improvement with the prior Monovisc injection to support a repeat injection consistent with evidence-based medical guidelines and literature. Therefore, the requested Monovisc injections are not medically necessary for treatment of this patients medical condition.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 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 Lyrica. In the peer-reviewed medical literature, researchers reviewed the efficacy of Lyrica for neuropathic pain in adults. The authors concluded that studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. In addition, the North American Spine Society (NASS) guidelines reported a lack of strong evidence to recommend Lyrica for lumbar radiculopathy. In this case, the patients history consists of chronic right lumbar radiculopathy status post lumbar laminectomy and fusion in 2017, with current symptoms of numbness and radicular pain to the right leg. The patient has tried and failed physical therapy as well as gabapentin and ibuprofen. Treatment with Lyrica reportedly improved the patients pain. However, the providers notes do not state that the patient has undergone an adequate trial of neuropathic agents from other drug classes which have been proven to be effective for this patients medical condition. Currently, the U.S. Food and Drug Administration (FDA) has not approved Lyrica for lumbar radicular pain. Based on these findings, the requested Lyrica is not supported as 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Alprazolam (Xanax). A review of the records indicates the patient with a history of grief, anxiety and depression came for renewal of her anxiety medication. Findings: The physician reviewer found that  the enrollee has been on Alprazolam for a long time and takes Norco for pain, as well. She had tried a number of medications that did not work as well as Alprazolam for her anxiety and/or caused side effects. The enrollee had panic attacks and was not able to leave the house or work. Alprazolam worked best to help her with these issues and she does not want to try other medication. The treatment plan was to taper Alprazolam and start a trial of gabapentin. According to the medical literature, Alprazolam has the potential to be addictive. Due to its addictive potential and sedating effects when given with Norco, it would not be considered safe to prescribe these two medications at the same time. The medical literature indicates the use of opioids and benzodiazepines should be avoided while taking Alprazolam. There are other first line medications for the treatment of panic disorder, which are not considered benzodiazepines.  Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician 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 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 fluoroscopic guided left hip injection with Synvisc One. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials pertaining to osteoarthritis of the knees indicate that although viscosupplementation may relieve pain in some patients with osteoarthritis, it remains unknown who will benefit. Additionally, viscosupplementation can provide improvement in patients with osteoarthritis of the hip, although the evidence is limited. In light of the foregoing, viscosupplementation can only be recommended in patients 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 known benefit from prior injections, and the remaining treatment options are limited, with the alternative being a complex total hip arthroplasty. As such, the requested fluoroscopic guided left hip injection with Synvisc One is medically necessary for treatment of osteoarthritis of the patients left hip.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 a referral for tertiary neurology services. Findings:  The physician reviewer found that the patient has a history of migraine headaches that have not adequately responded to prior therapies. The patient is currently under the care of a neurologist as reported in the medical records provided for review. The documentation reports the patient is being treated in a manner that is consistent with currently accepted standard of care and practice guidelines from the American Headache Society (AHS). Specifically, the patients current treating provider is addressing her condition using the most recent therapies available including Botox and calcitonin gene-related peptide (CGRP)-based medications. These are the same therapies that are used within tertiary care centers at this time. Given that the patient is receiving care that is consistent with the generally accepted standards of practice, the referral for tertiary neurology services exceeds the patients clinical needs. The referral for a tertiary care evaluation would not be expected to lead to any meaningful improvements in outcome. For these reasons, the requested referral for tertiary neurology services is not supported as medically necessary for treatment of this patients medical condition. 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 neurology 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 magnetic resonance imaging (MRI) of the right hip and entire spine. Rheumatoid arthritis has been found to initially attack the joints of the hands and feet, while the spine and sacroiliac joints are generally involved later in the course of the disease, if at all. This patient was evaluated with a MRI of the right hip on 10/2/18 which showed degenerative changes of cartilage, but no sign of erosions, as is common in rheumatoid arthritis. In addition, there are no plain film studies showing a dramatic change in the appearance of the patients right hip since October 2018. Further, there is no red flag to indicate immediate imaging of the thoracic or lumbar spine without the patient undergoing conservative management such as physical therapy. MRI of the cervical spine on 1/23/15 showed degenerative changes and no sign of rheumatoid arthritis, especially at C1-2, which can be present in rheumatoid arthritis. Since her laboratory work-up does not show serological evidence of increasing inflammation, the provider has recommended pain management and conservative measures. Based on the records provided for review, there is no current indication for MRI of the right hip or spine. In summary, the requested MRI of the right hip or entire spine are not supported as medically necessary for evaluation of this patients medical condition. 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 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 morphine. Researchers found adequate evidence to support short-term efficacy of opioids for chronic low back pain compared to placebo. Researchers determined that for patients with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Overall, researchers found that there is a paucity of evidence supporting the long-term efficacy of opioid medications for patients with chronic low back pain. Further, researchers reported on an outcome study on the effects of opioid therapy for lumbar disc herniation. Researchers found that patients who were treated with opioids had significantly worse baseline pain and quality of life. At final follow-up, there was no long-term difference in outcome associated with opioid pain medication use. In this case, the patient has been on high dose opioid therapy with morphine and Norco. She has chronic low back pain with radicular pain and lumbar spondylosis. She has been resistant to treatment with non-opioid strategies for managing her pain, including pain management injections. Her providers have recommended a slow tapering of morphine while continuing Norco for pain. A review of the records reveal the most recent bone density scan was significant for osteoporosis and the patient has a history of falls. High-dose opioid therapy has been shown to worsen osteoporosis in patients on long-term therapy. Based on the available records for review and the lack of evidence supporting long-term high-dose opioid therapy for non-cancer pain, the request for morphine is 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee has requested authorization and coverage for Monovisc injection in the left knee. The Health Plan has denied the request as not medically necessary.A review of current literature pertaining to viscosupplementation reveals mixed results. Colleagues found that intra-articular hyaluronic acid (HA) injections provide a moderate symptomatic benefit to knee osteoarthritis without major safety concerns. Colleagues performed a meta-analysis of double-blinded, sham-controlled trials with at least 60 patients and concluded that the evidence did not show clinically important differences of HA over placebo. Colleagues concluded that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In light of the foregoing, viscosupplementation is recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, there is known benefit from prior injections, and the options are limited, with the alternative being a total knee arthroplasty. Therefore, the request for the Monovisc injection in the left knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 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: At issue in this case was whether the residential treatment center (RTC) services that were provided were medically necessary for the treatment of the patients behavioral health condition. The patient was admitted to the residential treatment center (RTC) services after completing detoxification at another facility. The diagnoses included alcohol use disorder and obsessive-compulsive disorder.The American Society of Addiction Medicine (ASAM) supports individualized treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The ASAM criteria include: (1) acute intoxication and/or withdrawal potential, (2) biomedical conditions and complications; (3) emotional, behavioral, or cognitive conditions and complications; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. According to the ASAM 3.5, criteria were not met according to the patients presentation.Final Result: The reviewer determined that the requested services 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not indicate that the patient had active suicidal or homicidal ideation. The records do not demonstrate that the patient was experiencing psychosis. The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times. The progress notes do not indicate that the patient was engaging in aggressive behaviors. The patients family was involved in her treatment on a regular basis, and she denied illicit substance use. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to problems with role performance and ability to maintain some meaningful relationships. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living situation with intermittent interpersonal conflict. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the inpatient and residential treatment levels of care but without complete remission of the eating disorder symptoms. In terms of engagement and recovery status, the records support a score of 2 to 3 due to cooperation in treatment but also hesitation in acceptance of her illness. Thus, the patient has a composite score of 14 to 15. This score correlates with high intensity community based services, or treatment in an intensive outpatient clinic setting. Therefore, partial hospitalization program 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage for Hyaluronan (Euflexxa) injections in the right knee. The Health Plan denied the request as not medically necessary.Findings:  The physician reviewer found that the requested treatments are medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.A review of current literature pertaining to viscosupplementation reveals mixed results. Maheu and colleagues found that intra-articular hyaluronic acid (HA) injections provide a moderate symptomatic benefit to knee osteoarthritis without major safety concerns. Researchers performed a meta-analysis of double-blinded, sham-controlled trials with at least 60 enrollees and concluded that the evidence did not show clinically important differences of HA over placebo. Researchers concluded that viscosupplementation increased functional scores in enrollees with severe osteoarthritis of the knee, especially within three months of injection. However, it was not superior to triamcinolone. In light of the foregoing, viscosupplementation is recommended in enrollees with a history of lasting benefit from prior injections, and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, the options are limited, with the alternative being a total knee arthroplasty, which is not indicated for mild osteoarthritis. As such, the request for Hyaluronan (Euflexxa) injections in the right knee is medically necessary for treatment of osteoarthritis of the enrollees right knee.Final Result: The reviewer determined that the requested treatments are medically necessary for treatment of the enrollees 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.