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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited. Moreover, the patient has a history of substantial benefit from prior viscosupplementation and she has tried and failed conservative therapies. All told, the requested Synvisc One injections in both knees are 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 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 brain. The records provided for review document that this patient presented to his provider with complaints of nasal congestion and a loss of smell and taste that has not responded to standard therapies. The patients nasal obstruction has been unrelieved by decongestants. The provider recommended an MRI of the brain to evaluate the patients loss of smell and taste. MRI of the brain in patients who present with a loss of smell is appropriate to rule out tumors or other abnormalities of the olfactory areas of the brain. Given this support, the requested MRI of the brain is medically necessary for evaluation 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 otolaryngology 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 patient has requested authorization and coverage for occlusal orthotic device. This patients symptoms support a diagnosis of TMJ disorder and myofascial pain disorder. Occlusive splint devices have been shown to be beneficial in patients with TMJ disorder and myofascial pain, with improvement in up to 90% of patients. There are various types of splints available to treat myofascial pain. Overall, the medical literature supports the safety and utility of a single maxillary or mandibular splint as a well-accepted treatment method in this clinical setting. Given these findings, the requested occlusal orthotic 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 oral and maxillofacial 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

The patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG). The American Academy of Neurology (AAN) guidelines for IVIG in the treatment of neuromuscular disorders recommends that IVIG should be considered in the treatment of myasthenia gravis. The AAN noted that further studies on the safety and efficacy of IVIG in myasthenia gravis are lacking due to the few randomized trials and small study sizes available at this time. Researchers reported that there is class 1 evidence for the use of short-term IVIG in patients with worsening myasthenia gravis and good evidence for IVIG use in myasthenic crisis. However, for long-term maintenance therapy, there is a paucity of controlled studies and the evidence is limited to class III retrospective studies. In this case, the records provided for review do not document the severity of the patients disease to warrant the use of IVIG. The records suggest that the patient has been treated with IVIG as a long-term therapy, but the clinical evidence does not report on the benefits of IVIG or the patients specific response to treatment. The records also do not provide enough evidence of an inadequate response to immunosuppressive therapy. For these reasons, the requested IVIG 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for the medication Verzenio. The enrollee has breast cancer. She had surgery and treatment. There was evidence the disease had spread to her lungs and lymph nodes. The enrollee was started on two medications, but the disease continued to spread. The enrollee will undergo brain radiation therapy. The physician is requesting abemaciclib (Verzenio). The requested medication is in the same category as the one that enrollee is currently taking. Studies do not show this medication works better than the others the enrollee has used.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology and are actively practicing.  All three 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

The patient has been diagnosed with bilateral knee osteoarthritis. The records noted that the patient was status post posterior medial partial meniscectomy. Per the records, she was one-week status post irrigation and debridement for septic arthritis. The patient reported bilateral knee pain. Physical examination findings included right knee medial joint line tenderness. The patient has been treated with physical therapy, Pennsaid topical cream, and meloxicam. The patient reported that a previous Synvisc One injection provided pain relief for approximately two years. The patient has requested authorization and coverage for Euflexxa injections in both knees. 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 Euflexxa injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. In this case, the patient has had prior viscosupplementation with Synvisc One injections with good results. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a power pressure-reducing air mattress. The patient has been diagnosed with spina bifida. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a power pressure-reducing air mattress is medically necessary for the treatment of the patients medical condition. Medical literature states that treatment of pressure ulcers is necessary for patient comfort and to decrease risk of systemic infection. The mainstays of treatmentinclude debridement of devitalized tissue, control of remaining infection with antibiotics, medical and nutritional patient optimization, appropriate dressing selection, and frequent monitoring of progression of wound evolution. In this case, the records do not document that the patient currently has a pressure ulcer. The record indicates that patient had a sacral decubitus ulcer in 2008, but the recent documentation does not reveal skin rashes or lesions.  There is no indication that this patient has had a recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis or that the patient has failed recent appropriate skin care management, including management of moisture/incontinence, appropriate turning and positioning, education on the prevention and/or management of pressure ulcers, nutritional assessment, or regular monitoring of the skin by a medical practitioner. The medical evidence does not support the requested device in this clinical setting. Therefore, a power pressure-reducing air mattress is not medically necessary for the 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 with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for a vitamin D test. The enrollee has complaints of brain fog and an inability to focus. The enrollees past medical history includes high cholesterol and testicular cancer. As part of the enrollees health care maintenance, the provider ordered lab testing; including vitamin D. According to the medical exam and lab results, there was no clear medical need for vitamin D supplementation to treat a vitamin D-deficiency medical illness.  Therefore, there was no need for a vitamin D screening lab test.  There was no documentation of any prior issues related to vitamin D deficiencies; therefore, testing for vitamin D deficiency without a clear reason was not needed.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a hypoglossal nerve stimulation system. The enrollee has severe sleep apnea. He is unable to tolerate his continuous positive airway pressure machine because he is unable to keep it on for the duration of the night. There is no other appropriate and beneficial treatment available, and the enrollees health will continue to get worse if left untreated. The enrollee has failed continuous positive airway pressure. There are limited other options available. Due to his disease severity, he is a good candidate for oral appliance therapy. The physician is requesting authorization for upper airway stimulation. Studies show this procedure improves the symptoms of disease and is a good option for people who cannot tolerate the continuous positive airway pressure. Studies show this procedure is safe and effective.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cuvitru (CPT code J1555). As noted by Albin and Cunningham-Rundles, IgG subclass deficiency remains a controversial diagnosis, and most experts agree that the loss of one or more IgG isotype may not be clinically relevant if there is sufficient antibody production. In this case, there is evidence of normal total IgG levels and of the patients ability to produce polysaccharide antibodies. There is a lack of a documentation regarding the frequency or nature of bacterial infections. Moreover, the medical literature does not support that an isolated IgG4 subclass deficiency is associated with clinical disease (Perez, et al.). For these reasons, the requested Cuvitru (CPT code J1555) 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 internal medicine with subspecialty certification in infectious 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 53-year-old female who has been diagnosed with osteoarthritis of the right knee. A magnetic resonance imaging (MRI) of the right knee revealed greater than 50% thickness cartilage defects involving the medial femoral condyle. A less than 50% thickness cartilage defect was noted in the median ridge of the patella. The patient reported 40% pain relief from a right knee intra-articular steroid injection administered one month prior. The patient reported knee pain. Physical examination findings included tenderness to palpation over the right knee medial and lateral joint lines. The patient had been treated with a knee brace and physical therapy. The patient elected to pursue conservative management for knee pain. A right knee steroid injection was administered. The patient has requested authorization and coverage for Orthovisc injections in the right knee. 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 Orthovisc injections in the right knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed conservative treatments with the alternative being surgery. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for esophageal impedance test and endoscopy. The recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend endoscopy for the evaluation of upper gastrointestinal symptoms such as gastroesophageal reflux which are refractory to proton pump inhibitor (PPI) therapy, as documented in this case. The ASGE states that when combined with pH testing, impedance can identify whether the refluxate is acidic, and can provide correlation between reflux episodes and symptoms to help guide management. This data can be useful in patients with persistent symptoms on PPI therapy who have nonacid reflux as a cause for symptoms. The American College of Gastroenterology (ACG) guidelines for the management of gastroesophageal reflux disease (GERD) state that reflux monitoring can be performed by impedance-pH testing. The ACG noted that, Patients found to have abnormal amounts of non-acid reflux on PPI therapy with good symptom correlation may be considered for surgery. For patients who do not respond to PPI, diagnostic testing with impedance and/or pH monitoring are reasonable to exclude continued acid or weakly acid reflux, and can make the diagnosis of non-acid reflux possible. This patient has ongoing reflux symptoms despite long-term PPI treatment. In addition, there is a lack of esophagitis or other findings on esophagogastroduodenoscopy (EGD). Given these findings, the requested esophageal impedance test and endoscopy are medically necessary for evaluation 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 internal medicine with subspecialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for wilderness therapy.Findings:  Two of three physician reviewers found that the current medical literature supports the use of wilderness therapy in this clinical setting. Behrens and colleagues noted that a longitudinal outcome study of wilderness therapy programs has shown that youth in the study experienced significant decreases in suicidal ideation, anxiety, depression, substance abuse, social conflict, sleep disruption, violence, as well as an overall reduction in externalizing behaviors such as impulsivity, defiance, and hostility. Furthermore, these youth demonstrated improvements in work and academic functioning during the follow-up portion of the study. Hoag and colleagues conducted a pilot study that investigated the effectiveness of wilderness therapy for 297 young adult participants. Their 3-year study found statistically significant changes on measures of life effectiveness, motivation for therapy, therapeutic alliance, and dysfunctional attitudes. Magle-Haberek and colleagues have also conducted research which showed that residential treatment center programs were not more effective than outdoor behavioral healthcare, or wilderness programs, in predicting change. In this case, the patient has failed inpatient and residential treatment center treatment, and the patients illness is severe. Wilderness therapy, as noted in the medical literature, is also clinically appropriate for the patient's illness. Accordingly, wilderness therapy was and is likely to be more beneficial than any other available standard therapy for the patients medical condition.Final Result: Two of three reviewers determined that the services at issue and requested services were and are likely to be more beneficial than any other available standard therapy for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. Physician reviewers 2 and 3 are board certified in psychiatry 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.