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

Nature of Statutory Criteria/Case Summary: A patient requested Synvisc injections in the knees. Findings: The physician reviewer found that the medical evidence does not support repeat hyaluronic acid injections if there is no documentation of significant improvement in symptoms for six months or more. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic severe knee osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. The Health Technology Assessment for Viscosupplementation for Treating Osteoarthritic Knee Pain concluded that evidence from 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, which populations benefit most, and whether hyaluronic acid injections should be combined with other agents to increase effectiveness.  This patient has a history of chronic bilateral knee pain. Current pain and functional assessments are not documented. Clinical examination findings are generally consistent with x-ray findings of mild to moderate bilateral knee osteoarthritis. The patient has undergone a recent corticosteroid injection with insufficient relief. Detailed evidence of other conservative treatment trial and failure is not documented. The patient reports previous Synvisc injections with significant benefit, but there are no details provided relative to pain relief, functional improvement or duration of the benefit. The medical evidence does not support repeat hyaluronic acid injections if there is no documentation of significant improvement in symptoms for six months or more. Therefore, the requested Synvisc injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: At issue is whether the frozen shoulder procedure of the left shoulder provided was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. A review of the record indicates that the enrollee has a history of shoulder pain. She has undergone activity modification and physical therapy.Two out of three physician reviewers found that she underwent manipulation under anesthesia procedure that was a variation called the Oolo-Austin Trigenics Manual Capsular Dissection Procedure (OAT-MCD). There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this specific manipulative procedure for this patient. A recent extensive review of the literature notes that most patients (about 90%) will see complete resolution of symptoms with nonsurgical management.  Surgical intervention, including manipulation under anesthesia, with or without arthroscopic capsular release, is not recommended until after at least a 9 to 12 month failed trial of nonoperative treatment.Final Result: The reviewers determined that the requested procedure was not likely to have been 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 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 services at a residential treatment center for eating disorders. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for patient needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presents a composite score of 25, which correlates with a treatment intensity level of five, which is medically monitored residential services. According to the LOCUS guideline, the patient meets the criteria for residential placement in a facility that specializes in treating patients with eating disorders. For these reasons, the requested services at a residential treatment center for eating disorders is supported as medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a coronary angiogram procedure. This patient had known coronary artery disease and had a previously placed coronary stent. He had been free of symptoms until recently when he developed recurrent anginal type chest pain similar to the symptoms he experienced before his prior stent. He was on beta blocker therapy, and his systolic blood pressure was 108, making further medical therapy for angina problematic and not likely to be well-tolerated. Although he did not undergo stress testing prior to the angiogram, he had known established coronary artery disease, multiple coronary risk factors for progression of his disease and new onset typical and escalating symptoms of angina. Based on the American College of Cardiology criteria, even with a low risk stress test, in a symptomatic patient with known coronary artery disease and prior percutaneous coronary intervention, coronary angiography is medically reasonable. Escalating symptoms suggest an instability to the angina. Therefore, coronary angiogram procedure was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female has requested authorization and coverage for enoxaparin (Lovenox) injections. The Health Plan has denied the requested medication as experimental for treatment of the enrollees infertility.Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) practice bulletin indicates that testing for inherited thrombophilias in patients who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients. In addition, there is insufficient evidence of an association and, therefore, insufficient evidence to either screen for or treat women with inherited thrombophilia and obstetric histories that include complications such as fetal growth restriction or preeclampsia. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia. No such history is presented in this case. Therefore, the requested enoxaparin (Lovenox) 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 medication 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 obstetrics and gynecology 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: Upheld Decision of Health Plan

A male has requested authorization and coverage for an implanted Inspire sleep apnea control device. The Health Plan has denied the requested procedure as experimental or investigational for treatment of the enrollees obstructive sleep apnea (OSA).Findings:  Three physician reviewers found that the American Academy of Sleep Medicine guideline indicates that the diagnosis of OSA should be established prior to surgery and the severity determined by objective testing. In addition to a general sleep evaluation, patients should be evaluated for eligibility for surgery. This evaluation should include an anatomical examination to identify possible surgical sites, an assessment of any medical, psychological or social comorbidities that might affect the surgical outcome and a determination of the patient's desire for surgery. Across a multi-institutional registry of patients, upper airway stimulation therapy demonstrated significant improvement in subjective and objective OSA outcomes, good therapy adherence and high patient satisfaction. The documentation, in this case, does not demonstrate sufficient attempts at working with different interfaces for the patients CPAP. The records do not provide physical examination of the upper airway or the oral cavity, oropharynx or hypopharynx. Thus, the implanted Inspire sleep apnea control device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology with subspecialty certification in sleep medicine, otolaryngology with subspecialty certification in sleep medicine and otolaryngology respectively 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 authorization and coverage for Nuedexta 20/10 mg.Findings:  Two of the three physician reviewers found that this patient has been diagnosed with pseudobulbar affect secondary to Parkinsons disease. Pseudobulbar affect is a condition of contextually inappropriate emotional expression that often occurs in adults with neurological damage conditions, such as amyotrophic lateral sclerosis, multiple sclerosis, stroke, traumatic brain injury, Alzheimers disease, or Parkinsons disease. Nuedexta has been approved by the U.S. Food and Drug Administration for the treatment of pseudobulbar affect. This medication has been shown to reduce the rate of pseudobulbar affect episodes and improve pseudobulbar affect severity. This medication is generally well-tolerated. The current evidence indicates that Nuedexta is a useful option for the treatment of adults with pseudobulbar affect. Thus, Nuedexta 20/10 mg is likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested medication is 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 reviewers 1, 2 and 3 are board certified in neurology 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for ketamine infusions. The records indicate the patient has a history of depression as well as anxiety and obsessive-compulsive disorder symptoms. The recent progress notes indicate that the patients treating providers have recommended electroconvulsive therapy for his medication-resistant depression. The current evidence regarding ketamine is limited in nature. Colleagues noted the antidepressant efficacy of ketamine, and perhaps D-cycloserine and rapastinel, holds promise for future glutamate-modulating strategies; however, the ineffectiveness of other N-methyl-D-aspartate (NMDA) antagonists suggests that any forthcoming advances will depend on improving our understanding of ketamines mechanism of action. The fleeting nature of ketamines therapeutic benefit, coupled with its potential for abuse and neurotoxicity, suggest that its use in the clinical setting warrants caution. The literature indicates there are risks associated with this treatment. Colleagues noted damage to the urinary barrier initiates bladder pain and, in ketamine-induced cystitis, loss of urothelium from large areas of the bladder wall is a reported feature. This study offers first evidence for a mechanism of direct toxicity of ketamine to urothelial cells by activating the intrinsic apoptotic pathway. In sum, there is a lack of support for the requested medication in this clinical setting. Therefore, the requested ketamine infusions are not medically necessary for the 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 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 authorization and coverage for midazolam, meperidine and moderate sedation services provided during epidural steroid injections. The submitted documentation fails to demonstrate the medical necessity of the requested medications and requested services. Midazolam and meperidine are used for conscious sedation for certain in-office procedures. Epidurals for pain management are an appropriate indication for conscious sedation in patients who have anxiety, extreme fear of needles or risk of moving during the procedure. Most patients can tolerate local anesthesia for these epidural injections. Conscious sedation is generally reserved for patients who have tried but are unable to tolerate local anesthetic for these injections. In this patients case, the records do not document that the patient requires conscious sedation for this procedure. The records do not document previous attempts with local anesthesia where the patient was unable to tolerate the procedure under local anesthesia. Therefore, midazolam, meperidine and moderate sedation services provided during epidural steroid injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 anesthesiology with sub-specialty certification in pain 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 patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine without dye and MRI of the thoracic spine. Findings:  The physician reviewer found that he patient is currently asymptomatic. In addition, there is no detailed neurological examination demonstrating any red flags such as weakness or neurologic deficit. Further, there is no recent history of trauma, infection, or malignancy to support an indication for MRI. The records do not include abnormal findings on electromyography (EMG) or x-ray of cervical or thoracic spine. Absent current concerning symptoms or neurological deficit, there is no indication for MRI of the cervical or thoracic spine without a trial of conservative management including physical therapy. For these reasons, the requested MRI of the cervical spine without dye and MRI of the thoracic spine are not medically necessary for evaluation of this patients neck pain. 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: An enrollee has requested authorization and coverage for Cresemba 186 mg capsule, twice daily. This patient is receiving induction therapy for acute myeloblastic leukemia which is associated with a high risk of neutropenic fever. Some institutions administer prophylaxis with fluoroquinolones and/or antifungals (e.g., fluconazole, itraconazole, posaconazole, voriconazole, or amphotericin) during the period of neutropenia. The combination of Cresemba with any of the azoles carries a category D warning, except for fluconazole and Cresemba, which carries a category C warning on drug interaction check. Of note, amphotericin does not carry a drug interaction and could be use instead of Cresemba. Cresemba is not U.S. Food and Drug Administration (FDA) approved for use as prophylaxis and is not supported by major drug compendia for this indication. The National Comprehensive Cancer Network guidelines do not recommend Cresemba as fungal prophylaxis in acute myeloblastic leukemia. Therefore, Cresemba 186 mg capsule, twice daily is not medically necessary for the 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 sub-specialty certification in medical 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.