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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with synovial chondromatosis and degenerative joint disease. The patient reported left knee pain. The patient was noted to be status post open synovectomy for synovial chondromatosis. Physical examination findings included a mild left knee effusion and crepitation of the patellofemoral joint. An x-ray was noted to reveal significant synovial chondromatosis with joint space narrowing. A Celestone injection was administered to the left knee. The provider noted the Celestone injection did not provide the patient with pain relief. The patient has requested authorization and coverage for hyaluronan injections (CPT J7321) for the left knee. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether hyaluronan injections (CPT J7321) for the left 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed a corticosteroid injection with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, hyaluronan injections (CPT J7321) for the left 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for authorization and coverage for Humira, and if not then, Entyvio. The enrollee has diagnoses of Crohns disease with rectal bleeding, and pancreatic insufficiency. A progress note shows the enrollees current medications include Linzess, Creon, famotidine, metoclopramide, ondansetron, and pantoprazole. The enrollee started prednisone. A colonoscopy showed areas of moderately congested and ulcerated mucosa in the rectum and descending colon. A computed tomography scan of the abdomen was performed due to symptoms of weight loss and upper left quadrant pain, but records show no acute abdominal process was seen. The clinical guideline for the management of Crohns disease in adults from a professional society indicates, for mild to moderately severe disease, current options include Sulfasalazine and budesonide.  This enrollee has evidence of Crohns disease and appears to have had a good response to prednisone. A progress note reported the enrollee had normoactive bowel sounds, and no rebound, tenderness, or guarding was noted. No complaints were noted. Based on the records, the enrollee appears to have mild to moderate disease.  Biologic agents are advised for Crohns enrollees who are refractory to thiopurines or methotrexate, and have moderate to severe disease.  Humira and Entyvio are not medically necessary at this time, as the enrollee has not been tried on an immunomodulatory (medications used to normalize the immune system such as Azathioprine, Mercaptopurine or Methotrexate).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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a 62-year-old female with a history of hyperlipidemia. The provider reports the patient has tried and failed simvastatin and atorvastatin, and that the medications caused muscle spasms and myalgias. The patient was switched to Livalo in 2013 without adverse reactions to this medication and this medication has helped her reach her goals. At issue is whether the medication, Livalo 4 mg tablets, is medically necessary to treat the patients medical condition. Pitavastatin (Livalo) is medically necessary. There is documented history of the patients intolerance or lack of efficacy of other formulary alternative statin medications. Toth et al, states that switching to a different statin is an accepted strategy. In this patient, this approach has met with success since 2013. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage, and reimbursement, for physical therapy services. The enrollee has a history of hip pain and meralgia paresthetica. She injured her back about two years prior. The records report the enrollee has horrible groin pain, which causes difficulty with driving, sitting, standing for long periods, bending forward and an inability to lift anything greater than five pounds. A physical therapy progress note reports the enrollee would benefit from aquatic and physical therapy for pain relief and range of motion and strength improvements so that she can return to her normal activities. The enrollee reports she is currently on disability for this injury and cannot sit or stand for any significant length of time due to nerve pain. The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity for the dates of service under review as well as the requested additional hands-on physical therapy.  The clinical records do not establish the medical necessity of continuing a structured outpatient physical therapy treatment program.  After several months of treatment, the therapy notes do not provide evidence of objective impairment, such as motor strength, or lumbar range of motion, that has substantially improved to support the continuing necessity of physical therapy.Final Result: The reviewer determined that the requested services were not, and are not, medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for Anakinra (Kineret). The enrollee has an auto-inflammatory disorder, not otherwise specified, that includes symptoms of recurring fevers, swollen lymph nodes, nausea and vomiting. She began anakinra and the enrollee reports the anakinra has helped her symptoms significantly because she has experienced fewer disease flares, what flares she does experience are less severe, and she can continue to participate in school and work when experiencing a flare; which had not been possible in the past. The auto-inflammatory disorders are a rare family of disorders; usually starting in childhood. This enrollee is now an adult. Large trials of treatment are not available for most auto-inflammatory disorders. Anakinra is approved for one of these, cryopyrin-associated auto-inflammatory syndromes. It is used in many of the other auto-inflammatory disorders as well. Literature reports effective therapies are available for many of the syndromes, including colchicine, interleukin 1 blockade, and anti-tumor necrosis factor therapies. Interleukin 1 blockers, such as anakinra, are recognized as effective treatments for auto-inflammatory disorders, and the enrollee should be continued on it.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology 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 been diagnosed with chronic rhinosinusitis. A sinus computed tomography (CT) scan showed mild mucosal thickening of the left maxillary sinus with opacification of the ostiomeatal complex. The patient reported facial pressure, nasal congestion and postnasal drip. The patient reported he has experienced symptoms for 15 years. The patient was status post sinus surgery two to three years prior. The records indicated that except for a tree allergy, allergy testing was negative. Per the documentation, a two- anda-half month course of allergy shots did not help the patients symptoms. The patient has requested authorization and coverage for Dupixent 300 mg/2 ml. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Dupixent 300 mg/2 ml is medically necessary for the treatment of the patients medical condition. Kim and Naclerio reported, In July 2019, dupilumab was the first monoclonal antibody to gain U.S. Food and Drug Administration (FDA) approval for the treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP). Boyle and colleagues reported, Understanding of CRSwNP pathophysiology has progressively evolved and the identification of various inflammatory biomarkers has led to the development of monoclonal antibodies that target the underlying mechanisms of inflammation. Dupilumab, which targets IL-4 and IL-13 signaling, serves as a novel agent for CRSwNP treatment. In this case, the patients sinus CT scan did not reveal polyps, and the physical examination did not show evidence of nasal polyposis. The medical evidence does not support the requested medication in this clinical setting. Therefore, Dupixent 300 mg/2 ml 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for deep sedation (D9222) and excision of a benign lesion, up to 1.25 cm (D7410) for tooth #14.The submitted documentation does not support that the requested services are medically necessary. The submitted radiographs do not demonstrate a lesion on or adjacent to tooth #14, however, an appeal note states that a cone beam computed tomography (CBCT) radiograph showed a cyst on the palatal aspect of tooth #14. Clinical differentiation can only come from a microscopic evaluation and does not change the treatment involved. These lesions are typically an integral part of the approved extraction of tooth #14. As such, debridement of the excision site is an integral part of the extraction process. In this case, the submitted radiographs and records do not demonstrate that the requested excision of benign lesion for tooth #14 requires a stand-alone procedure and would not be an integral part of the extraction process for removal of tooth #14. Tooth #14 shows no complex condition which would indicate anything other than a routine extraction. Therefore, the requested excision of benign lesion, up to 1.25 cm (D7410) for tooth #14 is not medically necessary to treat the patients medical condition.With regard to the patients request for coverage for deep sedation, the extraction of tooth #14 and excision of a benign lesion constitute treatment of a chronic condition. The submitted records do not demonstrate extenuating clinical conditions, and no medical compromise is described that would necessitate general anesthesia. Under these circumstances, general anesthesia would be administered solely for the convenience of the patient and treating doctor, and not as a matter of medical necessity. Accordingly, the requested deep sedation (D9222) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed doctor of dental surgery who is board certified in dentistry 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 been diagnosed with right knee osteoarthritis. The patient reported right knee pain. The physical examination findings included antalgic gait and right knee medial joint line tenderness. It was noted the patient has been treated with meloxicam, steroid injections, and physical therapy, without long-term benefit. The patient has requested reimbursement for a Durolane injection in the right knee. The Health Plan denied the request and reported the service at issue was not medically necessary for the treatment of this patient. At issue in this case is whether a Durolane injection in the right knee received was medically necessary for 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options were limited. The patient had tried and failed other conservative treatments, including meloxicam, corticosteroid injections, and physical therapy, with the alternative being a total knee arthroplasty. The medical evidence supports the service at issue in this clinical setting. Therefore, a Durolane injection in the right knee received was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested reimbursement for partial hospitalization program services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children needing mental health treatment. The patients composite score corresponds with Level 4: Medically Monitored Community Based Services. Therefore, the partial hospitalization program services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying ASAM guidelines, this patient did not meet the criteria for RTC services 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 with expertise in addiction 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: Overturned Decision of Health Plan

An enrollee has requested reimbursement for residential treatment center level of services. The submitted documentation supports that residential treatment center level of services at issue were medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. The submitted documentation thereby reflects that the patient required a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level 3.5 treatment at least, which is similar to what the patient received at the facility. Treatment may be required at Level 3.5 if an individual is not progressing and faces imminent danger if not in a supportive treatment setting. Given the severity of the patients illness, residential treatment center level of services were clinically appropriate for the patient's illness. Therefore, the residential treatment center level of services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for Platelet-Rich Plasma Injections, any site, including image guidance, harvesting and preparation. The enrollee has a history of right shoulder pain and combination subacromial impingement/acromioclavicular (AC) joint flare up. Progress notes show the enrollees pain was just as bad, if not worse, than before surgery. The physical exam noted breakaway weakness with external rotation and internal positive impingement signs. Over the past months, the enrollee has tried pain medication, anti-inflammatories, steroids, muscle relaxants, and physical therapy. A recent magnetic resonance imaging (MRI) scan shows the tear is worse than before surgery. Literature highlights the methodologic and technical issues that markedly limit any determination of the value of platelet rich plasma. Significant variability exists in the methods used to prepare PRP, resulting in differences in blood component concentrations and biomolecular characteristics. Additionally, the final concentration of platelets, growth factors, and leukocytes has been shown to vary between and within individuals. The varying quality and preparations of PRP make comparison amongst clinical research studies challenging. Attempts to classify and standardize preparations have been made. However, no consensus has been reached regarding the optimal preparation. Studies also show platelet-rich fibrin matrix (PRFM) applied to the tendon-bone interface at the time of rotator cuff repair had no demonstrable effect on tendon healing, tendon vascularity, manual muscle strength, or clinical rating scales. In fact, analysis suggests PRFM may have a negative effect on healing. Final Result: The 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: The reviewers 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.