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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an increase of Applied Behavior Analysis (ABA) hours from 96 hours per month to 103 hours per month going forward. Findings:  The physician reviewer found that ouncil of Autism Service Providers (CASP) guidelines recommend service provision of 25 hours or less of Applied Behavior Analysis (ABA) services for individuals who need treatment only for a limited number of key functional skills. Papatola and Lustig define medically necessary ABA services as, (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care.In this case, the ABA service provider is targeting 24 goals, in addition to 3 challenging behaviors (and 3 additional behaviors with the caregivers). With 27 active goals being addressed, the requested increase of ABA hours will allow each program to be addressed for approximately 12 to 15 minutes each day. Given the breadth of treatment that the patient is receiving, the requested increase of ABA hours from 96 hours per month to 103 hours per month is warranted. Accordingly, an increase of Applied Behavior Analysis (ABA) hours from 96 hours per month to 103 hours per month going forward is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed psychologist who is a board certified behavior analyst 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 12 additional physical therapy sessions for the right knee.Nonoperative management of meniscal tears generally involves strengthening of the quadriceps and hamstrings, followed by dynamic proprioceptive training and conditioning. Specific protocols have not been well-studied in the literature. Surgery is often recommended in the setting of mechanical symptoms such as catching and locking, or when extensive conservative management fails, although the long-term marginal benefits of surgery over conservative management is not clear. A discoid lateral meniscus is a congenital anatomic variant that is prone to complex, degenerative tears, often of insidious onset. Treatment is surgical and is indicated when there are persistent symptoms limiting activities. Surgical interventions include meniscal saucerization, meniscal repair if tears are reparable, partial meniscectomy if tears are irreparable, and fixation when unstable. Management of patellofemoral pain syndromes is known to be challenging, with high rates of persistent symptoms despite extended follow up. The mainstays of management include strengthening of the hip abductors and quadriceps, and stretching of the quadriceps. There is no proven benefit of bracing, and surgery is generally recommended to be avoided.In the present case, the patient has a discoid lateral meniscus, multiple lateral meniscal tears and patellofemoral chondrosis. The patient has undergone extensive conservative management over years, and she has persistent symptoms, range of motion deficit, and weakness. While more physical therapy has been recommended, there are no indications that the patient has impairments that would preclude an ongoing independent program to improve on her range of motion, strength and function. The patient has had at least 25 physical therapy visits, and no marginal benefit would be expected with additional formal physical therapy versus an ongoing independent program. Under these circumstances, the requested 12 additional physical therapy sessions for the right knee are 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 patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Monovisc injections in the knees (HCPCS J7327). Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a documented benefit from bilateral Monovisc injections and her provider has recommended repeat viscosupplementation. Given the patients limited options, with the alternative being total knee arthroplasties, and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Monovisc injections in the knees (HCPCS J7327) 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 custom foot insoles. Healy and Chen note that plantar fasciitis is a common cause of heel pain, and treatments vary from stretching exercises to different surgical options. Custom orthotics are standard of care treatment to alleviate painful plantar fasciitis and are fabricated from customized molds of the patients feet. Custom orthotics manipulate and correct abnormal biomechanics of a patients foot, allowing for a reduction in pressure to the origin of the plantar fascia. In this case, the patient has a diagnosis of painful plantar fasciitis and has tried and failed other conservative treatments. Given that custom orthotics are standard of care for the treatment of plantar fasciitis, the requested equipment is medically indicated. Therefore, custom foot insoles are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 Orthovisc injections in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of good relief from prior viscosupplementation in the past two to three years. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested services are medically necessary. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair (heavy duty power chair) to perform one or more mobility-related ADLs or instrumental ADLs in or out of the home, including access to the community. In this case, the patient has multiple chronic health conditions, including a need for supplemental oxygen, and has been using a powered mobility device for several years. As such, it is not expected that the patient would be able to accomplish instrumental ADLs in the community using a manual wheelchair or by ambulating. However, the records note that the patient already has a power wheelchair. There are no indications that his current power wheelchair does not meet his mobility-related needs. Therefore, a power wheelchair (heavy duty power chair) is not medically necessary for this patient to perform one or more mobility-related ADLs or instrumental ADLs in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgery is medically necessary for treatment of this patient. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. For this patient with gender dysphoria, her providers have planned for her to undergo facial feminization procedures to better align her physical appearance and gender identity. Given this support, the requested facial feminization surgery is 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 psychiatry with subspecialty certification in transgender health 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: An enrollee has requested reimbursement for ultrasonic guidance for needle placement. Findings:  The physician reviewer found that eer-reviewed medical literature, there is limited medical literature supporting the use of ultrasound guidance when performing injection to the distal biceps femoris. However, Korbe and colleagues noted that ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures including improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. Daniels and colleagues found that, ultrasound-guided injections at the knee have superior efficacy to landmark-guided injections. The records provided for review document that this patient presented with diagnoses of distal biceps femoris tendinopathy, left knee osteoarthritis, and degenerative joint disease. She underwent a peritendinous injection under ultrasound guidance. The tendon that was injected was the left distal biceps femoris, which had hypoechoic, heterogenous swelling demonstrated on ultrasound. The medical literature supports the use of ultrasound-guided injections to the lower extremity in this clinical setting. Given these findings, the ultrasonic guidance for needle placement was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the ultrasonic guidance for needle placement was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ROM Plus rupture of membranes laboratory test (CPT code 84112). Qualitative immunochromatographic testing for rupture of membranes such as ROM Plus have been approved by the U.S. Food and Drug Administration (FDA). However, the current standard of care for a diagnosis of rupture of membranes includes three elements from an evaluation of vaginal fluid including ferning, nitrazine positive findings, and pooling. Tests such as ROM Plus have been shown to have higher false positive results than the current standard of care. The American College of Obstetricians and Gynecologists (ACOG) supports the use of ROM Plus as a second option in cases where traditional testing is equivocal, or the clinical situation is high-risk. In this case, the patient presented with no risk factors to support use of ROM Plus in lieu of standard testing to rule out rupture of membranes. Thus, the ROM Plus rupture of membranes laboratory test (CPT code 84112) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the ROM Plus rupture of membranes laboratory test (CPT code 84112) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were not likely to be 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the right knee (HCPCS J7323). Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections received over several years, with the last series received in February 2020. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections in the right knee (HCPCS J7323) 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 patients parent has requested authorization and coverage for bilateral foot inserts, removable, molded to patient model, longitudinal/metatarsal support orthotics (CPT L3020). Healy and Chen note that plantar fasciitis is a common cause of heel pain, and treatments vary from stretching exercises to different surgical options. Orthotic devices, including custom functional orthotics, are standard of care treatments for plantar fasciitis that keep the feet in a more neutral position, reducing over pronation and excessive strain on the plantar fascia and allowing for healing of the plantar fascia and reduction of plantar foot pain. In this case, the patient has bilateral hyperpronation of the feet and angles and pes valgo planus deformity, and a diagnosis of plantar fasciitis. Given that custom orthotics are standard of care for the treatment of plantar fasciitis, the requested equipment is medically indicated. Therefore, bilateral foot inserts, removable, molded to patient model, longitudinal/metatarsal support orthotics (CPT L3020) are medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 Monovisc for intra-articular injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed conservative treatments, including weight reduction, knee bracing, change of footwear, and physical therapy. She is not a candidate for total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically necessary. Therefore, Monovisc for intra-articular 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.