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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for aquatic therapy. Aquatic therapy is a form of exercise therapy which minimizes the effect of gravity and is beneficial for patients with morbid obesity and osteoarthritis who would otherwise not be able to exercise due to pain and excessive body weight. Researchers concluded that aquatic-based exercise generate a different exercise outcome and appear to provide an alternative option for older aged adults, allowing these tasks to be performed in a manner that is not possible on land. Land based physical therapy is difficult for morbidly obese patients. As such, the requested aquatic therapy is medically necessary for treatment of this patients medical condition. 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: An enrollee has requested authorization and coverage for Synvisc One injections for both knees. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees osteoarthritis.This patient presents with bilateral knee pain. Clinical examination findings have been consistent with the reported diagnosis of severe bilateral knee osteoarthritis. He has reportedly failed reasonable conservative treatment, including activity modification and non-steroidal anti-inflammatory drugs (NSAIDs). Prior Synvisc One injections to the bilateral knees have provided significant pain reduction for six months and allowed for medication reduction. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery.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: An enrollee has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees knee pain. At issue in this case is whether the requested Orthovisc injections in the right knee are medically necessary for treatment of the patients medical condition. In this case, the patient has documented knee osteoarthritis secondary to a complex root meniscus tear. Further, the records indicate that the patient had previously undergone Orthovisc injections, each with greater than 6 months of pain relief and functional improvement. In this case, there is documentation to substantiate the diagnosis of knee osteoarthritis refractory to standard therapies. Furthermore, there is documentation of efficacy and durability of prior Orthovisc injections to warrant repeat injection. Therefore, the requested services 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 anesthesiology with sub-specialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. As noted by the Centers for Disease Control (CDC) guidelines, the use of opiates for chronic non-malignant pain is not recommended. When using long-term opioid therapy, providers must document assessment of pain and function compared to baseline, evaluate risk of harm or misuse, and check that non-opioid therapies have been optimized. In this case, there is no evidence of a screening urine toxicology. This is a requirement of chronic opiate maintenance, and is necessary to evaluate the risk of harm or misuse. Therefore, the requested Norco is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. According to the American Society for Gastrointestinal Endoscopy (ASGE) published guidelines, monitored anesthesia care may be necessary when there is a potentially difficult airway for positive pressure ventilation. This patient is noted to have a body mass index (BMI) of 38 and a short, thick neck. The presence of these factors noted by the provider support an indication for monitored anesthesia care in this clinical setting. Moreover, the guidelines support use of an anesthesia trained provider in the case of a potentially difficult airway, which may be present given this patients short neck. Thus, the anesthesia services provided were medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the service at issue was 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 anesthesiology with a sub-specialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an appointment with the Psychiatry Department. The patient presented for a mental health assessment and was referred to addiction medicine. Subsequently, the patient requested treatment for her escalating alcohol problem. As noted in the current medical literature, a patients substance abuse issues must be addressed prior to her issues of depression, poor concentration, and excessive worry. The symptoms reported by the patient of depression, anxiety, poor concentration, and excessive worry are connected with active substance abuse. This patient was referred for early intervention or CDRP, which is appropriate in this clinical setting. Thus, a patients substance abuse issues must be addressed first. After a patient has addressed their substance abuse issues, a follow-up mental health assessment can be provided to determine if the patient requires additional services. Given these findings, the appointment with the Psychiatry Department is not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested service 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an esophageal motility testing. In this case, the patient complained of severe heartburn despite a maximal proton pump inhibitor dose. An anti-reflux surgery was planned as well as a gastrojejunostomy with Roux-en-Y reconstruction. One trial reported that the surgery bypass is superior to other bariatric surgeries for treatment of GERD symptoms. Another publication stated the surgery has a reported 70-90% symptomatic success rate at controlling reflux symptoms and a 60-80% objective reflux control rate. A third study noted the Roux-en-Y gastrojejunostomy was comparably effective with Nissen fundoplication for GERD. However, the authors concluded that Roux-en-Y gastrojejunostomy should be preferred in patients with obesity due to the additional benefits of weight loss. In this case, the patient had morbid obesity at the time of the surgery. Moreover, Tatum and colleagues found that esophageal manometryis important to rule out severe esophageal motility disorders, particularly achalasia, which is an absolute contraindication to antireflux surgery. The testing determines esophageal clearance, which is of particular significance for patients with GERD qualified for antireflux surgery. The procedure may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. As this patient had severe reflux resistant to medication, and this anti-reflux surgery was planned, the use of esophageal motility testing is supported. For these reasons, the esophageal motility testing was medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the service at issue was 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a portable oxygen concentrator that weighs less than three pounds. The Health Plan has approved a request for a portable oxygen concentrator from a company that can offer equipment weighing approximately 5 to 6 pounds; and has denied this request for a specific portable concentrator weighing less than three pounds, indicating that the requested equipment weighing less than three pounds is not medically necessary for treatment of the enrollees hypoxemia.The submitted documentation does not support the medical necessity of the requested smaller portable concentrator. The Health Plan has provided the patient with a larger home concentrator and a portable oxygen concentrator for travel and for her outdoor activities. The patient states it is too heavy for her to lift. The difference in the weight of her current concentrator and the one she is requesting is only 2-3 pounds.A study indicates that Every attempt should be made to provide portable or wearable oxygen systems in support of patients striving for an active lifestyle. The patient doesnt have a known cause at this time for her hypoxia and there is no documentation of a specific lung disease that would be causing hypoxia. Moreover there is not any documentation that the patient is capable of lifting 3 pounds but not capable of lifting 5-6 pounds. The patient has what she needs to treat her unknown cause of hypoxia at this time. Therefore, the requested equipment is not medically necessary for treatment of this beneficiary.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 internal medicine with sub-specialty certification in pulmonary 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator into the airway.Findings:  Three of the three physician reviewers determined that implantation of a hypoglossal nerve stimulator is not likely to be more beneficial for treating of the patients medical condition than any available standard therapy. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant of or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection. Per the FDA, HNS is used to treat severe OSA for patients with an AHI of 20-65 who are at least 22 years of age, for whom CPAP has been tried and failed, and  who do not have a complete concentric collapse at the soft palate level. Records show that this patient has an AHI of 82.5 and has documented concentric collapse in the soft palate level area. Per FDA guidance, this patient is not a candidate for HNS. Therefore, HNS is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service 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 reviewer 1 is board certified in internal medicine with subspecialty certification in  sleep medicine. Physician reviewer 2 is board certified in neurology with subspecialty certification in sleep medicine. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine. All three reviewers 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis in the right knee. The submitted documentation does not support the medical necessity of the requested Orthovisc injections. Guidelines for Treatment of Osteoarthritis of the Knee do not recommend hyaluronic acids for patients with symptomatic osteoarthritis, based on strong evidence. Fourteen hyaluronic acids studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet their minimum clinically important improvement thresholds. The American College of Rheumatology and Osteoarthritis Research Society makes no official recommendation regarding hyaluronic acids. The U.K. National Institute for Health and Care Excellence does not recommend hyaluronic acids. Therefore, the requested Orthovisc injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 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: An enrollee has requested authorization and coverage for sclerosant injections, for left leg. Findings:  Three physician reviewers found that the submitted documentation does not support the requested services. The records noted the mass in the patients left leg is painful, but there did not appear to be a plan with respect to this.  The duplex examination report did not seem to suggest that this mass was related to varicosities, and it would not be expected that the sclerotherapy would address this mass. Additionally, the patient has areas of truncal reflux that have not been addressed. Sclerotherapy in the absence of treatment of the truncal reflux would be subject to a high risk of recurrence. Therefore, the requested sclerosant injections, for left leg are not likely to be superior over other treatment options.  Final Result: The reviewers determined that the requested services are 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 vascular 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: An enrollee has requested authorization and coverage for a Dexcom continuous glucose monitoring (CGM) system. According to the Diabetes Control and Complications Trial (DCCT), diabetes related complications can be delayed or prevented with better diabetes control and hemoglobin A1C of around 7%. This patient has diabetes type 2 but he is insulin deficient and is managed with multiple insulin injections, basal insulin and premeal insulin, which he self-adjusts based on glucose readings and food intake. He has poor diabetes control and wide glucose fluctuations and hypoglycemic tendencies. As a result of longstanding suboptimal control he has diabetes related complications, nephropathy and neuropathy, which places him at higher risk for hypoglycemia unawareness and hyperglycemia. In order to optimize management and improve his prognosis, the requested Dexcom CGM is medically necessary for 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 residential treatment services (RTC). The American Psychiatric Association (APA) treatment guidelines recommends RTC or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The records provided for review document that this patient required a safe and stable living environment in order to develop their recovery skills. Applying the American Society of Addiction Medicine (ASAM) guidelines, this patient qualified for Level III treatment, which is consistent with RTC or inpatient treatment similar to what patient received at the facility. The patients risk factors include his environment and he has limited social support. He needs time to both rehabilitate from substances but also come up with treatment for his underlying depression and anxiety. Given his rapid relapse after detoxification the month prior admission to RTC, the patient was at elevated risk for further relapses. Accordingly, the RTC services provided from Final Result: The reviewer determined that the services at issue were 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.