Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mitral valve repair (MitraClip). Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approved percutaneous mitral valve repair using the MitraClip device for high risk patients with degenerative or other primary mitral valve regurgitation. The COAPT trial evaluated patients with 3-4+ mitral regurgitation who remained symptomatic despite maximally tolerated guideline directed medical therapy (Asch, et al.). The authors found that the patients benefited from MitraClip implantation, regardless of their degree of left ventricle (LV) dysfunction, LV dilatation, pulmonary hypertension or individual mitral regurgitation characteristics. However, the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for the management of patients with valvular heart disease included the MitraClip with a Class IIb recommendation for severely symptomatic patients with chronic, severe primary mitral regurgitation who have favorable anatomy for the procedure and but have a prohibitive surgical risk because of severe co-morbidities and remain severely symptomatic despite optimal medical therapy. Based on the available documentation, this patients preliminary surgical risk is less than 1%, which is not consistent with a prohibitive surgical risk. Therefore, the requested MitraClip is not 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 requested MitraClip is 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 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with an appropriately qualified provider who specializes in ocular facial revision surgery. The records provided for review do not support an indication for the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery. With regard to the patients lipoma, examination was reportedly normal by two providers without concern for pathology or lipoma. One provider noted that the patient experiences pain with lesions and also outside of the individual lesions. The provider charted that the patient has whole body pain and pain sensitivity that may benefit from evaluation with pain management. Based on the available records, the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery is not medically necessary for evaluation and treatment of this patients scalp condition. Moreover, the requested consultation is not medically necessary for evaluation and treatment of this patients ophthalmologic condition. Srivastava and colleagues noted that, Facial asymmetry is defined as the presence of a clinically significant variation between the two halves of the face that the patient is concerned about and that can be quantified by the clinician. The authors also stated that, Slight nonpathologic asymmetry is usually indiscernible and often considered normal. This patients records document that she is well healed status post bilateral strabismus repair and bilateral upper lid blepharoplasty. The patient was examined by ophthalmology and by a neuro-ophthalmologist. Physical examination confirmed the presence of an asymmetric palpebral fissure, which the provider noted is a hereditary trait that has been present in the patients family for three generations. The provider recommended an MRI to rule out an intraorbital cause. The records do not include report of an MRI as recommended by the provider. Therefore, the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery is not medically necessary for this patients ophthalmology condition. All told, the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery is not medically necessary for 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 plastic 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 Orthovisc injection series in the left knee. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of severe glaucoma and corticosteroid injections are contraindicated. Overall, the patients treatment options are limited. The requested viscosupplementation with Orthovisc injections of the left knee is appropriate for treatment of this patients osteoarthritis of the left knee. Therefore, the requested Orthovisc injection series in the left knee 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 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 56 hours of licensed vocational nurse (LVN) level of care and two visits registered nurse (RN) supervision weekly for three months.Findings:  The physician reviewer found that  records provided for review document that this patient has multiple medical problems as a result of prematurity and Prader-Willi syndrome. The provider noted that the patient has required treatment in the emergency department, and he has been hospitalized multiple times with acute respiratory illnesses, including infection with COVID-19. Despite the patients acute and chronic issues, his medical condition is currently stable. The patients daily care includes services that can be safely and effectively met by a trained caregiver (Parab, et al.; Nageswaran and Golden). Overall, the patient does not require the services of skilled nursing providers. There is mention of maternal anxiety related to the patients care. However, the records do not document that the severity of illness interferes in the parents ability to manage the care of the patient or her other child. Thus, the records do not support an indication for skilled nursing assistance. For these reasons, the requested 56 hours of LVN level of care and two visits RN supervision weekly for three months is not medically necessary for 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 pediatrics with subspecialty certification in pediatric critical care 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 patients parent has requested authorization and coverage for weekly in-person individual therapy. Findings:  The physician reviewer found that American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. Applying the CALOCUS-CASII framework, the patient meets criteria for high intensity community-based services.With regard to risk of harm, the records support a score of 3. The patient has significant risk of harm, due to struggles with impulsivity and managing his anger. The patient is described as explosive and aggressive and has engaged in property damage. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to mood dysregulation and anger dyscontrol. The records note problems at home and at school. With regard to comorbidity, the records support a score of 1. The patient does not have any comorbidities.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment as the patients parents are noted as not being aligned and consistent in their parenting approaches. The patients mother is described as highly reactive, and the patient is noted has having difficulty in school. With regard to level of support of the recovery environment, the records support a score of 3 as the patients parents have struggled to implement recommendations from parental coaching and demonstrate only a partial ability to make necessary changes during treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation treatment (CPT-77520 x 28), (CPT-77522 x 28), (CPT-77523 x 28), and (CPT-77525 x 28). Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue. There is a lack of strong medical evidence to suggest that treatment with proton beam therapy is associated with a clinical benefit compared to standard treatment. Furthermore, proton beam therapy has not been validated in a comparative randomized study to standard treatment with photons. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer and compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. The American Society for Radiation Oncology (ASTRO) Model Policy stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. ASTRO noted that the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, proton beam radiation treatment (CPT-77520 x 28), (CPT-77522 x 28), (CPT-77523 x 28), and (CPT-77525 x 28) is 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 upheldCredentials/Qualifications: The reviewer is board certified in radiation 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for osteopathic manipulation treatment. A study found studies have demonstrated that osteopathic manipulative treatment has proven beneficial in providing pain relief and improved thoracic motion in patients with costochondritis, costovertebral joint dysfunction, and poststernotomy rib dysfunction. Researchers report that costochondritis refractory to conservative management may have a beneficial response to osteopathic manipulative treatment and tissue mobilization. In this case, the records demonstrate that osteopathic manipulative treatment has proven effective in the past. In this clinical setting, the requested services are medically indicated for the treatment of the patients costochondritis. Therefore, osteopathic manipulation treatment is 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 occupational 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Euflexxa injections. 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 Euflexxa injections to the bilateral knees with the relief lasting six months each time. The patient 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, bilateral Euflexxa injections 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a cervical discography (CPT 62291, 62291-59 and 72285-26).Findings:  The physician reviewer found that Findings:  Three of the three physician reviewers found the cervical discography (CPT 62291, 62291-59 and 72285-26) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Current medical literature does not clearly show that cervical discography is superior to conventional treatment. Onyewu and colleagues, as well as Manchikanti and colleagues, note that literature on cervical level discography is limited at best, with contradictory and variable evidence for the procedure. DeFrancesch and colleagues report that one of the problems with discography is that the results rely heavily on patient experience of the pain produced by the procedure. Therefore, the cervical discography (CPT 62291, 62291-59 and 72285-26) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapyFinal Result: The reviewers determined that the service at issue was not likely to have been 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 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 patients parent has requested reimbursement for an additional 12.5 hours of neuropsychological testing (5 units CPT 96133 and 15 units of CPT 96139 for 27 total hours/41 units).Findings:  The physician reviewer found that Health Plan approved 14.5 out of the 27 hours of neuropsychological testing requested. Given that the diagnosis of attention deficit hyperactivity disorder (ADHD) is most often a clinical diagnosis and does not require neuropsychological testing to confirm, Wechsler Individual Achievement Test, 5th Edition (WIAT-5) and Conners Continuous Performance Test, 3rd Edition (CPT-3) testing were not medically necessary. The total testing time for medically necessary tests was six hours, including the following tests: Behavioral Assessment System for Children, 3rd Edition (BASC-3); Behavior Rating Inventory of Executive Function 2 (BRIEF-2); Wechsler Intelligence Scale for Children, 5th Edition (WISC-5); California Verbal Learning Test Childrens Version (CVLT-C); Delis-Kaplan Executive Function System (D-KEFS); Rey Complex Figure Test and Recognition Trial (RCFT); Beery-Buktenica Developmental Test of Visual-Motor Integration, 6th Edition (BEERY VMI-6); ChAMP; Multidimensional Anxiety Scale for Children, 2nd Edition (MASC-2); and NEPSY-II. Allotting an additional three hours to score these tests, one hour of neurobehavioral status examination, one hour of professional integration of patient data, four hours for report writing, and one hour of feedback brings the total time of medically indicated neuropsychological testing to 16 hours. Therefore, an additional 1.5 hours in addition to the originally approved 14.5 hours was medically indicated. In this patients case, an additional 1.5 hours was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the service at issue was clinically appropriate in terms of type, frequency, extent, site, and duration. The service at issue was not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, an additional 1.5 hours was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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.