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 an Orthovisc injection series (weekly for a total of 4 injections) in the left knee.Findings: Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, there is a history of benefit from viscosupplementation of the left knee for several years and other modalities have not provided significant improvement. Under these circumstances, the requested Orthovisc injection series (weekly for a total of 4 injections) in the left knee is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for anal fistula plug surgical procedure. The American Society of Colon and Rectal Surgeons guideline for management of fistula-in-ano states that, despite the variability in healing with a fistula plug, the real possibility of success coupled with its sphincter-preserving nature allows this therapy to remain an option that may be considered for the treatment of fistula-in-ano (Vogel, et al.). Multiple studies have shown that fistula plug placement is safe and effective over the long-term with a low risk of adverse events (Limura, et al.; Tao, et al.). A summary of guidelines concluded that fistula plugs are a valid option for the treatment of patients with perianal fistula (de Groof, et al.). In this case, the patient has a persistent symptomatic fistula despite surgical intervention. Previous fistula eradication attempts have been associated with failure of guideline recommended alternatives such as ligation of the intersphincteric fistula tract (LIFT) and endoanal advancement flaps (Vogel, et al.). Therefore, the requested anal fistula plug surgical procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zilretta injections (every four months in both knees). The U.S. Food and Drug Administration approves the use of Zilretta, an extended-release synthetic corticosteroid, as an intra-articular injection for the management of osteoarthritis pain of the knee. Zilretta relieves the pain of osteoarthritis of the knees and improves function by means of its slow release into the synovium and articular cartilage of the knee, providing a longer lasting benefit and avoiding harmful effects on the articular cartilage and systemic effects such as elevation of the blood sugar level. Palik and colleagues note that repeat administration of triamcinolone acetonide extended-release may be similarly efficacious to an initial injection without having deleterious effects on cartilage or other aspects of joint structure. In this case, the patient has osteoarthritis of the bilateral knees, previously treated with viscosupplementation and Zilretta. The patient reported a preference for Zilretta based on the degree of pain relief. X-rays documented the presence of chondrocalcinosis, or calcium pyrophosphate deposition disease, which benefits from steroid injections. In this clinical setting, the requested services are medically indicated. Therefore, Zilretta injections (every four months 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for coronary angiography. Based upon guidelines published by the American College of Cardiology (ACC), coronary angiography is considered a Class I recommendation for patients with suspected ischemic heart disease when results of noninvasive testing indicates a high likelihood of severe coronary disease (Fihn, et al.). This patient was found to have abnormal findings on a stress echocardiogram but the location and degree of provokable ischemia was not stated. A coronary computed tomography (CT) angiogram demonstrated borderline left main coronary artery (LMCA) obstructive disease with 25-49% stenosis. This degree of disease in the LMCA is potentially sufficient to warrant coronary intervention such as coronary artery bypass surgery or percutaneous coronary intervention if the degree of stenosis is confirmed to be 50% or greater on angiography or if the lesion is determined to be hemodynamically significant based upon fractional flow reserve and/or intravascular ultrasound (Figini and Latib). These data can only be obtained during invasive coronary angiography. Therefore, the requested coronary angiography is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 subspecialty certification in cardiology 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. 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, there is a history of good response to viscosupplementation in the past, and inadequate response to medications, physical therapy, and cortisone injections. The provider has recommended repeat viscosupplementation of both knees with Monovisc injections. Based on this patients prior excellent response to viscosupplementation, treatment with bilateral Monovisc injections to the knees is appropriate for treatment of this patients osteoarthritis of both knees. All told, the requested bilateral Monovisc injections 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 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 Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). All told, the requested Ozempic 1 mg is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 subspecialty 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

Findings:  The physician reviewer found that  The patient has requested authorization and coverage for electrolysis on the extremities and buttocks. The World Professional Association for Transgender Health (WPATH) states that hair removal is a treatment for gender dysphoria, noting, In addition (or as an alternative) to the psychological and medical treatment options described above, other options can be considered to help alleviate gender dysphoria, for example  hair removal through electrolysis, laser treatment, or waxing. In a study on hair removal and psychological well-being in transfeminine adults, Bradford and colleagues concluded, Results of this study suggest that hair removal is associated with both decreased distress but also increased subjective well-being (e.g. higher positive affect). Given that correcting male-pattern body hair with hair removal treats gender dysphoria, the requested services are medically indicated. Therefore, electrolysis on the extremities and buttocks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Acthar 80 units/ml.Madan and colleagues conducted a retrospective case series to examine Acthar gel (adrenocorticotropic hormone, ACTH) in patients with varied-etiology nephrotic syndrome (NS). They concluded that Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. Chakraborty and colleagues performed a systematic review to analyze the published literature on ACTH therapy in various NS etiologies, including IgA nephropathy (IgAN), to determine its efficacy. They concluded that ACTH showed benefits in proteinuria reduction across all etiologies of NS. In this case, IgA nephropathy has a significant long-term risk for progressive renal failure in this young patient who presented with nephrotic range proteinuria. IgA nephropathy can be refractory to therapy. Records indicate that the patient has been stable on Acthar 80 units/ml. Stopping or putting on alternate therapy under these circumstances has the potential for causing irreversible long term renal damage and increasing the long-term risk that the patient might need dialysis or a transplant. Accordingly, the requested Acthar 80 units/ml is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in nephrology, 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 reimbursement for (1) facet joint injection to the right cervical thoracic region and (2) facet joint injections to the lumbar region. In a systematic review of lumbar facet joint injections and medial branch blocks for chronic low back pain, medical literatures reported that steroids promoted a reduction of numeric rating scale (NRS) by 28% and an improvement of the Oswestry Disability Index (ODI) by 13.2%. The authors further reported that local anesthetics produced an improvement of the ODI by 9.8%, concluding,  Injections for chronic low back pain deriving from facet joints osteoarthritis are encouraging, especially when considering medial branch blocks. Researchers report state, The level of evidence is II in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. The authors further state, The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of three relevant randomized controlled trials, with long-term improvement. In this case, the patient has axial mechanical back pain, without signs or symptoms or radicular pain, such as shooting electrical pain in the abdomen or legs, paresthesias, or deep tendon reflex abnormalities. Magnetic resonance imaging (MRI) of the lumbar spine did not reveal signs of high grade canal stenosis. The patient was diagnosed with suspected facet joint related back pain and had attempted physical therapy and medication management for six weeks without relief. In this clinical setting, given the evidence in current medical literature that medial branch blocks can effectively diagnose and treat low back pain related to facet joint disease, the services at issue were medically indicated. Therefore, (1) facet joint injection to the right cervical thoracic region and (2) facet joint injections to the lumbar region were medically necessary for the treatment of this patient.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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for biofeedback services. Biofeedback has been shown to be beneficial to the treatment of patients with urinary problems when used as supplemental therapy. In addition, data from peer-reviewed medical literature reports that biofeedback can be beneficial for patients who have failed other treatment. In this case, the patient was being managed with pessary and physical therapy. Biofeedback can help allow female patients to isolate pelvic floor accessory muscles during pelvic floor contractions, which can aide in treatment of urinary issues. Thus, pelvic floor physical therapy with biofeedback was an appropriate next step and consistent with standard of care in the management of this patients symptoms. Dumoulin and colleagues reported that group based pelvic floor muscle training was not inferior to the recommended individual pelvic floor muscle training for the treatment of stress and mixed urinary incontinence in older female patients. All told, the biofeedback services were 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 services at issue were 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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 computed tomography (CT) scan of the heart, without contrast, with qualitative evaluation of coronary calcium. Coronary artery calcium measured by cardiac CT can help provide an estimate of total coronary plaque burden and is an established tool for cardiovascular risk stratification and preventive therapy. Several guidelines have recommended the use of coronary artery calcium testing in shared decision making between the provider and patient. However, the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines do not recommend coronary artery calcium for further evaluation of patients with ventricular tachycardia (Al-Khatib, et al.). Per the AHA/ACC guidelines, echocardiogram has a class 1 recommendation while cardiac CT or magnetic resonance imaging (MRI) have class 2A recommendations for the evaluation of cardiac structure and function in this clinical setting (Al-Khatib, et al.). The European Society of Cardiology (ESC) guidelines recommend echocardiography and exercise stress testing as Class 1 recommendations and cardiac MRI and cardiac CT as Class 2 recommendations in screening patients with documented or suspected ventricular arrhythmias (Priori, et al.). This patient was noted to have an elevated 10-year risk for atherosclerotic cardiovascular disease. Overall, there is a lack of data to support an indication for coronary artery calcium as a useful tool in this patient as a part of his work-up for ventricular tachycardia. Accordingly, the CT scan of the heart, without contrast, with qualitative evaluation of coronary calcium was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in interventional cardiology 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.