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 Orthovisc injection (hyaluronan) for treatment of knee pain due to osteoarthritis. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Researchers have noted that medical guidelines recommend intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption); and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. In addition, other researchers have conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested services are medically necessary.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 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 prolotherapy. The current peer-reviewed medical literature does not support treatment with prolotherapy for posterior tibial tendon dysfunction. There are a few case reviews that reported positive findings, but there is a need for further study to establish the long-term outcomes and side effects. Overall, the evidence is limited on prolotherapy for use in this clinical setting. Given these findings, the requested prolotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested prolotherapy 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 prolotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in podiatry 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: A 51-year-old female enrollee has requested reimbursement for the inpatient psychiatric hospitalization services. The American Psychiatric Association (APA) guideline states that, hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patient posed a serious threat of harm to herself through discharge. The patient reported intermittent suicidal thoughts. She was unable to contract for her safety. Given these findings, discharge prior to the date the patient was discharged would have been premature. The treatment provided to this patient was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Thus, the inpatient psychiatric hospitalization services provided were medically necessary for treatment of this patients psychosis and major depressive disorder.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 57 year-old female enrollee has requested authorization and coverage for Euflexxa injections for her right knee. As evidenced by the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. A study have noted that the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption); and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. In addition, a study has conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested services are medically necessary.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for non-surgical scoliosis services (ADL, posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999). This patient has juvenile idiopathic scoliosis. At present, the efficacy of non-specific manual therapy in the treatment of patients with idiopathic scoliosis cannot be reliably evaluated. Studies do not show conclusively that this type of treatment in this clinical setting is beneficial. This patient had extensive therapy over the course of three years and the claims of improvement are inconsistent. All told, the non-surgical scoliosis services (ADL, posture, gait, and neuromuscular retraining - 97110, 97112, 97530, 97116; administration and prescribed home use of custom mechanical traction equipment - 97012, E1399; custom scoliosis brace - L1300, L1210, L1220, L1240, L1250, L1260, L1270, L1290, L0999) from 1/2/17 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of this patients scoliosis.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a board certified chiropractor 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 Ozempic 1 mg/dose pen. Ozempic is a member of  the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1.  The use of this class of medications may result in improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Ozempic is the newest agent of the GLP-1 analogues.  While it appears to be quite effective for glycemic control, as well as for promoting weight loss, it is currently only approved by the U.S. Food and Drug Administration (FDA) for patients with a history of type 2 diabetes. Therefore, Ozempic 1 mg/dose pen is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified 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 authorization and coverage for Oncotype DX testing. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Oncotype DX testing may be appropriate in select patients to guide the addition of combination chemotherapy to standard hormone therapy. Guidelines endorses the use of Oncotype DX testing in select patients with one to three positive nodes. This woman with one positive node and a lobular breast cancer which is generally felt to be less chemoresponsive. The medical evidence supports the requested services in this patients case. Thus, Oncotype DX testing is medically necessary for the 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 sub-specialty certification in medical 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: A male enrollee has requested authorization and coverage for Euflexxa injections. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. The current medical literature supports the use of viscosupplementation for osteoarthritis of the knees. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Campbell and colleagues noted that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. The medical literature supports the use of viscosupplementation for osteoarthritis of the knees. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks.  Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Orthovisc 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractor appointments twice per week or once per week. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has a chronic and stable condition that shows no sign of improvement, even with continuous care. She is requesting coverage for additional chiropractic care at a frequency of one or two visits per week. There is no documentation of re-injury or flare-up. The requested services are considered maintenance therapy and are not medically indicated. Therefore, chiropractor appointments twice per week or once per week are 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 upheld.Credentials/Qualifications: The reviewer is board certified in chiropractic care 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: A patient has requested authorization and coverage for mastectomy (CPT code 19303) with nipple areola reconstruction (CPT code 19350). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients back pain. The submitted documentation does not support the medical necessity of the requested services. This patient has well-documented evidence of significant, symptomatic macromastia. This patient has evidence of chronic back and neck pain as well as photographs indicating shoulder grooving. This has significantly impacted the patients daily activities. The medical documentation submitted for review, including a review of the photograph, supports that the patients macromastia is likely contributing significantly to the functional complaint of pain. However, this patients clinical presentation supports the need for a possible breast reduction, not a mastectomy. Therefore, the requested mastectomy (CPT code 19303) with nipple areola reconstruction (CPT code 19350) 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services deem an emergency. Findings:  The physician reviewer found that For a hospital to hospital transport, air ambulance is indicated if using a ground ambulance would endanger the patients health and if the initial hospital cannot provide necessary medical services. Certain specialized services are not available at all hospitals. This patient was in an inpatient hospital. She was hemodynamically stable with mild hyperphosphatemia, but otherwise normal laboratory values. There is no documentation to support that the patient suffered an acute change in her condition warranting emergency air ambulance transport. Rather, the records indicate that this was a planned transport for inpatient eating disorder services following an acute hospitalization. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurofeedback. Neurofeedback is a type of biofeedback that teaches self-control of brain functions to patients by measuring their brain functions and providing feedback signals. Neurofeedback targets brain and cognitive functions through the use of electroencephalography (EEG) (Renton, et al). Neurofeedback has been studied in a variety of conditions including stroke, mild traumatic brain injury, epilepsy, autism spectrum disorders, and depression. However, per a review article on neurofeedback and its clinical applications, current research does not support conclusive results about its efficacy. Based on the documentation provided and current medical literature, the requested neurofeedback is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested neurofeedback 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 neurofeedback is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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.