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 Euflexxa injections every six months for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which 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. All told, the requested Euflexxa injections every six months is supported as medically necessary for treatment of this patients knee osteoarthritis. 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 Euflexxa knee injection services for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested services in this clinical setting. Evidence-based, peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections. In this case, the patient has been diagnosed with moderate to severe osteoarthritis of the right knee. She underwent prior Euflexxa injections, which reportedly worked well for months. She presents with recurrent right knee pain with difficulty in weight-bearing. Repeat injections have been requested in an attempt to delay total knee replacement due to her young age. Inadequate symptoms relief has been reported with corticosteroid injection. The current medical evidence supports the requested services in this patients case. Therefore, the requested Euflexxa knee injection services 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 three uninterrupted cycles of residential treatment at Psychologist Care and Healing Treatment Center, followed by three months of step down treatment. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of residential placement at this time. Although patient needs vary case-by-case, a four-month residential stay is a lengthy admission by community standards. The patient did have an emotional response at the prospect of discharge, but there was no evidence of an underlying acute psychiatric syndrome or the need for access to specialty care in a supervised setting 24-hours per day. The case file did not include records from the residential program demonstrating the need for the requested services, such as a psychiatric evaluation, psychosocial assessment, interpretative summary, physician narrative, multidisciplinary treatment plan, or progress notes. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. The records do not indicate that comprehensive, evidence-based services provided in a less restrictive treatment setting is unsafe, insufficient or inadequate. The current medical evidence does not support the requested services in this clinical setting. Therefore, three uninterrupted cycles of residential treatment at Psychologist Care and Healing Treatment Center, followed by three months of step down treatment 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, there was no emergent medical condition noted in the records submitted for review. The patient presented with a history of breast augmentation. The patient states that she had extreme pain from her breast implants and thus needed to have them removed. However, the provider notes that the primary diagnosis is that the patient is dissatisfied with her implants and that the patient feels the implants are making her sick. The operative note does not support that there were significantly abnormal conditions. There was no evidence of capsular contracture or gross evidence of infection. The provider does not document that this procedure was performed emergently or that there was an indication for emergency surgery. In addition, there was no medical documentation to support significant pain or any attempted treatment of significant pain. Therefore, the services provided were not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that There is no documentation of emergency room visits or acute inpatient hospitalization between the patients discharge from the wilderness therapy program and admission to residential facility. The provided documentation for admission to the RTC did not contain reports of suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, documentation of withdrawal from substances, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living. There was no documentation of persistent mood instability.  Although the patient intermittently documented to be isolative and anxious there was no indication that this severely affected the patients functioning.   The American Society of Addiction Medication Criteria (ASAM) is a set of objective guidelines used to assist with treatment planning, and advocates for service intensity provided in the least intensive but safe treatment setting. In this case, there is no documentation of active withdrawal symptoms, unstable vital signs, dangerous or non-supportive recovery environment, or failure of treatment at lower level of care immediately preceding the residential admission that would support treatment at RTC level of care. Research supports the use of short-term residential treatment after acute inpatient hospitalization for stabilization of patients with serious mental illness. Patients with admissions less than 28 days are no more likely to have a readmission, leave abruptly, or not follow through with services as patients who have longer stays. In this case, the patient had no documentation of admission to an acute inpatient hospitalization prior to residential care. There is also no documentation of failed treatment at the intensive outpatient or partial hospital level of care prior to residential care. Based on the clinical documentation provided and current medical literature the RTC level of care services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Edarbyclor 40-25 mg for treatment of the enrollees hypertension. Findings:  The physician reviewer found that In the medical literature the Eighth Joint National Committee (JNC 8) support the use of monotherapy before use of combination or second agents. In addition, the use of step therapy with anti-hypertensive medications and requiring trial of formulary medications before approving other similar medications is considered within the standard of care. Multiple choices are offered by the Health Plan including Avapro, Avalde, Cozaar, Hyzaar, Diovan, and Diovan HCT. These options are very similar medications in the angiotensin receptor blocker (ARB) class. All told, the requested Edarbyclor 40/25 mg is not supported as medically necessary for treatment of this patients hypertension. Final Result: The reviewer determined that the requested medication is not 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 internal medicine with sub-specialty certification in cardiovascular 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 transcatheter closure of the left atrial appendage and one day inpatient stay for treatment of the enrollees atrial fibrillation. Findings:  2/3 of the physician reviewers found that the Watchman device is U.S. Food and Drug Administration (FDA) approved and has been shown to be safe and successful in a high percentage of patients. However, the guidelines suggest use of the device in patients with contraindications to anticoagulants. Randomized studies have not shown that the use of the Watchman device is superior to medical treatment. The clinical documentation submitted for review fails to demonstrate that the patient has a contraindication to anticoagulants. Therefore, the request for transcatheter closure of the left atrial appendage and one day inpatient stay are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of 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 number one is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 400-100 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cell-free fetal DNA-based prenatal testing for evaluation of the enrollees advanced maternal age. Findings:  The 3 physician reviewers found that the American College of Obstetricians and Gynecologists and the Society for MaternalFetal Medicine recommended cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy or trisomy, and women with positive first-trimester or second-trimester screening test results. Given that the patient is years old, the aneuploidy risk for this patient in this pregnancy warrants cell free DNA testing for aneuploidy. Therefore, the cell-free fetal DNA-based prenatal testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 replacement hearing aids for treatment of the enrollees mild to moderate bilateral sensorineural hearing loss. Findings:  The physician reviewer found that hearing loss is the most common form of sensory impairment in patients and hearing aids are a first-line of audiologic intervention for many patients. Untreated hearing loss can interfere with a patients cognitive abilities and intellectual function. This patient has been able to use hearing aids, however, her current hearing aids do not provide adequate amplification. This patient has mild to moderate sensorineural hearing loss bilaterally. Her current hearing aids do not support her activities of daily living. She would benefit from amplification which would allow her to hear in her work environment. Thus, the patient requires replacement hearing aids with enhanced technology to improve her hearing quality. All told, the requested replacement hearing aids are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 corneal collagen cross-linking procedure for treatment of the enrollees bilateral keratoconus. Findings:  The 3 physician reviewers found that there is support in the medical literature for the superior efficacy of the services at issue in this patients case. Based on the patients vision loss and previous treatment with glasses and contacts, the cross-linking was the most appropriate and effective treatment available. There is a large body of available literature in support of corneal collagen cross-linking for treatment of this patient. The evidence shows corneal collagen cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is limited treatment options available to slow or halt disease progression. Therefore, collagen cross-linking for treatment of this patient was likely to have been superior to the available standard options. Final Result: The 3 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 number one is board certified in ophthalmology 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.Physician reviewer number two is board certified in ophthalmology 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.Physician reviewer number three is board certified in ophthalmology 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.