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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan injections to the bilateral knees. 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 standard 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. The records document that this patient has severe bilateral knee pain. His symptoms have affected his quality of life and ability to perform activities of daily living. Imaging studies have revealed patellofemoral arthritis. He has tried and failed conservative treatments including NSAIDs and strengthening exercises. He is unable to tolerate NSAIDs. Total knee arthroplasties are not appropriate as the patients osteoarthritis involves only one of the three compartments. Consistent with the recommendations from the AAOS, the requested hyaluronan injections to bilateral knees are medically necessary for management 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 authorization and coverage for proton beam therapy. Findings:  Three physician reviewers found that upon review of available data, proton therapy is not likely to be more beneficial for the treatment of the patients breast cancer in comparison to conventional treatment consisting of photon radiation. The noted advantage of proton therapy is that with its Bragg Peak, it is better able to spare normal tissue from radiation exposure. Whether this dosimetric advantage translates to a clinical advantage depends on the clinical setting. The normal tissue at risk when treating breast cancer with radiotherapy consists of the heart and lungs. However, this patients treatment is planned for the right chest wall, which means that the heart, a left-sided organ, is at virtually no risk for radiation exposure. With regard to the lungs, conventional radiation with photons already results in an extremely low rate of exposure. Thus, the requested proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for amniotic membrane graft in the setting of pterygium excision surgery. Pterygium is a fibrovascular growth over the cornea, most often from nasal side. Progressive conditions may require excision. In order to lower the chance of recurrence, the two most common techniques are to cover the bare sclera with a conjunctival autograft or with an amniotic membrane graft. In this case, amniotic membrane was used which is a well-established technique. There is good evidence in the literature that amniotic membrane graft improves the outcomes by reducing recurrence (Rosen, et al.). Thus, the amniotic membrane graft in the setting of pterygium excision surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in ophthalmology and is actively practicing. One Reviewer is board certified in ophthalmology and is actively practicing.  One Reviewer is board certified in ophthalmology and is actively practicing.  All three 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 patient has been diagnosed with osteoarthritis. Findings:  The physician reviewer found that the patient had excellent pain relief from previous viscosupplementation injections with her pain relief lasting approximately one year. The patient has requested authorization and coverage for Supartz injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz injections in the knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is not known which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had an excellent response to prior viscosupplementation. The patient has tried and failed conservative treatments, with the alternative being a total knee arthroplasty. Medical evidence supports the requested services in this clinical setting. Therefore, Supartz injections in the right knee 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 sclerotherapy injections.Submitted documentation supports that sclerotherapy injections are partially medically necessary. Medical literature shows that care of patients with varicose veins of the lower limbs and pelvis. SVS/AVF clinical practice guidelines recommend liquid or foam sclerotherapy for telangiectasia, reticular veins, and varicose veins (SVS/AVF guidelines, Recommendation 12.1). Accordingly, sclerotherapy injections to the non-axial veins is medically necessary to treat the patients medical condition. Sclerotherapy injections to the major axial veins, however, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in surgery, with primary specialty certification in vascular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a bone density test.Findings:  Two out of three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Serial central dual-energy x-ray absorptiometry (DEXA) testing is an important component of osteoporosis management. The International Society for Clinical Densitometry (ISCD) guidelines indicate that intervals between bone mineral density testing should be determined according to each patients clinical status. This patient had a DEXA, which showed osteopenia. It was important to monitor progression of bone density with a follow-up bone density test. Therefore, the bone density test performed was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to have been 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a surgical consultation for hemorrhoidectomy.Hemorrhoids are a collection of blood vessels around the anus that are typically asymptomatic. The most common complaint associated with hemorrhoidal disease is rectal bleeding or itching during bowel movements. Hemorrhoids are classified into internal, external and mixed hemorrhoids. Their initial treatment includes dietary (increasing dietary fiber) and lifestyle modification. If the initial treatment is not sufficient, then medications for symptomatic relief are recommended. Topical ointments containing anesthetics, steroids, emollients, antispasmodic agents and antiseptics are often tried, but there is a lack of evidence that supports the efficacy of these treatments. Additional treatment includes sitz baths. Referral to a specialist is indicated for individuals with symptomatic internal hemorrhoids that have been refractory to at least six weeks of medical treatment, individuals with symptomatic high-grade internal hemorrhoids (prolapse of tissue), or individuals with thrombosed hemorrhoids.The submitted documentation does not support that a surgical consultation for a hemorrhoidectomy is medically necessary. In this case, there is no documentation to support that the patient has failed treatment with dietary and lifestyle modification. Submitted records do not identify the patients symptoms or what type of hemorrhoids she has. Under these circumstances, the medical necessity of a surgical consult is not established due to a lack of details of a failure of conservative care or an indication that the patient has high grade hemorrhoids with tissue prolapse. Accordingly, a surgical consultation for a hemorrhoidectomy is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 patient has requested reimbursement and prospective authorization and coverage for skilled nursing rehabilitation services. Functional impairments due to acquired brain insults such as stroke can be profound. Some recovery is expected with time, and many of these impairments are addressable by compensatory measures and directed rehabilitation efforts. The current standard of care for this condition includes rehabilitation services. Initial treatment may be in the inpatient setting, followed by rehabilitation in the community setting if indicated. The determination for level of care focuses on a patients impairments and the potential for achieving practical, functional goals. Most of the significant neurological and functional recovery following a stroke, notably, occurs in the early stages after stroke and gains are slower to come in the subsequent year. Rehabilitation efforts are appropriate at the lowest level of intensity commensurate with deficits. This patient sustained a stroke resulting in right upper greater than lower hemiparesis. She had grossly functional range of motion in the limbs and was at the contact-guard assistance level for her household mobility. She continued to require some assistance for self-care. The patient was stable enough for further rehabilitation in the community setting with custodial level assistance for safety outside of therapy sessions. There are no documented indications that the patient has ongoing functional goals, medical needs, or nursing issues requiring further skilled nursing rehabilitation services. Therefore, the skilled nursing rehabilitation services were not and are not medically necessary for treatment of this patient. 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 board certified in physical medicine and rehabilitation 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 the advanced lipoprotein testing. Based on the records provided, the patient presented with some cardiovascular risk, given her diagnoses of hypertension, hyperlipidemia, and abnormal liver panel, and obesity. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein associated phospholipase A2, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein (a), C-reactive protein (CRP), high sensitivity CRP, and homocysteine. Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Accordingly, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be overturned. 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. For these reasons, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement  for partial hospitalization program (PHP) services. The enrollee has bipolar disorder and substance abuse.  He has a history of suicide attempts and abuse.  He transitioned to the partial hospitalization program (PHP) from a residential treatment center. A psychological evaluation indicated the enrollee had significant levels of anxiety. The therapist indicated the enrollee required 24-hour monitoring because he was at high risk for relapse. Documentation consistently reports no signs of suicidal ideation/homicidal ideation or psychosis. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms.  He attempted rehabilitation treatments in the past and has relapsed. The enrollees composite score is 19, which correlates with community based services. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for amniotic membrane graft of the left ocular surface following excision of a pterygium with Mitomycin-C (MMC). Findings:  Three physician reviewers found the amniotic membrane graft of the left ocular surface following excision of a pterygium with MMC is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. When a patients vision is threatened by the presence of pterygium, excision must be considered. Primary excision without further intervention results in a high rate of recurrence. Recurrences are frequently more aggressive than the original lesion. The use of MMC over the defect has resulted in statistically significant reductions in the recurrence rate. A combination of MMC and either conjunctival autograft or amniotic membrane graft has been shown to be more effective than either therapy alone. Alternatively, conjunctival autograft is associated with higher levels of pain due to the extent of surgery. Amniotic membrane graft has been shown to provide anti-inflammatory properties to aid wound healing and reduce scarring. For this reason, amniotic membrane graft has become the standard of care for minimizing recurrence after pterygium excision. Thus, the requested amniotic membrane graft of the left ocular surface following excision of a pterygium with MMC is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the amniotic membrane graft of the left ocular surface following excision of a pterygium with MMC is likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Tecfidera.Findings:  The physician reviewer found that the submitted documentation supports that the requested medication Tecfidera is medically necessary. The submitted documentation indicates that the patient has Multiple Sclerosis (MS) and has been under treatment with Tecfidera for more than two years. The patient is reported to have tolerated Tecfidera well and has had a good response in terms of any progression. The patient would be put at risk of having a relapse, progression, and/or further neurologic decline if his medication were changed now, when the medication is being well tolerated and with good effect on condition. While evidence may show benefit to a population as a whole, any new agent may not be as well tolerated or have the same treatment effect for the patient. Under these circumstances, the requested medication Tecfidera is medically necessary to treat the patients medical condition.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 neurology 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.