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

The enrollee is requesting authorization and coverage for hyaluronan injection (Synvisc) to the left knee. The enrollee has chronic left anterior knee pain and type one complex regional pain syndrome. The enrollee has a history of left knee arthroscopic meniscectomy and chondroplasty. The enrollee reports a previous hyaluronan injection (Synvisc) to the left knee helped significantly. The enrollees physician strongly recommends hyaluronan injection (Synvisc) because of the enrollees osteoarthritis, her inability to take non-steroidal anti-inflammatory drugs, and her strong desire to minimize opioids. The medical records indicate the enrollee has completed conservative treatment without resolution of symptoms.  The use of hyaluronan injection (Synvisc) injection is supported as a conservative option to address knee arthritis.  Studies show hyaluronan injection (Synvisc) is effective for osteoarthritis. It improves both pain and function, while sparing additional use of anti-inflammatory treatment and corticosteroids. A professional society recommends intra-articular hyaluronan injection (Synvisc) for the treatment of osteoarthritis of the knee for adults who do not respond to other treatment options, and a task force of experts support hyaluronan injection (Synvisc) injection for early and advanced cases of osteoarthritis when the individual declines surgical intervention.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested authorization and coverage, and reimbursement, for the medical device, eNeura sTMS mini. The enrollee describes her migraine as a visual aura, followed by numbness and tingling of the face, arm, and leg, or blank spots in her vision. She is exhausted afterwards and requires several days to recover. Magnetic resonance imaging, magnetic resonance angiography, and an electroencephalogram were all unremarkable. Medical records report she has tried multiple medications; including Verapamil, Topamax, nortriptyline, Riboflavin, Magnesium, Motrin, Zonisamide, Maxalt, and Effexor. The enrollees provider reports she has been using the eNeura sTMS mini device for about a year and a half. The enrollee states that, since she has been using the device, she has achieved improvement in the amount and length of migraine episodes. Transcranial magnetic stimulation has been shown to reduce the frequency and severity of migraine headaches. Researchers report a randomized study of adults who experienced four or more migraine attacks per month showed a reduction in migraine and an improvement in visual analogue scale scores. A professional societys consensus statement reports transcranial magnetic stimulation is an option that may be effective for acute migraine, and for preventive treatment of migraine, especially in those for whom pharmacologic treatment is contraindicated, poorly tolerated, ineffective, or not preferred.  This enrollee has tried medications without success.Final Result: Two of the three reviewers determined that the requested service was likely to have been, and is likely to be, more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology and are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for a laboratory test. The American College of Obstetricians and Gynecologists (ACOG) supports the utility of additional testing, such as AmniSure, in this clinical setting as a second-line evaluation for premature rupture of membranes. ACOG recommends AmniSure testing in equivocal cases when testing for prelabor rupture of membranes. This patients records do not document that first-line evaluation with ferning, pooling, and nitrazine testing was non-diagnostic. Therefore, the laboratory test 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 laboratory test was 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 obstetrics and gynecology 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 with subspecialty certification in maternal and fetal medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting reimbursement for bilateral lumbar facet injections at L3-4, L4-5, and L5-S1. The enrollee has a history of lumbosacral degenerative disc disease and lumbar spondylosis. She received trigger point injections and a sacroiliac joint injection. She subsequently experienced a severe exacerbation of her back pain and underwent bilateral lumbar facet injections at L3-4, L4-5, and L5-S1. The enrollee reports the bilateral injections are performed each year and she experiences about 11 to 12 months of pain relief from them. A literature review demonstrated no clear differences between various types of lumbar facet injections and placebo interventions. This enrollees pain medication usage has not decreased; even with the lumbar facet injection. Therefore, despite the enrollees report of symptom improvement, clinically, this enrollees pain management did not improve with the lumbar facet injection.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient has demonstrated moderate withdrawal. Although the patient does not have significant biomedical comorbidities, he does have an unhealthy religious preoccupation. In addition, the patient is currently on antipsychotic and mood stabilizing medications. The provider described the patient as in the preparation stage for change. The patient reported that he would stop taking medications if he is transitioned to a lower level of care. The patient remains at risk for relapse as prior to this admission, he left prior treatment against medical advice as he was feeling agitated. Once discharged, the patient returned to using substances within hours. The patients recovery environment is described as intermittently unstable. The patient requires a safe and stable living environment in order to develop his recovery skills. Thus, he qualifies for ASAM Level III treatment similar the services received at the current RTC facility. Given the severity of the patients illness, the RTC services provided were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction 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

The patient has requested authorization and coverage for tubal reanastomosis. The patients age makes a successful spontaneous pregnancy unlikely. In addition, the reported pregnancy loss in her age group is greater than 93%. In the current peer-reviewed medical literature, tubal reanastomosis is recommended for female patients who are 37 years of age and younger. This recommendation is supported by a large study of 10,689 women that determined the only prognostic factor for successful tubal reanastomosis was age. Moreover, the requested tubal reanastomosis is not indicated as a treatment for the patients pelvic pain. The provider noted that the patient was referred for pain management. Overall, the medical records do not demonstrate that the patient has exhausted standard treatment modalities for management of her pelvic pain. All told, the requested tubal reanastomosis is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

The patient has requested authorization and coverage for Orthovisc injections for the right knee. This patient has a history of severe osteoarthritis and anterior cruciate ligament deficiency of the right knee. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and viscosupplementation. She reports little response to corticosteroids but had excellent relief from viscosupplementation in the past. Her provider recommended repeat viscosupplementation with Orthovisc injections as they gave the patient excellent relief in the past. 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 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. In this case, there is a long history of excellent relief from viscosupplementation in the past. Furthermore, the options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. For these reasons, Orthovisc injections for the right knee 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: Upheld Decision of Health Plan

The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has diagnoses of major depressive disorder, adjustment disorder, and cannabis use disorder. His parents report the enrollee demonstrated difficulties with hyperactivity and has been receiving therapy since the age of five, but neither individual nor family therapy has helped. The enrollee entered a residential treatment center. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollee frequently misses or arrives late to treatment appointments, and/or is not invested in treatment; including medication and homework assignments. The enrollees composite CALOCUS score is 20, which correlates with Level IV care, a partial hospitalization program.Final Result: The reviewer determined that the requested services were 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: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy. The medical literature does not support that the services at issue were medically necessary. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for sedation and anesthesia in GI endoscopy concluded that the combination of an opioid and benzodiazepine is recommended, with high quality of evidence, as a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The guidelines recommend, with moderate quality of evidence, that anesthesia provideradministered sedation be considered for complex endoscopic procedures or for patients with multiple medical comorbidities or at risk for airway compromise. In this case, the patient was undergoing a routine colonoscopy for chronic diarrhea. She was otherwise healthy and without serious cardiac or pulmonary disease. Under ASGE guidelines for sedation and anesthesia in GI endoscopy, moderate sedation by the endoscopist was appropriate for this patient. The ASGE guidelines recommend propofol anesthesia with an anesthesia provider for complex medical cases or for patients who have had previous problems with sedation. ASGE guidelines also indicate that the use of propofol administered sedation by an anesthesia provider for patient comfort, safety, and procedural efficacy, as was done for the patient, has low quality of evidence in support. Accordingly, the services at issue were not medically necessary for 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 anesthesiology, with subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollees parent is requesting authorization and coverage for 60 days of RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollees composite CALOCUS score correlates with Level IV, Medically Monitored Community Based Services.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a spinal cord stimulator. Researchers evaluated the benefits of high frequency spinal cord stimulation for surgery naive patients with low back pain. The authors reported that their results showed a 50% improvement of low back pain with a mean follow-up of 306 days after implantation. They also concluded that, the option of spinal cord stimulation should be considered after conservative therapy has failed. In this case, the patient has diffuse low back pain with radiation into the right anterolateral thigh and right groin along with a history of multiple falls. The patients chronic pain involves the neck, shoulders, fingers, calves and feet. She has magnetic resonance imaging (MRI) results confirming degenerative changes at L3-4 and L4-5 with foraminal narrowing. She also has a history that is notable for fibromyalgia and bipolar disorder. She has tried and failed multiple medications and interventional therapies such as sacroiliac joint injections, lumbar facet injection, radiofrequency ablation, and epidural steroid injections. The records do not include a pain psychology evaluation to determine if she is an appropriate candidate for spinal cord stimulation. The patient has complaints involving several areas beyond the low back that would not be treated by the spinal cord stimulator. Further, the patients fibromyalgia and bipolar disorder are contraindications to a spinal cord stimulator, as they affect the expectations of pain relief and perception of benefit from the stimulator. Given these findings, the requested spinal cord stimulator is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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

An enrollee has requested reimbursement for exhaled nitric oxide test. The role of fractional concentration of exhaled nitric oxide (FENO) in the diagnosis of asthma remains unclear. The American Thoracic Society (ATS) noted that, FENO values of themselves do not justify a diagnosis or change in treatment. Medical literature states that a systematic review of FENO in the management of asthma in adults. The authors concluded that, FENO guided management showed no statistically significant benefit in terms of severe exacerbations or ICS [inhaled corticosteroid] use, but showed a statistically significant reduction in exacerbations of any severity. This patients records do not include documentation of exacerbations. In addition, the records do not support that FENO testing was utilized in the context of guiding management to prevent exacerbations. Moreover, the Global Initiative for Asthma does not support the use of FENO testing for the diagnosis of asthma. All told, the exhaled nitric oxide test was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found that the exhaled nitric oxide test was not likely to be more beneficial for evaluation of the patients 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 certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease 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.