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

The patient has requested authorization and coverage for a Synvisc-One injection in the right ankle. Researchers reported that intra-articular hyaluronic acid (HA) administration can significantly reduce pain for patients with ankle OA. The authors also noted that locally injected HA treatment is an effective treatment for OA based on its effects of patients pain, function and patient global assessment. In terms of safety, it has also been shown that there are no statistically significant negative side effects in patients receiving injection treatment. Furthermore, the patient has a history of benefit from a prior viscosupplementation injection to the ankle. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the right ankle is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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 patient has requested authorization and coverage for consultation with an infectious disease specialist. The records provided for review do not support an indication for a consultation with an infectious disease specialist. There is no documentation that the patients symptoms are concerning for recurrent urinary tract infection given the normal urinalysis as well as an abdominal CT that did not reveal any urinary tract pathology. The patient has undergone a standard evaluation for infectious disease processes based on his presentation. His primary care provider, a gastroenterologist, and urologist have participated in his care. However, there is no report of fevers or laboratory finding to support the requested consultation. In the medical literature, the primary care providers routinely encounter and treat urinary tract infections, including cystitis and pyelonephritis. 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 internal medicine with subspecialty certification in infectious diseases 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 additional CPT codes L5647, L5781, and L5988 for prosthetic device of the right leg. In this case, the patient has a transtibial amputation and is ready for a definitive prosthesis, given his significant residual limb volume reduction. He has used a preparatory prosthesis for a sufficient period of time. Notably, he is reported to have congestive heart failure with a reduced ejection fracture. A traditional suction socket and suspension system (L5647) with sleeve is appropriate and necessary to maintain adhesion of the definitive prosthesis to the residual limb.  In this patients case, a vertical shock reducing pylon (L5988) is necessary and appropriate to reduce the transmission of ground reactive forces to the residual limb, improving gait and reducing the risk of residual limb soft tissue injury. Active vacuum-assisted suspension systems aim to minimize residual limb volume changes to provide better fit during the day. Authors found that further investigations are needed to evaluate the long-term effects of these systems, and even though suction sockets could create better suspension, fit, and gait performance, overall satisfaction was higher with the pin/lock system. In a study evaluating gait with an active or inactive vacuum suspension system, Researchers found that the differences were small and not considered clinically significant. Therefore, CPT code L5781 is not medically necessary. All told, CPT codes L5647 and L5988 for prosthetic device of the right leg are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilation and curettage (D&C) procedure and intravenous (IV) antibiotics. D&C is a surgical procedure that is indicated for multiple gynecologic diagnoses, including the need to sample endometrial tissue when outpatient evaluation cannot be performed. It can be done in a therapeutic setting for abnormal bleeding or obstetric issues. In this case, there is no clinical documentation to support the patients inability to undergo endometrial biopsy in the office. There is no clinical documentation to support abnormal bleeding or obstetric issues. While oral or intravaginal antibiotics may be suggested, intravenous antibiotics have not been shown to be a treatment for persistent abnormal vaginal discharge. IV antibiotics may worsen vaginal flora symptoms. This patients clinical course has not been typical, as her symptoms have persisted despite multiple treatments. Although further evaluation may be warranted, the requested D&C procedure and IV antibiotics are not diagnostic, but rather therapeutic, and are not indicated for this patient. Therefore, the requested D&C procedure and IV antibiotics 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator. Researchers reviewed outcome measures and adherence data for patients treated with hypoglossal nerve stimulation for moderate to severe obstructive sleep apnea. The authors noted that hypoglossal nerve stimulation therapy is associated with good objective adherence, low morbidity, and improved OSA outcome measures. In comparing uvulopalatopharyngoplasty and hypoglossal nerve stimulation therapy, a study concluded, while both traditional surgery and hypoglossal nerve stimulation therapy were effective treatments for patients with moderate to severe OSA with CPAP intolerance, our study demonstrated that hypoglossal nerve stimulation is curative in normalizing the AHI to less than 5 in the majority of patients. In this case, the patient meets U.S. Food and Drug Administration (FDA) criteria for hypoglossal nerve stimulator. The patient has tried and failed CPAP treatment, and his AHI is within the appropriate range. Thus, the requested hypoglossal nerve stimulator 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 requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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

An enrollee has requested reimbursement for a DecisionDx-Melanoma gene assay. A study found the use of gene expression profiling in patients with stage 1-2 melanomas as a risk stratification tool in patients with melanomas with high risk features. In this patients case, the records document melanoma with a thick Breslow depth transected at initial biopsy, negative surgical margins on wide local excision, and negative sentinel lymph node biopsy.  Based on the initial pathology report, the patient appeared to have an increased risk of cancer recurrence. The DecisionDx-Melanoma gene test assesses the risk of recurrence based on the genetic expression profile. In this patients case, the DecisionDx-Melanoma gene test showed a lower risk profile and, therefore, changed management to include less frequent skin examinations and surveillance imaging. This is superior to standard of care, which includes excision, sentinel lymph node biopsy, and routine skin examinations scheduled at arbitrary intervals. Therefore, the DecisionDx-Melanoma gene assay was likely to have been more beneficial than any other available standard service for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The patient has requested reimbursement for behavioral health residential treatment center services. The Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) provides a framework for determining the clinically appropriate level of care in mental health treatment. The patients composite score reveals that the patient is qualified for medically monitored residential services. Therefore, behavioral health residential treatment center services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene test. In this patients case, the records document melanoma, 1.5 mm Breslow thickness. On pathology, the specimen showed areas of regression and lymphovascular invasion, which both can be features of higher risk of metastasis. In this setting, the National Comprehensive Cancer Network recommends offering sentinel lymph node biopsy. Younger age and lymphovascular invasion are positive predictors of positive sentinel lymph node testing. Per the records, this patient has both a positive and negative predictor of positive sentinel lymph node biopsy. DecisionDx-Melanoma testing can be useful in certain instances where more information and data are needed. Therefore, the DecisionDx-Melanoma gene test was likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma gene test at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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 patient has requested reimbursement for VASER liposuction (suction assisted lipectomy CPT 15879). Researchers noted that, Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. The authors commented that, One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle. The records provided for review document that this patient has generalized adiposity, not localized to the lower extremities. The patient has a demonstrated ability to lose a significant amount of weight from 295 pounds to 150 pounds. Her present weight is 260 pounds with a BMI of 42.0 kg/m2. There is a lack of evidence of persistence of fat despite weight loss. She does have a characteristic collection of fat in her lower legs while sparing her feet, but there is no reported functional disability from this finding. Based on peer-reviewed medical literature, the VASER liposuction (suction assisted lipectomy CPT 15879) was not medically necessary for treatment of the patient. While the patient demonstrates obesity with a BMI over 40.0 kg/m2, this is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. The patients condition is not an abnormal structure of the body, rather is a normal structural change that is an accommodative response to gain of body mass. The appearance of the patient is normal and consistent with the gain of weight. There is no report of loss of function due to lipedema and the procedure at issue would not have provided a more than minimal improvement in the patients appearance. Thus, the VASER liposuction (suction assisted lipectomy CPT 15879) was not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary and not reconstructive in nature 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: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for hip replacement surgery.The American College of Rheumatology recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy includes exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. Researchers have concluded that six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing total joint replacement to relieve symptoms.In this case, the patient has a history of chronic right hip pain and dysfunction. He reports severe right hip pain that is interfering with his ambulatory tolerance. There is radiographic evidence of severe right hip osteoarthritis. His pain is not currently controlled. The submitted documentation includes detailed evidence of recent, reasonable and comprehensive non-operative treatment including activity modification, medications, use of a cane, weight loss and steroid injection without sustained improvement. The patient has lost weight and reduced his body mass index. He has reported difficulty with additional weight loss, and bariatric surgery is reportedly contraindicated due to a large ventral hernia. He has met other evidence based medical criteria for hip replacement surgery. Current evidence based medical literature supports proceeding with hip replacement surgery in the setting of the current body mass index, indicating that obesity itself should not be a deterrent to undergoing total joint replacement to relieve symptoms. Therefore, the requested hip replacement surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's 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 enrollee requested coverage for proton beam radiotherapy. The patient had symptoms of urinary frequency, urinary intermittency, and nocturia. The treating physician recommended proton beam radiotherapy as the best available treatment option for the patient. Proton beam radiotherapy has not been shown to be superior to intensity modulated radiation therapy for prostate cancer. The current literature shows that when considering metrics of higher doses delivered to the adjacent normal structures, the superiority of proton beam radiotherapy is less clear and some studies show a slight disadvantage with proton beam radiotherapy.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in radiation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for the brand name medication NuvaRing. The NuvaRing is a hormonal form of contraception with etonogestrel/ethinyl estradiol (ENG/EE). Unlike oral contraceptive agents where the peak concentration of the progestin occurs daily, the ENG/EE vaginal ring reaches its peak hormone concentration once per cycle, within seven days of insertion. Every hormonal contraceptive agent has a side effect profile that varies per patient. The NuvaRing is one of few vaginal ring options. In this case, the patient has tolerated the NuvaRing well for many years without side effects. It is standard practice to continue the preferred method of hormonal control in order to optimize compliance and overall satisfaction with contraception. The medical evidence supports the requested medication in this clinical setting. Therefore, the brand name medication NuvaRing is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for 30-day residential treatment in a post-traumatic stress disorder (PTSD) and trauma recovery program. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient does not meet the criteria for the requested 30-day residential treatment in a PTSD and trauma recovery program. These findings give the patient a composite score which is consistent with high intensity community based services. Per LOCUS, programs of this type are traditionally clinic-based programs with contact several times per week. For these reasons, the requested 30-day residential treatment in a PTSD and trauma recovery program 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 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.