Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dopamine transporter single photon emission computed tomography (DaT-SPECT). The diagnosis of Parkinsons disease is determined by clinical means. Several other diseases can have Parkinsonian features, making them difficult to distinguish from primary Parkinsons disease. DaT-SPECT uses imaging to determine presence, location, and the amount of dopamine transporters in dopaminergic cells. This modality is effective in distinguishing patients with Parkinsonian syndromes from those with Parkinsons disease. Given this support, the requested DaT-SPECT imaging scan is likely to be more beneficial for evaluation of the patients medical condition than any available medical therapy.Findings:  Three physician reviewers found the requested DaT-SPECT imaging scan is likely to be more beneficial for evaluation of the patients medical condition than any available medical therapy.Final Result: The reviewers determined that the requested DaT-SPECT imaging scan is likely to be more beneficial for evaluation of the patients medical condition than any available medical therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bone density test (CPT code 77081). Findings:  Three physician reviewers found that the medical evidence does not support the services at issue in this patients case. There is a lack of clinical documentation to show why this patient needed peripheral bone density testing instead of a standard bone density test, where the spine and hips are imaged. Peripheral bone density devices are portable machines that use the same technology as dual-energy x-ray absorptiometry (DEXA) to measure bone mineral density at peripheral sites, such as the forearm. Evaluation of fracture risk prediction with these machines is confounded by technical differences, variation in the definitions of the bone regions of interest measured, and lack of standardized reference databases for calculating T-scores. Peripheral bone density cannot be used for diagnostic classification, other than with measurement at the distal one-third radius site to evaluate for conditions like primary hyperparathyroidism. In sum, bone density test (CPT code 77081) was not likely to have been superior over other methods of evaluating this patient. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for five Supartz injections 10mg/ml. The Health Plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees bilateral knee osteoarthritis.At issue in this case is whether the requested five Supartz injections 10mg/ml are medically necessary for treatment of the patients medical condition.Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Researchers concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was found efficacious during a 54-month follow-up period. The American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Evidence based medical peer-reviewed literature supports the use of vicsosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Vicsosupplementation 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 presents with bilateral knee pain and has been diagnosed with bilateral knee osteoarthritis. Painful bilateral knee range of motion and crepitus is documented. He has failed to respond to conservative treatment with intra-articular steroid injections and prescribed non-steroidal anti-inflammatory drugs. Prior Supartz injections on three occasions have provided total elimination of pain and functional restoration in knee motion. Therefore, the requested Supartz injections for the bilateral knees are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injections 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 osteogenesis stimulator. The submitted documentation fails to demonstrate the medical necessity of the requested device. Bone growth stimulators may be considered medically necessary as an adjunct to spinal fusion surgery for patients with any of the following risk factors for failed fusion: one of more previous failed spinal fusion(s); grade III or worse spondylolisthesis; fusion to be performed at more than one level; current smoking habit; diabetes, renal disease, or alcoholism; or significant osteoporosis. Foley and colleagues concluded that electric bone growth stimulation significantly improved the fusion rate at six months postoperatively in patients undergoing anterior cervical discectomy and fusion with an allograft and an anterior cervical plate, the eligibility criteria being patients who were smokers or had undergone multilevel cervical fusion. In this case, the patient was diagnosed with a large C6-7 disc herniation/extrusion with cord compression. She underwent anterior cervical discectomy and fusion with plate at C6-7. There is no documentation of any significant comorbidities, history of prior failed spinal fusion, history of smoking, cervical spondylolisthesis, or significant osteoporosis to support the medical necessity of this device. Therefore, the requested osteogenesis stimulator is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 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 physical therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees femur fracture. At issue in this case is whether the requested physical therapy is medically necessary for treatment of the enrollees medical condition.Based on the clinical information provided, the patient improved significantly with skilled intervention from her occupational and physical therapist. The therapists both documented that the claimant was safe and had met goals for discharge. She was discharged from ongoing care by the occupational therapist. In addition, she was independent with transfers and was able to ambulate household distances according to the physical therapist. Given these clinical findings, the medical records do not support that the patient requires ongoing intervention by the physical therapist. The patient is safe to transition to a home program for ongoing exercise. There is moderate evidence that physical therapy can help in the initial phase of rehabilitation, but in this case, given her clinical improvement, ongoing physical therapy would not be warranted at this time. Therefore, the requested physical therapy is not medically necessary.Final Result: The reviewer determined that the requested treatment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (cell-free fetal DNA-based prenatal screening for fetal aneuploidy). Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing (cell-free fetal DNA-based prenatal screening for fetal aneuploidy) was likely to have been more effective than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 reviewers 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewers 3 is board certified in clinical cytogenetics and genomics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Monovisc injection. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for the treatment of the enrollees osteoarthritis of the hip (hip joint disorder). At issue in this case is whether the requested Monovisc is medically necessary for the treatment of the patients medical condtion. In this case, the patient reported left hip pain with magnetic resonance imaging evidence noted of osteoarthrits and labral tear. The patient previously underwent a left hip steroid injection with significant side effects to the steroid noted post-procedurally. The patient has now requested Monovisc as an alternative intra-articular injection. Monovisc is indicated for severe knee osteoarthritis and does not carry an indication for intra-articular injection. Therefore, the requested service is not medically necessary.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 sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for partial hospitalization program services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees anxiety; bipolar disorder; substance abuse; alcohol abuse; depression; and stress disorder.At issue in this case is whether the requested partial hospitalization program services are medically necessary for treatment of the enrollees behavioral health condition.The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use.. lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.The patient requires safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM Level III treatment at least i.e. similar to what patient received at the facility. Given the severity of the patients illness (daily blackouts,) her high relapse risk and consequent risk of immediate harm, the partial hospitalization program is in accordance with generally accepted standards of medical practice; clinically appropriate for the patient's illness, and is therefore medically necessary.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 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: A 64-year-old male enrollee has requested authorization and coverage for Synvisc injections.  Findings:  The physician reviewer found that the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for well selected patients with knee osteoarthritis, based on a large network meta-analysis. This patient presents with intermittent left knee pain with a history of locking, buckling, and swelling. He reports debilitating pain affecting his ability to work. Clinical examination findings are consistent with imaging evidence of chondromalacia patella and reported x-ray findings of mild medial and patellofemoral compartment degenerative changes. Evidence based medical peer-reviewed literature generally supports the use of viscosupplementation injections for the treatment of pain in patients with moderate to severe osteoarthritis of the knee. However, in this case, there is a lack of evidence of moderate to severe osteoarthritis of the left knee or failure of available conservative treatment. Therefore, the requested Synvisc injections for the left knee are not medically necessary for treatment of this patients medical condition. 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 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

An enrollee has requested authorization and coverage for the medication Trintellix 10mg. The patient was first noted as showing depression and anxiety in the providers office visit of, in which he documented anxiety and depression with the diagnosis of depression unspecified. The patient described herself as suffering from severe depression. There is no diagnosis of major depressive disorder in the records provided for review. There is no past psychiatric medication history with other medications tried and failed, other than the patients statement in her application for independent medical review that others had been attempted and had not worked. Trintellix is indicated for depression and the patient made a statement, also in her application for independent medical review that it helps. However, in the exam there are no subjective findings describing the patients depression and/or anxiety, and there is a paucity of objective findings which would provide rationale for treatment. Therefore, at this time, the submitted documentation does not support medical necessity.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified 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: An enrollee has requested reimbursement for the percutaneous cryoablation of the left kidney received and prospective authorization and coverage for future percutaneous cryoablation of the left kidney. The current criteria for kidney percutaneous cryoablation include documentation that the patient has a contraindication to surgery, only one kidney, or decreased renal function. This patients records do not indicate that this patient has a contraindication to surgery, only one kidney, or decreased renal function. Moreover, there is a lack of adequate evidence in the peer-reviewed medical literature demonstrating an improved long-term clinical result in a patient who may be an appropriate surgical candidate for a partial nephrectomy, has two kidneys, and has normal renal function. Thus, the percutaneous cryoablation of the left kidney received and prospective authorization and coverage for future percutaneous cryoablation of the left kidney was not and is not medically necessary for treatment of this patients medical condition. 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 diagnostic radiology with subspecialty certification in vascular and interventional radiology 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 3D myelograms of the cervical, thoracic, and lumbar spine with contrast. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees hypermobile Ehlers Danlos syndrome, postural orthostatic tachycardia, and cerebral spinal fluid leak. At issue in this case is whether the requested 3D myelograms of the cervical, thoracic, and lumbar spine with contrast are medically necessary for treatment of the enrollees medical condition. The patient presents with the clinical criteria of a spontaneous cerebral spinal fluid leak. It is appropriate to discover the site of the leak, in order to repair the leak. This is done with 3D myelography. Therefore, the request for this service is medically necessary.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 neurological 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.