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 Monovisc injection in the right knee. This patient presents with chronic right knee pain due to osteoarthritis. She has tried and failed treatment with non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, three months of physical therapy, and corticosteroid injections. Her provider has documented prior benefit from viscosupplementation. The provider recommended an injection of Monovisc for the right knee. 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. Per the AAOS, viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This patients records indicate that she previously experienced adequate positive benefit from prior viscosupplementation injections. Furthermore, the patients remaining treatment options are limited as she has tried and failed conservative treatment modalities. For these reasons, the requested Monovisc injection in right knee is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a regimen of Entyvio infusions 300 mg every four weeks. Entyvio is supported as primary therapy for patients with moderate-to-severe ulcerative colitis per the American College of Gastroenterology (ACG) guidelines. Dose intensification of Entyvio with infusions more frequently than every eight weeks has been studied in high-quality clinical trials. Randomized placebo-controlled trials support the safety and efficacy of more frequent dosing of Entyvio in patients who failed to achieve remission by week six to every four weeks instead of every eight weeks. Additionally, guidelines for the treatment of ulcerative colitis recommend dosage increase in the setting of uncontrolled disease, when the drug level is low and anti-drug antibodies are absent, as is present in this patients clinical setting. Without an increase in Entyvio dosing, this patient is at risk for complications of ulcerative colitis. In this clinical setting, the requested dose escalation of Entyvio to 300 mg every four weeks is supported by current medical literature (Park and Jeen). Therefore, the requested regimen of Entyvio infusions 300 mg every four weeks is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections every 10 weeks, or in the alternative, Botox injections every 12 weeks. The American Headache Society (AHS) recommends preventive treatment when migraine attacks significantly interfere with a patients daily routine despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. In 2016, the American Academy of Neurology (AAN) updated its guidelines to include Botox for the management of chronic migraine, which is defined as attacks lasting four or more hours on at least 15 days each month for three months. Botox has been demonstrated to be safe and effective to increase headache-free days. In this case, the patient has a history of chronic migraines that have not responded to multiple oral preventative medications. Based on the AHS statement and AAN guideline, this patient is an appropriate candidate for prophylactic treatment with Botox therapy. The records demonstrate that the patient has maintained fewer and less severe migraines with use of Botox since 2017. The patient has experienced clinical improvement with Botox therapy. Moreover, Botox dosing every 12 weeks is consistent with current medical literature and guidelines. Given these findings, the requested Botox injections every 12 weeks 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) hydroxychloroquine and (2) ivermectin treatment. There is a lack of support for the requested medications in this clinical setting. Studies report that available evidence does not support the use of hydroxychloroquine in the prevention or treatment of COVID-19. While Hosseini and colleagues note that ivermectin is of potential interest in the treatment of patients with mild and moderately severe COVID-19, there is insufficient clinical evidence on the efficacy and safety of this treatment. Given current medical literature, the requested medications are not medically indicated. Therefore, (1) hydroxychloroquine and (2) ivermectin treatment are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 sub-specialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for air ambulance services provided by Mercy Air Service, Inc.Findings:  The physician reviewer found that the circumstances of the COVID-19 pandemic have mandated a change to standard management of infantile spasms. The authors note that the initial evaluation for infantile spasms typically includes an inpatient admission for video electroencephalography (EEG) and that the hospital admission allows the clinical team to confirm the diagnosis, begin treatment, investigate the etiology via brain magnetic resonance imaging and other testing, and provide counseling to the family. In this case, the patient had a suspected diagnosis of infantile spasms, a potentially serious medical condition requiring urgent evaluation and treatment. Per the submitted notes, ground ambulance was not available or safe due to riots. Air transportation was the only mode of transportation available to the patient. Given that the patient required urgent inpatient treatment, the services at issue were medically indicated. Therefore, air ambulance services provided by Mercy Air Service, Inc. were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for DOC Band cranial remolding orthotic device. As noted in the records provided for review, this patient has a cranial vault asymmetry index (CVAI) of 6.2, cephalic index of 89.5, and a cranial vault asymmetry of 8 mm. Per the Plagiocephaly Severity Scale of the Childrens Hospital of Atlanta, the patients CVAI of 6.2 places him in the stage 2, mild range. The authors report that a CVAI of 3.5-6.25 with minimal asymmetry in one posterior quadrant and no secondary changes should be treated with a repositioning program. This patient is described as having right occipital flattening, left frontal flattening, anterior ear shift right, anterior orbital shift right and eye fissure narrowing left. This presentation includes some overlap with stage 3, moderate plagiocephaly. However, his CVAI is in the mild range rather than moderate, stage 3 range. Researchers found a lack of data demonstrating a causal connection between positional plagiocephaly and lower cognitive scores in school-aged patients to support an indication for treatment with a cranial remolding orthotic. All told, the DOC Band cranial remolding orthotic device was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 neurology with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance angiography (MRA).Findings:  The physician reviewer found that the available documentation, this patient underwent evaluation with contrast-enhanced computed tomography (CT) of the chest, which showed normal pulmonary parenchyma and thoracic vascular anatomy. A coronary CT angiography demonstrated normal coronary anatomy and confirmed that the patients mediastinal mass was stable at the four-month interval. Based on current medical literature, the requested MRA is not expected to provide further advantage to visualizing the patients thoracic anatomy or anterior mediastinal mass beyond the studies already performed. Moreover, in common differential diagnoses of vestibular migraine, audiologic testing and magnetic resonance imaging (MRI) have greater initial clinical utility than vascular imaging (Ackman, et al.). Given that a CT of the chest and CT angiography have been performed to evaluate this patient for vascular pathology, MRA of the same region is not consistent with current medical literature recommendations. For these reasons, the requested MRA is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care 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 authorization and coverage for a tertiary level cardiology consultation. The submitted documentation does not support the medical necessity of the requested service. Studies note, Stable coronary artery disease refers to a reversible supply and demand mismatch related to ischemia, a history of myocardial infarction, or the presence of plaque documented by catheterization or computed tomography angiography. The authors further note that patients are considered stable if they are asymptomatic or their symptoms are controlled by medications or revascularization, and that treatment may include risk factor management, antiplatelet therapy, and antianginal medications. In this case, while the patient has a reported history of remote myocardial infarction, she currently does not have angina. A stress test from December 2017 was negative for ischemia, and her echocardiogram showed normal left ventricular function without wall motion abnormalities. The records do not reflect that the patient is currently taking medications for angina and is only on propranolol for hypertension. The records do not document current cardiac symptoms, active cardiac disease, congestive heart failure, congenital heart disease, or complex cardiac conditions. Given that this patients conditions may be managed by regular ambulatory follow-up and risk factor reduction, the requested service is not medically indicated. Therefore, a tertiary level cardiology consultation is not medically necessary for the treatment of this patient.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 with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for orthodontic dental treatment. In this clinical setting, while the records note that the patient has an overbite, the presence of an overbite in and of itself is not an indication for orthodontic therapy. Given the handicapping labio-lingual deviation (HLD) score of 21, there is a lack of support for the requested orthodontic dental treatment. Orthodontic treatment is also not the appropriate treatment modality for pain from a third molar impaction. Therefore, orthodontic dental treatment is not necessary to prevent disease and promote oral health or restore oral structures to health and function in this patient.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 a licensed D.D.S., board certified in dentistry 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 Monovisc injection in both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, Platelet Rich Plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed various other conservative treatments with the alternative being bilateral total knee arthroplasties. Under these circumstances, the requested Monovisc injection in both knees is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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 spinal epidural injections.A 2018 systemic review by Lee and colleagues concluded that lumbar epidural steroid injections were more effective injections than those without steroid for improved pain relief and function. Manchikanti and colleagues concluded in their 2013 update of guidelines that for lumbar disc herniation with radiculitis, the evidence is considered good for short-term and long-term relief with local anesthetics with steroids. They stated that the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis.In this case, the patient has low back pain with radiation into the lower extremities. She has a prior history of lumbar fusion surgery, with demonstration of lumbar stenosis consistent with her current complaints. The patient is also noted to have had a previous epidural steroid injection with substantial pain relief and associated functional improvements. The provider has offered the patient a spinal cord stimulator trial, but the patient has declined. The patient was also offered a surgical consult, but this was declined as well. The patient has requested a repeat epidural steroid injection based on her previous response to the earlier injection. Under these circumstances, the requested spinal epidural injections are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for upper and lower eyelift, cheek implants and upper lip lift. The records reviewed document that this patient has a history of gender dysphoria that has been improved with voice surgery and hormone therapy. The patient reports that her mood, breast development, and facial changes are more in line with her female identity. Her providers concur that the requested upper and lower eyelift, cheek implants and upper lip lift are indicated to address the patients gender dysphoria and associated distress. Facial feminization surgery is medically necessary for many transgender females to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. The WPATH has acknowledged that, For certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The guidelines further report that, These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. Given this support, the upper and lower eyelift, cheek implants and upper lip lift are medically necessary for treatment of this patient.