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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of the right knee.  The patient reported right knee pain associated with crepitation and stiffness. The provider noted the patient had moderately responded to a corticosteroid injection in the past with a limited duration. Physical examination findings included mild right knee valgus alignment. Tenderness to palpation was noted over the right knee lateral and patellofemoral compartments. There is no documentation of past relief from viscosupplementation injections. The patient has requested authorization and coverage for Euflexxa injections in the right knee only. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in the right knee only are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had limited benefit from a corticosteroid injection. The provider has therefore recommended viscosupplementation with Euflexxa injections. The patients options are limited. He has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in the right knee only are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Partial hospitalization program (PHP) services. The American Psychiatric Association (APA) treatment guidelines lists PHP as Level 3 treatment for patients who need some structure to gain weight and intensive outpatient program (IOP) for those who are self-sufficient. This patients records document that she required structure and was not self-sufficient during the PHP admission. Similarly, PHP is appropriate for patients with partial motivation who are cooperative, but remain preoccupied with intrusive, repetitive thoughts. This patient was partially motivated as she stopped taking diet pills, laxatives and reduced excessive exercise. However, she also reported ongoing rumination about food and continued to restrict and binge. Per APA guidelines, the PHP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services (evaluation of reproductive potential, ovarian stimulation, oocyte retrieval, oocyte fertilization, and storage of oocytes and/or embryos). Chemotherapy is a gonadotoxic treatment that can result in infertility. For reproductive aged patients with newly diagnosed cancer, it is within the current standard of care to counsel them about their options for preservation of fertility and, if appropriate, potential preservation of ovarian hormone production. Providers should discuss the risk of treatment-induced infertility as well as possible interventions to preserve fertility and hormone production prior to initiating gonadotoxic therapy, as was done in this patients case. Although there is a lack of large randomized clinical trials with long-term follow-up studies assessing the possible impact of fertility treatment on cancer patients, the current medical literature supports fertility preservation in this clinical setting.  Established techniques for fertility preservation include cryopreservation of embryos and oocytes, which is associated with the greatest likelihood of successfully generating offspring. Given these findings, fertility preservation services (evaluation of reproductive potential, ovarian stimulation, oocyte retrieval, oocyte fertilization, and storage of oocytes and/or embryos) were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for left inguinal hernia repair surgery. The emergent need to repair inguinal hernias oftentimes arises in the setting of incarceration or small bowel obstruction. Otherwise, published literature supports observation of a patients symptoms. Refractory pain, large hernia, or a hernia increasing in size are also indications to consider repair. This patient has a longstanding known left inguinal hernia, which is increasingly symptomatic. A CT scan confirmed the presence of the inguinal hernia. The provider noted the surgery is contraindicated due to the patients history of smoking. Although smoking increases the risks associated with any surgery, there is no published guideline to mandate cessation as a condition of surgical repair. Therefore, the requested left inguinal hernia repair 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 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 Ativan (lorazepam). The U.S. Food and Drug Administration (FDA) has approved Ativan for short-term relief of anxiety symptoms and for the treatment of epileptic seizures. The FDA has not approved Ativan or benzodiazepines for the treatment of chronic low back pain, or pain related to a hernia. A review by Tanguay Bernard and colleagues reports that patients with a history of substance abuse should not take benzodiazepines. In addition, providers should exercise caution with a patient that has other risk factors, including a history of chronic pain, polysubstance abuse, and untreated schizophrenia. In general, the use of both opioids and benzodiazepines is contraindicated due to concerns of respiratory depression, which is further elevated for this patient given his comorbid medical issues. Based on the medical records for review, lorazepam (Ativan) with refills is not medically necessary for treatment of this patient. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement and prospective authorization and coverage for twice-weekly nutritional therapy services. Anorexia nervosa is one of the most difficult psychiatric disorders to treat. Patients with this disorder are generally resistant to treatment and are ambivalent about therapy. Given how difficult it is for patients with anorexia to engage in treatment, this patients trust and rapport with her current therapist and motivation to continue treatment are highly positive predictors of success. Training and experience in nutrition therapy specific to eating disorders promote a positive outcome in patients (Reiter and Graves). The physician reviewer found American Psychiatric Association (APA) recommends that normalization of nutrition and eating habits is a central goal in the treatment of patients with bulimia nervosa. Since this patient has failed prior treatment at the RTC and PHP levels of care but has demonstrated commitment and improvement with nutritional therapy, she is likely to continue to benefit with this modality. Therefore, twice-weekly nutritional therapy services provided were and are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for masculinization chest reconstruction procedures (CPT codes 19303  simple complete mastectomy, 19350-50 or 15200-50  nipple reconstruction). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) states that chest surgery in female to male patients can be performed earlier than age of majority, preferably after ample time of living in the desired gender role and after one year of testosterone treatment (Coleman, et al.). Chest surgery has been demonstrated an effective treatment in transmasculine youth with gender dysphoria. Olson-Kennedy and colleagues found that chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. According to the WPATH SOC, one letter from a mental health professional meets the criteria for the requested chest reconstruction surgery. This patient has been treated with testosterone since April 2018. The patients appearance has become more masculine with testosterone, but his anxiety about his chest has become increasingly intense. The patient continues to bind his chest daily. Further, his therapist and physician support the requested surgical intervention to address the patients gender identification as male. Given these findings, the requested masculinization chest reconstruction procedures (CPT codes 19303  simple complete mastectomy, 19350-50 or 15200-50  nipple reconstruction) 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 psychiatry with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Rasuvo. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Rasuvo is medically necessary for the treatment of the patients medical condition. Researchers reported that orally administered methotrexate is well absorbed in patients with inflammatory bowel disease, including those with severe small bowel disease or resection. In this case, injectable methotrexate is being used in combination with Stelara. The patient has intolerance to sulfasalazine due to GI side effects. Other therapy has included prednisone, Humira, and Rasuvo. There is no evidence the patient has taken oral methotrexate or has severe GI disease. The medical evidence does not support the requested medication in this clinical setting. Therefore, Rasuvo is not medically necessary for the treatment of this patient. 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 allergy and immunology and internal medicine with sub-specialty certification in rheumatology 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 reimbursement for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections were medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections. The patients options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the services at issue in this clinical setting. Therefore, bilateral knee Orthovisc injections were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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

The patient has requested authorization and coverage for referral for consultation with an oral maxillofacial surgeon. The patient has a maxillofacial skeletal deformity. Based on the photographs and x-rays, the patient may require orthognathic surgery as well as orthodontics to repair her condition. Consultation with an oral surgeon is appropriate to assess if the patient is a candidate for orthognathic surgery. Correction of the patients maxillofacial skeletal deformity would improve her musculoskeletal and dento-osseous relationships and should help alleviate this patients associated muscular disorders and facial pain. Given these findings, the requested referral for consultation with an oral maxillofacial surgeon 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 oral and maxillofacial 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

An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) to the liver. This patients records document findings of a single liver metastasis in the setting of metastatic pancreatic adenocarcinoma. The patients provider has recommended treatment with RFA to the liver. The use of RFA for ablation of the liver lesion is supported by the medical literature. Clinical data suggests that RFA is safe and effective for extending survival in patients with liver metastases from many different primaries, including pancreatic cancer (McDermott and Gervais; Pandya and Shelat; Park, et al.). Even in cases with more than one metastasis, RFA has been demonstrated to be a safe, minimally invasive treatment option (Hua, et al.). The records indicate that this patient is now on palliative chemotherapy and has attempted radiation therapy. The use of RFA is a safe and potentially effective treatment option for the therapy of this patients single liver metastasis. Given this support, the requested RFA to the liver  is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested RFA to the liver 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 reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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

An enrollee has requested authorization and coverage for an in-center polysomnography test. American Academy of Sleep Medicine (AASM) guidelines recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adult patients who present with signs and symptoms that indicate an increased risk of moderate to severe OSA. These guidelines recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography should then be performed for the diagnosis of OSA. The guidelines state that polysomnography, rather than home sleep apnea testing, is recommended for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia.In this case, while the submitted documentation reflects that the patient experienced palpitations, shortness of breath and irregular heart rate, these symptoms do not establish that the patient has significant cardiorespiratory disease. Similarly, the patients elevated coronary artery calcium scores do not constitute significant cardiorespiratory disease that would warrant in-center polysomnography testing. Consistent with AASM guidelines, the patient may proceed with a home sleep study first, and in the event that the home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography could then be performed for the diagnosis of OSA. Accordingly, an in-center polysomnography test is not medically necessary to treat the patients medical condition at this time.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 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.