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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21.Findings: Three out of three physician reviewers found that left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21 were likely to have been more beneficial for you than any available standard therapy.Cankurtaran and colleagues compared the effectiveness of ultrasound-guided versus blind genicular nerve block for the treatment of osteoarthritis. The authors noted, Both ultrasound-guided and blind genicular nerve block, in the treatment of knee osteoarthritis, were effective in reducing symptoms and improving physical function. Konya and colleagues found that visual analogue scale (VAS) scores were significantly lower after genicular radiofrequency ablation. The report noted that genicular radiofrequency ablation reduced the need for opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Further, the authors concluded, In chronic refractory knee pain due to osteoarthritis, the application of radiofrequency ablation to the genicular nerve is an effective and safe treatment option in the medium to long term. Finally, El-Hakeim and colleagues reported superior pain relief in patients treated with radiofrequency ablation than in patients undergoing conservative management consisting of oral acetaminophen, diclofenac, and physical therapy. In this case, the patient has chronic knee pain with magnetic resonance imaging confirming severe osteoarthritis. The patient has tried and failed conservative care options, including intra-articular steroid injections, viscosupplementation injections, and physical therapy. There is evidence in the literature to suggest radiofrequency ablation is effective for treating knee pain and that this therapy is superior to conservative therapy. Therefore, left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21 were likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in anesthesiology with sub-specialty certification in pain medicine. All reviewers 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 authorization and coverage for hyperbaric therapy. Findings:  The physician reviewer found that records provided for review document that this patient has undergone hyperbaric oxygen therapy over the past year for the treatment of soft tissue radiation necrosis. The records suggest that the duration of the benefit with hyperbaric therapy has been brief. In addition, records suggest that the patients facial and eye weakness may be partially due to recent treatment with Botox. Moreover, there is a lack of a recent brain MRI demonstrating focal contrast sparing to establish a current diagnosis of radiation necrosis. In the absence of this documentation, there is a lack of diagnosis to support an indication for additional hyperbaric oxygen therapy. Therefore, the requested hyperbaric therapy 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 family practice with subspecialty certification in undersea and hyperbaric 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast augmentation. This patients records document male-to-female transition with orchiectomy and treatment for at least three years with hormones. The patients providers have documented persistent gender dysphoria with regard to the patients chest. Her providers have recommended feminizing mammoplasty. The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges 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 WPATH noted that feminizing mammoplasty for the male-to-female patient is often of greater practical significance in the patients daily life than reconstruction of the genitals. Moreover, the requested breast augmentation surgery is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested breast augmentation 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 psychiatry with expertise in transgender health 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 posterior laminectomy/decompression with fusion from T4 through L2 (CPT 22612 arthrodesis, posterior or posterolateral technique, single level; lumbar and CPT 22614 each additional vertebral segment with approved CPT code 22610 thoracic arthrodesis; CPT code 22843 posterior segmental instrumentation, CPT code 22214 osteotomy of spine, and CPT code 22216 osteotomy of spine). Hu and colleagues note that pedicle subtraction osteotomy and disc resection with cage placement and long-segment fixation are effective and safe methods to treat thoracolumbar post-traumatic kyphosis. Likewise, Chen and colleagues note that modified pedicle subtraction osteotomy is a safe and effective technique for the treatment of old fracture with kyphosis. In this case, the patient requires surgical intervention to correct a focal kyphotic deformity and to rebalance the spine. In visit notes, the provider recommended a shorter fusion focusing on the thoracolumbar kyphosis, from T9 to L2, with a possible three column pedicle subtraction osteotomy. Given that the records do not document a global deformity, fusion of the entire thoracic spine from T4 to L2 is not medically indicated and would not correct a focal angular deformity at the thoracolumbar junction. Therefore, posterior laminectomy/decompression with fusion from T-4 through L-2 (CPT 22612 arthrodesis, posterior or posterolateral technique, single level; lumbar and CPT 22614 each additional vertebral segment with approved CPT code 22610 thoracic arthrodesis; CPT code 22843 posterior segmental instrumentation, CPT code 22214 osteotomy of spine, and CPT code 22216 osteotomy of spine) 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 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: The patient has requested authorization and coverage for shower bench with back support. The records reviewed document that this patient has multiple pain complaints with diagnoses including fibromyalgia and complex regional pain syndrome (CRPS). The recommended treatment of fibromyalgia and CRPS involves analgesics and physical activity to the extent possible. In addition, desensitization to stimuli is a classic modality that has long been employed for the treatment of CRPS. In this case, the patient has undergone multiple examinations that have not revealed neurological, musculoskeletal, or other deficits suggestive of functional impairments with respect to bathing or other basic self-care activities. The provider noted that the patient has demonstrated a normal to a mildly ataxic gait. The patient reports that she is unable to stand for prolonged periods of time. However, there is a lack of evidence that the patient cannot tolerate standing for the duration of a shower to perform basic hygiene. The records do not include a formal therapy evaluation to establish that the patient requires a shower bench with back support to perform her bodily hygiene activities. Therefore, the requested shower bench with back support is not medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging. The indications for breast MRI include high and intermediate risk screening, for patients with a new diagnosis of breast cancer, for evaluation of response to chemotherapy prior to surgery, for evaluation of recurrence and metastatic cancer of an unknown primary source, and when mammographic and sonographic findings are inconclusive. In this case, if the asymmetry visualized on diagnostic mammography remained suspicious, then stereotactic biopsy is indicated. The records do not suggest that the breast asymmetry is concerning for implant rupture or that biopsy is not technically feasible. Accordingly, the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 3 is board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavior analysis (ABA) assessment and/or therapy services. The ABA Coding Coalition has endorsed ABA therapy for patients with mild intellectual disability and/or ADHD. The Coalition noted that, When designed and overseen by qualified professionals, ABA treatments have proved effective for ameliorating symptoms, developing adaptive behaviors, and reducing maladaptive behaviors so as to enhance healthy, successful functioning and prevent deterioration and regression in patients with disorders that arise during the developmental period. Considering this patients behavioral issues, the requested evaluation to determine the focus and ABA treatment plan is medically necessary. In addition, ABA therapy is a recommended strategy to treat ADHD as identified by the Centers for Disease Control and Prevention (CDC). Caye and colleagues recommend that preschool aged patients should start with ABA therapy due to the potential safety concerns of starting medication at a young age. The CDC suggests ABA therapy, including parent training to help manage behavior, as one of two effective strategies to treat ADHD. Given this patients presenting behavioral issues, the requested ABA therapy with an emphasis on parent training is medically necessary. To adequately determine the intensity and scope of ABA treatment plan, the requested assessment must first be completed. Moreover, the requested ABA evaluation and therapy are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested ABA assessment and therapy services 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 a licensed B.C.B.A, board certified in psychology, 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 acute inpatient rehabilitation services including occupational therapy, physical therapy, and recreational therapy. This patient sustained severe trauma due to a motor vehicle accident resulting in major injuries to both of her lower limbs. The accident may have prolonged effects on the patients health, function and well-being, including in the social and vocational domains (Solvang, et al.). The records provided for review document that the patient  has undergone extensive inpatient rehabilitation. However, the patients progress suggests that she has largely plateaued with respect to her functionality given her ongoing bilateral leg non-weightbearing restrictions, pain, and endurance issues. The patient is able to transfer with a slide board at a supervision level and is independent propelling a manual wheelchair. She continues to require some physical assistance for her lower body self-care activities. The patients rehabilitation goals focus on optimizing her compensatory skills at a wheelchair level until her bones have sufficiently healed enough for weight bearing activities. These compensatory skills goals can be further pursued at the skilled nursing facility (SNF) or in the community. There is a lack of documentation of intensive rehabilitation needs, need for close physician supervision, or need for 24-hour per day rehabilitation nursing availability to support an indication for acute inpatient rehabilitation facility services including occupational and physical therapies (Mayer, et al.). Treatment with recreational therapy can be a helpful adjunct in the convalescence of a patient who has faced significant trauma, but there is a paucity of data demonstrating that this type of intervention is medically necessary in this clinical setting. For recreational therapy, patient peers do not have to be the same or similar age to have a positive influence on the patient. All told, the requested acute inpatient rehabilitation services including occupational therapy, physical therapy, and recreational therapy are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for lumbar/sacral interlaminar epidural injections. The American Society of Interventional Pain Physicians (ASIPP) guidelines on epidural interventions in the management of chronic spinal pain note, Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. In a systemic review of the efficacy and safety of transforaminal epidural steroid injections, researchers report, There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations. In this case, the patient has chronic lumbar radiculopathy with radiation into the lower extremities. MRI showed degenerative disc changes leading to neuroforaminal stenosis. The patient has tried and failed conservative care using medication management, physical therapy, and a home exercise program. The patient reported pain relief with a previous epidural steroid injection. Given that current medical literature supports the efficacy of lumbar epidural steroid injections in reducing radicular pain, the services at issue are medically indicated. Therefore, lumbar/sacral interlaminar epidural injections were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prevymis 480 mg tablets. Bhoopat and colleagues note that in the treatment of cytomegalovirus anterior uveitis, valganciclovir appears effective and safe, and while long-term antiviral prophylaxis does not abolish recurrences, it may possibly reduce their frequency. Tsui and colleagues note that letermovir may be an alternative treatment for cytomegalovirus anterior uveitis in patients with persistent inflammation or side effects on valganciclovir. In this case, while the provider noted in a letter that the patient experienced side effects of dizziness and flares while on Valcyte, visit notes reported that the patients most recent flare occurred while they were off Valcyte, and that the patient preferred management with letermovir in order to avoid blood monitoring. Given that the patients most recent flare appears to have occurred due to medication stoppage rather than medication failure, the requested medication is not medically indicated. Therefore, Prevymis 480 mg tablets are 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 ophthalmology 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 Restasis cyclosporine eye drops. Findings: In a systematic review to evaluate the safety and efficacy of topical cyclosporine in treating patients with dry eye syndrome, a study concluded that twice daily application significantly improved both objective and subjective outcomes. Another study notes that there is consistent evidence of objective improvements in chronic dry eye disease with the use of cyclosporine ophthalmic emulsion 0.05%. Patients with recalcitrant dry eye disease underlying inflammation are most likely to respond to this medication. Given that the records show that the patient has continued symptoms despite already been using artificial tears and has a diagnosis of Hashimotos disease, which may result in underlying inflammation, the requested medication is medically indicated. Therefore, Restasis cyclosporine 0.05% eye drops are 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 ophthalmology 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.