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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Additionally, the literature indicates that if there is significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. In this case, the patient has been diagnosed with osteoarthritis of the knee. The patient has reported severe right knee pain with functional limitations in walking and prolonged sitting. Clinical examination was consistent with x-ray findings of bilateral knee osteoarthritis, including medial joint space narrowing and tricompartmental osteophyte formation. The records note that the patient has failed to adequately respond to other conservative treatment including activity modification, medications, and home exercise. The patient reported that the patient does not want to undergo further corticosteroid injections due to health concerns. Prior Synvisc injections to the right knee have provided six to 12 months of pain relief and functional improvement. Therefore, the requested Synvisc injections are medically necessary for treatment of the patients medical condition. Final Result: The physician 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 physician 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: According to the documentation submitted for review, the patient presented with right-sided abdominal pain. Although symptoms commenced gradually, the pain had worsened and become persistent. There is no single historical, clinical, or physical finding sufficient to rule out appendicitis. Localization to the right lower quadrant occurs as the natural course progresses and the time from onset of symptoms to diagnosis varies considerably. Based on the clinical documentation submitted for review, the patients right lower quadrant abdominal pain symptoms were severe and persistent and met an emergent medical condition. For the reasons provided, the medical services provided were emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: An enrollee has requested authorization and coverage for Percocet 5-325 mg for treatment of the enrollees acute stroke with right-sided lumbar pain with radiation to right leg. Findings:  The physician reviewer found that the Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. This patients records do not include documentation of objective treatment goals for pain and function supporting an indication for Percocet. In addition, the records do not document completion of behavior therapy despite much research to support its use. Moreover, not all non-opioid medication classes have been optimized. Also, the need to use opioids as the primary medication treatment strategy for this patients pain has not been established. All told, the requested Percocet 5-325 mg is not medically necessary for treatment of this patients medical condition. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for thermography for evaluation of the enrollee, who has a history of a breast lump and family history of breast cancer. Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. Breast thermography does not have a role in the primary detection or screening for breast cancer. The American College of Radiology noted there is insufficient evidence to support the use of other imaging modalities, such as thermography, breast-specific gamma imaging, positron emission mammography, and optical imaging, for breast cancer screening.  Breast thermography has been approved by the U.S. Food and Drug Administration only as an adjunct to mammography. A study noted a recent systematic review concluded that there is currently insufficient evidence to recommend the use of this technology for breast cancer screening, with significant heterogeneity identified in published studies for both digital infrared thermal imagings sensitivity and specificity. In this patients case, a palpable lump cannot be ignored, and a repeat mammogram is warranted. She indicates that her prior mammograms have been inconclusive, but that is not the case. Many women have heterogeneously dense breast tissue and do not have breast cancer. In recent years, breast tomosynthesis has become commonplace to evaluate patients in this clinical setting. All told, the requested thermography is not medically necessary for the evaluation of 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 diagnostic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma should not be used outside of a clinical trial setting. The use of this type of testing is not considered the standard of care in the treatment of the patient melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, gene expression profiling provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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 number one is board certified in dermatology 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.Physician reviewer number two is board certified in dermatology 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.Physician reviewer number three is board certified in dermatology 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 26 sessions of physical therapy over 26 weeks for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. Close therapist supervision and guidance can be important in the initial stages of a rehabilitation program for partial rotator cuff tears and other shoulder conditions, but long-term skilled physical therapy, including supervised exercises, modalities and formal manual therapies/modalities, is not of proven benefit in this clinical setting. As range of motion and strength are restored and the patient becomes accustomed to the exercises, the patient can be transitioned to an independent program. Although the patient has persistent symptoms, further physical therapy is not expected to favorably impact the clinical or functional outcomes or course. In this case, the records do not support prolonged skilled exercise supervision. There is also no proven marginally significant benefit of formal manual therapy or other formal passive palliative modalities over palliative measures that can be applied independently. The medical evidence does not support the requested services in this patients case. All told, the requested 26 sessions of physical therapy over 26 weeks are not medically necessary for the treatment of this patient. Final Result: The physician 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines for non-small cell lung cancer endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component for the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, Guardant360 test performed was likely to have been of greater benefit 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. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is support for the medical necessity of a portion of the services at issue in this clinical setting. This patients anxiety, prior history of suicidality with plan of overdose, self-inflicted gunshot wound or jumping from a bridge, and family history of mental illness heightens his vulnerability and further compromises his prognosis. The adequately dosed, evidence based pharmacotherapy and bi-weekly psychotherapy facilitated by specialty providers in the outpatient setting was inadequate in treating his burgeoning illness complex. The patient was depressed, overwhelmed and anhedonic. His sleep was hampered by initial insomnia and nightmares.  His affect was restricted and he endorsed suicidal ideation.  Upon admission to the program, it appears that the patient actively engaged the treatment opportunity. He showed signs of improved emotional regulation via dialectical behavior therapy and a better understanding of his condition from the group dynamic and psychoeducation.  He also demonstrated effective cognitive restructuring of fear based schemas aimed at reducing his anxiety and enhanced self-awareness from mindfulness training. In sum, this patient has a serious mental illness. He failed treatment services in a less restrictive setting while the record illustrates that the services in dispute have been beneficial. As such, the treatment has improved the patients condition and more than likely prevented a more serious episode of illness.  Further, by community standards, the IOP placement is considered safe, appropriate and consistent with good practice. Therefore, the IOP services on the dates in question were and are medically necessary but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 parent of an enrollee has requested authorization and coverage for a shoe lift (L3310 x 3 lift elevated heel and sole neoprene inch up to eight in one year). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment. Russell-Silver Syndrome is a disorder resulting from an abnormality in an imprinted gene. Neonates may present with intrauterine growth retardation. There are characteristic facial features, including broad prominent forehead, triangular shaped face, and downturned mouth. Affected children may also have leg length discrepancies, developmental delay, hypoglycemia, and diaphoresis. In this patients case, he is at risk for complications from leg length discrepancy, including pain, inflammation, ambulation difficulties, and scoliosis. Without surgical intervention, in order to ambulate independently, this patient requires shoe lifts which are custom fitted and attached to his shoes. Without the lifts, he is unable to participate in appropriate activities of daily living. Custom shoe lifts are medically indicated until such time that his leg length discrepancy has been surgically corrected. All told, the requested equipment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics 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 denosumab (Prolia) injections for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that Prolia is approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Prolia has been shown to reduce the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and non-vertebral fractures by about 20% over three years. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Prolia reduces the incidence of vertebral, non-vertebral, and hip fractures. In this case, the patient has severe osteoporosis and treatment is necessary. Evista has helped maintain the bone mineral density (BMD) in the spine stable, but the BMD of the patients hips has worsened. The patient requires a therapy that will target both vertebral and hip bone density. Reclast and Prolia are similarly effective in preventing fractures of spine and hip. However, this patient is noted to have experienced side effects with oral bisphosphonate. Thus, the likelihood that she will have the same reaction to a medication in the same class is high. It is a contraindication to expose the patient to another bisphosphonate and take a risk of causing another reaction. Requiring the patient to take Reclast is not appropriate and is contraindicated. Thus, treatment with Prolia is medically necessary for the management of this patients severe osteoporosis. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 and prospective authorization and coverage for Synvisc One injection in the right knee every six months and ongoing for treatment of the enrollees osteoarthritis in the right knee. Findings:  The physician reviewer found that studies concluded that there is a general lack of reliable evidence that any specific brand of viscosupplementation agents is superior to others. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. This patient presented with recurrent right knee pain that was functionally limiting. Clinical examination findings were consistent with imaging evidence of right knee osteoarthritis, with complete collapse of the medial joint space. There is a lack of evidence in the submitted record that the patient failed to adequately respond or was intolerant of the preferred viscosupplementation agents, Euflexxa or Orthovisc. Accordingly, the submitted records do not show a compelling rationale presented to support the medical necessity of Synvisc One over Orthovisc or Euflexxa. With regards to the request for future injections, the medical necessity of future viscosupplementation injections is based on response to the prior injection lasting for at least six months. Accordingly, at this time this request cannot be established for ongoing future injections. For these reasons, Synvisc One injections to the right knee were not and are not medically necessary. 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 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.