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

Nature of Statutory Criteria/Case Summary: An enrollee has requested monitored anesthesia care for her colonoscopy and esophagogastroduodenoscopy.  Findings: The physician reviewer found that there is no documentation of clinical findings that would support the need for monitored anesthesia care. The patient has a low (ASA) preoperative physical status classification score, which indicates low pre-operative risk. There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist are well supported in both clinical practice and in the research. Therefore, given a low preoperative physical status classification score, the requested monitored anesthesia care was not medically necessary during the patients colonoscopy and esophagogastroduodenoscopy. Therefore, the Health Plans denial for the monitored anesthesia care services at issue should be upheld.Final Result: The reviewer determined that the monitored anesthesia care at issue was not medically necessary during the patients colonoscopy and esophagogastroduodenoscopy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 radiofrequency ablation of uterine fibroids for treatment of her medical condition.  Findings: Three physician reviewers found that there are a number of non-surgical and surgical treatments for heavy periods and fibroids, including nonsteroidal anti-inflammatory drugs, progestins, oral contraceptives, Lupron, uterine artery embolization, minimally-invasive surgery such as laparoscopic myomectomy, and abdominal myomectomy or hysterectomy, which can also be done in a minimally-invasive fashion (mini-laparotomy).  Although this procedure may prove to be a good option for some patients with fibroids in the future, there is insufficient evidence available at this time to conclude that it is more beneficial than other available treatments.  Thus, radiofrequency ablation of uterine fibroids was not likely to have been more effective than other treatment alternatives. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in obstetrics and gynecology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Euflexxa injections for treatment of her osteoarthritis. Findings: The physician reviewer found that the evidence based medical guidelines and peer-reviewed literature does not support the use of hyaluronic acid injections, such as Euflexxa, for osteoarthritis in the knees. Its use for treatment of osteoarthritis of the knee remains the subject of debate because the use of hyaluronan is not consistently supported by evidence based literature. The rationale for the use of hyaluronan includes the concept that proinflammatory mediators and metalloproteinases (MMPs) that stimulate chondrocytes to syntheses endogenous hyaluronic acid and proteoglycans will be affected positively by the injection of hyaluronic acid. There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection in a number of joints including the knee joint and the hip joint. A recent meta-analysis of the efficacy of viscosupplementation has been performed. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes, et al). The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines state the following regarding the use of hyaluronic acid, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. A meta-analysis by Lo and colleagues concluded that intraarticular hyaluronic acid has a small effect when compared to intraarticular placebo and that publication bias suggests that this effect may be overestimated. Moreover, the medical literature also discusses possibilities of complications, such as iatrogenic intraarticular infection and negative effects of lidocaine or Marcaine intraarticular and sensitivity reactions. The incidents of sensitivity reactions are likely to increase following repeated exposures such as has occurred for this patient in her multiple injections series. In summary, given the weak literature support as well as the possibility of complications with repeated injections, there is inadequate evidence to warrant the use of hyaluronan, in the form of Euflexxa in this case. For these reasons, the requested injections are not medically necessary for treatment and management of this patients medical condition.  Final Result: The reviewer determined that the requested injections are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing for evaluation of her medical condition.  Findings: Three physician reviewers found that the  requested gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of sufficient support in the peer-reviewed literature for the genetic testing at issue in this clinical setting. According to Smith In most cases, altered opioid metabolism in older patients, women, or specific ethnic groups can be addressed by careful dose adjustment. In addition, there is a lack of rationale provided for the genetic testing in dispute. Therefore, the gene testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient program services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, a treatment course was recommended for this patient with a history of addictive illness, trauma, anxiety and depression.  Despite support from family, friends and community meetings, the patient was unable to achieve sustained sobriety while her substance use was impairing multiple domains of functionality.  Subsequently, the patient had made progress but had not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The treatment provided thereafter focused on cognitive and interpersonal interventions, along with group interventions, to improve insight and bolster relapse prevention efforts. The treatment was reasonably expected to improve the patients condition and prevent a more serious episode of illness via relapse.  Considering the relevant peer-reviewed literature and current practice guidelines, the services in dispute were safe, appropriate and consistent with good medical practice.  Further, the duration of care was consistent with community standards.  In sum, the requested intensive outpatient program services 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Euflexxa injections for treatment of his medical condition.  Findings:  The physician reviewer found that  evidence based peer-reviewed literature and clinical practice guidelines have indicated that intraarticular steroid injections are a first line pharmacological intervention consideration in the treatment of knee arthritis, while intraarticular hyaluronan injections like Euflexxa are a second line consideration (Cheng, et al; 2012; Henrotin, et al; and Hochberg, et al). Jevsevar and colleagues performed a systematic review of the published evidence and concluded that, Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA treatment over placebo.  When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials. In light of this recent evidence, viscosupplementation injections, like Euflexxa, may be used as a clinical consideration, but they should not be pursued unless other conservative clinical options are attempted and failed. In addition, the increasing risk of adverse effects in the setting of repeated injections should be considered (Webber, et al). In the present case, the patient underwent one steroid injection, but there is no documentation of any follow up since this injection was administered. In addition, a neoprene sleeve was recommended but there are no indications that this was initiated and had failed. Furthermore, there are no clear indications other conservative treatments have been tried and failed for treatment of this patients bilateral knee pain. Therefore, in consideration of the submitted clinical records and medical literature, the requested Euflexxa injections are not medically necessary.  Final Result: The reviewer determined that the requested injections 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a positron emission tomography/computed tomography (PET/CT) for evaluation of his medical condition.  Findings:  Two physician reviewers found that in terms of follow-up for this patient, the provider suggested two possibilities that might explain the lesion, and the conclusion was that the lesion had overall benign features. Both lymphangiomas and duplication cysts are relatively rare lesions. In the lesser sac, one is more likely to find a pancreatic pseudocyst or a gastrointestinal stromal tumor (GIST). Significant pancreatic lesions can also be cystic. GIST tumors are the most frequent mesenchymal malignancy of the gastrointestinal tract, and on occasion, may also have cystic or otherwise benign features. PET/CT scans have been shown to be useful both in the evaluation of pancreatic neoplasia as well as the management of GIST tumors. If the lesion were found to be metabolically active, one would proceed with a more aggressive approach. Alternatively, if the lesion was not fluorodeoxyglucose (FDG) avid, simply obtaining a follow-up CT scan would be appropriate. This patient had an inconclusive CT scan, which means the tumor is suspicious. In this clinical setting, a PET/CT will help direct future evaluation and treatment of this patient. Thus, the requested PET/CT is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a panniculectomy and abdominoplasty for treatment of her medical condition.  Findings:  The physician reviewer found that this patient presents with evidence of a symptomatic, lower abdominal pannus. She has a complicating factor of an umbilical hernia. Her symptoms have included chronic rashes treated with typical dermatologic medications, including cortisone and antifungal creams. The photographs support that the patient has a significant lower abdominal pannus which is contributing to her functional deficit of chronic rashes. The likely cause of her functional deficit is directly related to the size and overhang of the lower abdominal pannus. However, this is not likely the case with regard to the patients upper abdomen. A panniculectomy would directly address the size of the lower abdominal pannus and likely correct the skin-to-skin overlap. This is not the case for the upper abdomen, as there is a lack of evidence of a significant overlap of the upper abdomen. Her abdominal pain may be related to her history of chronic rashes and open sores, the lower abdominal pannus, as well as the umbilical hernia but it is unlikely related to her upper abdominal excess. Thus, as the patient has a functional deficit related to chronic rashes and possible abdominal pain that would be addressed with lower abdominal panniculectomy, it is considered medically necessary. As the abdominoplasty would not likely address the patients functional deficit it should not be considered functional in nature or medically necessary. The American Society of Plastic Surgeons (ASPS) state that a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Further, an abdominoplasty is typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. Manahan and Shermak noted that, the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus for which panniculectomy may be indicated. All told, the requested panniculectomy satisfies the criteria for medical necessity whereas abdominoplasty does not. Final Result: The reviewer determined that a portion of the requested services 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 plastic 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 parent of an enrollee has requested Pulmicort Respules for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is a lack of documentation submitted for review establishing the medical necessity for Pulmicort Respules in this clinical setting. Nebulization provides a useful alternative mode for delivery of corticosteroids that are available as a nebulizing suspension (beclomethasone and budesonide) in situations where a metered dose inhaler (MDI) or dry powder inhaler (DPI) device may not be suitable. Situations where budesonide inhalation suspension (Pulmicort Respules) would prove useful include in children up to five years of age (approved up to eight years of age in the US), patients greater than five years of age who experience difficulty using MDIs or DPIs or patients of any age who cannot coordinate or activate a MDI or DPI because of dyspnea (Thorsson and Geller). In this case, there is a lack of documentation showing that a MDI or DPI device is not suitable for use, demonstration of a poor technique/coordination with MDI or DPI device, previous or current inability to use MDI or DPI device, or history of local side effects from use of MDI or DPI device. The patient has documentation of current use of the MDI device, Qvar. All told, Pulmicort Respules have not been established as medically necessary for treatment of the 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 pediatrics and allergy and immunology 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 Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center (RTC) services for treatment of his medical condition.  The records indicate that on the dates at issue, the patient was not a danger to himself or others. He had no coexisting medical conditions, he did not show aggression or violence, and he was compliant with his medication regimen. He was cooperative with staff and respectful. His social skills were no longer problematic and he no longer required one-to-one supervision and only received prompting for daily living skills. There was no evidence to suggest that returning the patient to the community would result in decompensation or exacerbation in his prior symptoms that would result in the need to continue RTC level of care. He had improved and no longer required 24-hour nursing or medical supervision; psychotherapy did not need to be delivered in the RTC setting. He could have been treated at a less restrictive level of care. Thus, the RTC services on the dates at issue were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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.