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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral hyaluronan (Gel-Syn) injections. Findings:  The physician reviewer found that Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited.  In this case, the patient has a history of relief from prior injections of both knees lasting up to six months. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral hyaluronan (Gel-Syn) injections 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tramadol. Findings:  The physician reviewer found that On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The authors further note, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. Maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the records indicate that the patient was previously prescribed tramadol in 2019. Her diagnoses included chronic joint pain and fibromyalgia. The submitted records did not include documentation from the patients provider recommending or prescribing tramadol. There was also no evidence that the appropriate opioid compliance monitoring has taken place such as a check of the California Controlled Substances and Utilization Review Evaluation System (CURES) or evidence of a baseline urine drug screen. Therefore, Tramadol 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy services. Findings:  The physician reviewer found that Proton therapy can result in more conformal dose distribution with less low dose spillage versus standard three-dimensional conformal radiation therapy (3DCRT) or intensity modulated radiation therapy (IMRT). However, there is a paucity of studies directly comparing the health outcomes and risks associated with proton versus photon palliative radiation therapy. In this patients clinical setting, palliative radiation is routinely performed with photons via simple, 3DCRT, and IMRT techniques with excellent response. On review of this patients records, the recommended dose is well below the tolerance of adjacent normal tissue. Treatment with photons would not exceed the appropriate dose limits to the heart or spinal cord. Moreover, given the beam arrangement of the provided proton plan, there was no significant improvement in the spinal cord dose-volume-histogram plan versus the photon plan. In addition, the American College of Radiology (ACR) does not support treatment with proton beam therapy for this patients metastatic breast cancer (Lo, et al.). The authors noted that, The treatment of spinal bone metastases depends on histology, site of disease, extent of epidural disease, extent of metastases elsewhere, and neurologic status. On review of this patients clinical presentation, current medical literature and ACR guidelines, as well as the provided comparative planned dose-volume-histogram of photon versus protons do not support an indication for treatment with proton beam radiation in lieu of standard 3DCRT or IMRT. Therefore, the proton beam therapy services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for subcutaneous immunoglobulin (IVIG) therapy with Hizentra. Findings:  The physician reviewer found that In a recent review of patients with small fiber neuropathy, Basantsova and colleagues noted that small fiber neuropathy is a disease highlighted by severe burning pain, sometimes induced by skin stimulation, and/or sensory symptoms of numbness, allodynia, and burning pain in the limbs. On review of the records provided for review, this patient does have these reported clinical symptoms. Novak and colleagues reported that mast cell activation syndrome patients can have small fiber neuropathy symptoms on biopsy and testing. Moreover, treatment with IVIG remains controversial in this patients clinical setting. Pindi Sala and colleagues reported good long-term benefit with IVIG in the treatment of patients with Sjogrens syndrome related small fiber neuropathy. However, Geerts and colleagues reported on a double blind placebo controlled study of 60 patients with biopsy proven idiopathic small fiber neuropathy not associated with other auto-immune condition who were treated with IVIG. The authors concluded that the patients who were treated with IVIG showed no significant difference in outcomes from placebo. Moreover, the treatment of patients with idiopathic small fiber neuropathy with IVIG has not been demonstrated as effective in this patient population (Wilder-Smith and Spoendlin). This patients records do not support the presence of an autoimmune systemic disease diagnosis associated with her small fiber neuropathy. Therefore, the requested subcutaneous IVIG therapy with Hizentra 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 neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tolvaptan 30 mg tablets. Findings:  The physician reviewer found that Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is challenging to treat, requiring a strict intake of fluids and generally leading to recurrent hospitalizations and significant morbidity and mortality due to severe hyponatremia. Thajudeen, and Salahudeen report that antidiuretic hormone (ADH) receptor antagonists, especially tolvaptan appear to be an effective treatment strategy for hyponatremia. In this case, the patient has profound hyponatremia, which may have life threatening consequences and result in repeated hospitalizations. Given that current medical literature supports the use of tolvaptan as effective in this clinical setting, the requested medication is medically indicated. Therefore, tolvaptan 30 mg tablets 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 internal medicine with sub-specialty certification in nephrology 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 total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (CPT-22857), with posterior redo decompression left L4-5 and possible L5-S1. Findings:  The physician reviewer found that In this case, there are several concerns regarding the patient's condition. The patient has seen several physicians and there is not a consensus about her condition and the need for surgery. There is not a consensus about what the patients MRI testing shows, what her complaints are, or what her physical examinations have noted. The patient has a complex pain syndrome that is not made simpler by her complex regional pain syndrome and fibromyalgia. The patient's neuropsychological evaluation documented concerning, persistent psychiatric illness that could interfere with the outcome of her surgery . Moreover, the neuropsychologist specifically stated that traditional medical treatment will likely be unsuccessful in reducing the patients pain. Furthermore, the patient possesses several contraindications to the use of lumbar disc arthroplasty. The patient seems to have an isolated radiculopathy, or is at least felt to by her treatment surgeon. In addition, facet arthropathy is a contraindication to performance of arthroplasty, and the patients MRI reports mild facet disease, and the patients orthopedic surgeon reported significant facet arthropathy from L3-S1. In summary, lumbar disc arthroplasty remains a controversial procedure. The patient has seen several providers, and there is variability in their assessments. There are also some contraindications to spine surgery in general, and to lumbar disc arthroplasty specifically. Under these circumstances, the requested total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (CPT-22857), with posterior redo decompression left L4-5 and possible L5-S1 is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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 Orthovisc injections (J7324) in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has been treated with and failed medications and physical therapy. As noted in the current peer-reviewed medical literature, viscosupplementation can promote production of endogenous hyaluronic acid, thereby relieving the symptoms of osteoarthritis. As such, the Orthovisc injections (J7324) in both knees at issue were medically necessary to treat 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a knee scooter. Findings:  The physician reviewer found that Non-weightbearing restrictions are commonly employed for multiple weeks following hallux valgus repair to allow for proper healing with a stable alignment. Although non-weightbearing status can be challenging from a functional standpoint, but limitations can be mitigated by using various compensatory measures such as a walker. As noted in the medical literature, postoperative pain after hallux valgus repair can be addressed with various oral analgesics and local anesthetics. This patient underwent a left bunionectomy on 6/27/22. The patient reported pain and difficulty walking preoperatively and postoperatively. However, a specific functional history is not described in any significant detail in the available documentation. The records lack description of how the patient managed her mobility issues before surgery, or the patients plans for mobility after the surgery. There is no indication that the patient could not use a walker to safely manage her mobility-related activities of daily living. Moreover, the records do not adequately report that the patient has the ability to use a knee scooter. Furthermore, the providers notes do not include a recommendation for a knee scooter. All told, the requested knee scooter 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for orthopedic surgery consultation with a tertiary provider. Findings:  The physician reviewer found that This patients records document that he is being treated for Kienbocks disease on the right wrist. The patient presented to his provider with a right fifth finger injury and Kienbocks of the right wrist. Evaluation has included assessments by neurology and hand surgeon. The patient has requested a second opinion with another hand surgeon. Overall, the patients records do not support an indication for evaluation with a tertiary level of care orthopedic surgeon. There is a lack of detailed information regarding a right wrist physical examination by the patients primary care provider or that conservative management has been attempted. The evaluation and management of this patients complaints is within the expertise of the patients primary care provider. In addition, detailed documentation is not evident regarding significant pathology that would require a specialized provider at the tertiary level of care. The current evidence-based peer reviewed literature supports decision aids in the orthopedic management of patients, utilizing appropriate levels of care for initial evaluation and treatment. Anoushiravani and colleagues noted that as health care models shift from volume-based to value-based models, orthopedic surgeons must provide patients with highly reliable care, while consciously maintaining quality and providing timely interventions. Consistent with these recommendations, the patient does not meet the requirements for evaluation and treatment by an orthopedic surgeon at the tertiary level of care. Therefore, the requested orthopedic surgery consultation with a tertiary provider is not medically necessary for 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) (34 sessions). Findings:  The physician reviewer found that  The records provided for review document that this patient has a history of moderate major depression. The provider noted that the patient has not responded to treatment with multiple classes of antidepressants as well as psychotherapy. The patients provider has recommended treatment with TMS for treatment of the patients moderate major depressive disorder. For patients who have not responded to treatment with multiple classes of antidepressants, the chance of achieving remission from pharmacotherapy is low. In the medical literature, multiple studies have reported the safety and efficacy of repetitive TMS therapy for patients with moderate depression non-responsive to pharmacotherapy. Voight and colleagues evaluated six articles were graded high quality demonstrating that the repetitive TMS was clinically efficacious in patients after one medication trial. In addition, the authors noted that four additional trials of lower quality also reported a positive effect with repetitive TMS in patients after one medication trial. Moreover, the U.S. Food and Drug Administration (FDA) has approved repetitive TMS for patients who have not responded to at least one adequate antidepressant trial in the current depressive episode (Cohen, et al.; Somani and Kar). Given these findings, the requested TMS services (34 sessions) 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 in preventive 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.