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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the bilateral Orthovisc injection series into the knees. 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 and reported only short-term relief from other conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series into the knees were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for HALO ablation treatments. Findings:  The physician reviewer found that  current medical literature and guidelines support the use of radiofrequency ablation in Barretts esophagus with high-grade dysplasia and especially with low-grade dysplasia, confirmation of the presence of dysplasia by a second pathologist, or panel of pathologists is recommended. The American College of Gastroenterology (ACG) notes, Current evidence supports the importance of having all readings of dysplasia confirmed by a second pathologist with extensive experience in the interpretation of Barretts associated neoplasia. The ACG notes that diagnoses of both high-grade and low-grade dysplasia should first be confirmed by a second pathologist with expertise in gastrointestinal pathology and in Barretts esophagus. Belghazi and colleagues report that in cases of low-grade dysplasia confirmed by an expert pathologist, prophylactic ablation using radiofrequency ablation of the Barrett's segment has proven to significantly reduce risk of neoplastic progression. Regarding endoscopic eradication therapy for patients with Barretts esophagus-associated dysplasia and intramucosal cancer, the Standards of Practice Committee guidelines recommend continued surveillance biopsies even after ablation, as buried glands may persist and become dysplastic or neoplastic.  In this clinical setting, given that the records did not demonstrate a diagnosis of low-grade dysplasia established and confirmed by more than one pathologist, the services at issue were not medically necessary. Therefore, HALO ablation treatments were and are not medically necessary for the treatment of this patient.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 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: The patients parent has requested authorization and coverage for Nutropin-AQ NuSpin. Medical literatures report that idiopathic short stature (ISS), also called non-growth hormone-deficient short stature, is defined by a height standard deviation score (SDS) at or below -2.25 SD and associated with growth rates unlikely to permit attainment of adult height in the normal range. The authors note that the height cutoff of -2.25 SD corresponds in adults to 63 inches for North American men. In this case, the records did not document that the patients height was at or below -2.25 SD prior to initiation of growth hormone therapy. Given that the records document that the patient is likely to attain a height within the normal range for North American adult men and within two SDs of the mid-parental target height (MPTH) without further somatotropin therapy, the requested medication is not medically indicated.  Therefore, Nutropin-AQ NuSpin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 laser hair removal. Treatment of pilonidal sinuses can be challenging as there are multiple modalities and options with varying rates of success and support in the current medical literature. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of pilonidal disease  provide a comprehensive summary of many treatment modalities for pilonidal sinuses. In particular, elimination of hair from the gluteal cleft and surrounding skin by shaving or laser removal is given a weak recommendation based on low quality evidence, and the guidelines do not include evidence that one modality, laser removal, is better than the other, shaving. The guidelines give surgical excision, which is considered a standard treatment for chronic pilonidal sinuses, a stronger recommendation based on moderate quality evidence. In this case, the records document that the patient has already undergone surgical management of the pilonidal cyst. Given the weak nature of the evidence supporting laser hair removal for the treatment of pilonidal sinuses, the requested service is not medically indicated. Therefore, laser hair removal is not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the records document that a pilonidal sinus has already been surgically removed, and the requested laser hair removal is for the potential prevention of a recurrence of pilonidal sinus. In this case, hair growth is not an abnormal structure of the body. The requested service is not to improve function, to create a normal appearance, or provide more than a minimal improvement in the appearance of the patient. Accordingly, the requested laser hair removal is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device. Hara notes that patients with PFO should undergo evaluation by both a cardiologist and a neurologist. Messe and Brecker report that PFO closure may be indicated in certain patients with a history of prior stroke. In this case, the submitted records did not include a neurology evaluation, or of clinical or radiographic evidence of a prior stroke. Therefore, transcatheter closure of a PFO using a cardiac occlusion device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested transcatheter closure of a PFO using a cardiac occlusion device is 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 requested service is 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 internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for xanthelasma removal. Findings:  The physician reviewer found that records and photographs provided for review support that this patient presents with a recurrent xanthelasma, which is a collection of lipid deposits under the eyelid skin. As discussed by Laftah and Al-Niaimi, treatment options include topical trichloroacetic acid, liquid nitrogen cryotherapy, and lasers. The authors reported that surgical excision often yields excellent outcomes, but the incidence of recurrence is increased in patients who undergo incomplete excision. The authors concluded that surgical excision is the mainstay of treatment for xanthelasma lesions that involve the deep dermis or infiltrate the underlying muscle. In this patients case, the xanthelasma has failed to respond to treatment with hyfrecation and liquid nitrogen cryotherapy. Consistent with the recommendations in the medical literature, the requested surgical excision is likely to provide a more definitive treatment for this patient. Therefore, the requested xanthelasma removal is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Although benign, xanthelasma is an abnormal structure of the body. The records do not document a functional problem related to this patients xanthelasma. However, based on the available documentation and photographs, surgical excision would provide a more than minimal improvement in the patients appearance. Thus, the requested xanthelasma removal is reconstructive in nature for treatment of this patient. All told, the requested xanthelasma removal is medically necessary and reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasonic guidance for needle placement of the trigger point injections. There is no proven marginal benefit of trigger point injections into the soft tissues over placebo with respect to health, pain, or functional outcomes in the setting of any musculoskeletal condition, including neck and back pains attributed to myofascial pain or any other underlying etiology.  Dommerholt and colleagues report that most  studies investigating this intervention are inadequately blinded, and that without effective blinding and adequate blinding procedures, the specific effects of the intervention are called in question. The authors further note that while diagnostic testing, such as ultrasound, may be used to identify trigger points, in the clinical setting, palpatory examinations are more commonly performed, and that future studies should investigate if ultrasound is comparable to manual palpation. Trigger point injection therapy remains an empirical option for treatment of pain attributed to myofascial pain, and using ultrasound as an imaging modality to identify trigger points, or to guide dry needling or the administration of injections, is not proven to make this intervention efficacious. Quinter and colleagues report that there is no established difference in the sonographic appearance of trigger points versus normal muscle tissue. In this case, there is a lack of evidence that the service at issue would have been more beneficial than standard therapies for the patients conditions including exercise, independently applied modalities such as heat, and pharmacotherapy as needed. Therefore, ultrasonic guidance for needle placement of the trigger point injections was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the ultrasonic guidance for needle placement of the trigger point injections was not likely to have been 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 have been 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 physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for spinal injections. In a study of the effectiveness of lumbar facet joint blocks, Cohen and colleagues report that therapeutic facet injections appear to have little long-term utility, and multicenter randomized trials are needed to ascertain the best way to diagnose facet joint pain, confirm the efficacy of radiofrequency ablation, and determine which patients benefit most. The authors concluded  that facet blocks are not therapeutic and that higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Kwak and colleagues report that intraarticular lumbar facet joint corticosteroid injection treatment may be effective, regardless of facet joint osteoarthritis severity. The authors note that while intraarticular lumbar facet joint corticosteroid injections may be a useful clinical option for the management of facet joint osteoarthritis mediated low back pain, the present study was limited by its retrospective design and relatively small sample size, and that further studies are required on the long-term effects of intraarticular lumbar facet joint corticosteroid injection. The authors did not evaluate the long-term effects of intra-articular lumbar facet joint corticosteroid injections. In this case, the patient presented with constant, unchanged, and severe back pain that was described as stabbing and rated at an eight to ten out of ten on average. The patient reported increased pain with lying down, sitting, bending, twisting, and household chores. The patient had recently completed physical therapy with mild effect. An examination revealed severe tenderness at the lower lumbar spine L3-S1 and bilateral sciatic nerves, a moderately decreased lumbar range of motion, positive Kemps tests bilaterally, and intact strength, sensation, and reflexes. However, magnetic resonance imaging (MRI) did not provide detailed documentation regarding facet pathology. While the records noted that x-rays showed facet hypertrophy at L4-5 and L5-S1, formal x-ray reports were not provided for review despite being requested. Given the limited nature of published, large-scale, long-term peer-reviewed literature supporting the requested service as an effective and/or safe treatment for the noted pathology, the requested service is not medically indicated. Therefore, spinal injections are not medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 400 unit/5 mL vial. Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approves the use of Acthar Gel for the treatment of nephrotic syndrome. Madan and colleagues report that Acthar Gel may benefit patients with nephrotic syndrome who do not respond to or are unable to tolerate first-line therapies, and in patients with advanced disease. Hogan and colleagues report that Acthar Gel may be a viable treatment option for some patients with resistant nephrotic syndrome due to idiopathic FSGS. In this case, given that the patient has failed standard first-line agents and now has some deterioration of renal function, the requested medication is medically indicated. Therefore, Acthar Gel 400 unit/5 mL vial is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stretta radiofrequency ablation. Findings:  The physician reviewer found that review of the current medical literature and guidelines, Stretta radiofrequency ablation is not supported as likely to be more beneficial than any standard therapy for treatment of this patients gastroesophageal reflux disease (GERD) symptoms. A systematic review to evaluate the evidence on the efficacy of Stretta for the management of GERD did not show any benefit of Stretta over placebo or medical therapy (Lipka, et al.). A recent review on the available studies on Stretta concluded that, high-quality randomized trials are warranted to address the controversy generated by analysis of randomized trials of Stretta (Nabi, et al.). Furthermore, the current American College of Gastroenterology (ACG) guidelines for the treatment of GERD do not recommend Stretta in lieu of standard procedures (Katz, et al.). The ACG noted that, Because data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies. Given these findings, the requested Stretta radiofrequency ablation is 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 requested Stretta radiofrequency ablation is 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 requested services are 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.