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 Monovisc injections for bilateral knees. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees bilateral knee osteoarthritis. At issue in this case is whether the requested Monovisc injections for the knees are medically necessary for treatment of the enrollees medical condition.Three separate clinical practice guidelines have found that viscosupplementation does not produce clinically significant improvement as compared to placebo injections. None of these practice guidelines support the continued use of viscosupplements. Therefore, the requested Monovisc injections are not medically necessary.Final Result: The reviewer determined that the requested treatment 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 subspecialty certification in pain management 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 authorization and coverage for Synvisc injection to the left knee. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. At issue in this case is whether the requested Synvisc injection to the left knee is medically necessary for treatment of the enrollees medical condition.Clinical practice guidelines from the Osteoarthritis Research Society International, American Academy of Orthopaedic Surgeons and American College of Rheumatology indicate that viscosupplementation does not produce clinically significant improvement as compared to placebo injections. None of these practice guidelines support the continued use of viscosupplements. Therefore the requested Synvisc injection is not medically necessary. Final Result: The reviewer determined that the requested treatment 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 subspecialty certification in pain management 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 authorization and coverage for Synvisc injections in the left knee, series of three. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee's arthritis.At issue in this case is whether the requested Synvisc injections in the left knee, series of three, are medically necessary for treatment of the enrollees medical condition.The American Academy of Orthopedic Surgeons clinical practice guidelines do not support the use of viscosupplementation, Literature suggests that the injection is no better than placebo injections and does not produce a clinically meaningful change.  Researchers conducted a systematic review and did not find convincing evidence to support the continued use of viscosupplementation injections. Therefore, the requested injections are not medically necessary. Final Result: The reviewer determined that the requested treatment 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 subspecialty certification in pain management 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 authorization and coverage for Synvisc One injections. The current medical evidence supports the requested services in this patients case. Per the records, he has benefited from prior Synvisc One injections. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Per the authors, its use results in improvement in knee pain and function that can persist for up to 26 weeks. The authors reported that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Synvisc One 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: An enrollee has requested authorization and coverage for Radicava (Edaravone Injection). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees amyotrophic lateral sclerosis (ALS). At issue in this case is whether the requested medication Radicava (Edaravone Injection) is medically necessary for treatment of the enrollees medical condition.Amyotrophic lateral sclerosis is a progressive neurological disease that causes degeneration of muscles and leads to weakness with significant morbidity and mortality. The characteristics of the disease have a combination of lower motor neurological problems with upper motor neurological problems. Survival is poor with a median time of three to five years. Edaravone works on free radicals. It seeks out free radicals and it is believed to reduce oxidative stress. Oxidative stress is believed to be a mechanism in the disease process of amyotrophic lateral sclerosis. A randomized trial of 206 patients with ALS (independent living, forced vital capacity (FVC) greater than seventy percent, and disease duration of three years) by colleagues showed no benefit with edaravone versus placebo. A post hoc analysis of that trial showed efficacy of edaravone in patients with definite or probable ALS, entry scores of 2 or more on all items of the revised ALS functional rating scale, FVC of at least 80 percent of baseline, and disease duration of two years or less. A subsequent controlled trial of 137 patients designed to replicate the subset in the post hoc analysis of the trial confirmed a smaller decline in function with patient receiving Edavarone. The noted benefit reached clinical significance with slowing of about thirty-three percent in the defined population above. Regarding the use of edavarone the data for slowing of disease progression is in patients with early ALS as defined by the trials above. The patients history of ALS for longer than 2 years, several functional scores less than 2, and forced vital capacity of 54 percent does not correspond with the successful clinical trial criteria. The successful clinical trial results were in patients with forced vital capacity of at least 80 percent and disease duration of two years or less. Evidence to support efficacy and improvement in outcomes in this patient who has more advanced disease than the patient population in the successful trials is limited.  Therefore, the requested Radicava medication is not medically necessary.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 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 authorization and coverage for orthotics. The Health Plan has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees metatarsalgia of the right foot. At issue in this case is whether the requested orthotics are medically necessary for treatment of the enrollees medical condition.Researchers concluded that manufacturing custom-made orthotics for metatarsalgia has been shown to produce good functional improvement, patients satisfaction and subjective ratings of improvement (pain, surface of the symptomatic area) after two years of usage. The progress notes advise that the patient demonstrates foot pain with a diagnosis of metatarsalgia and plantar fasciitis. Orthotics are the standard of care for the treatment of both plantar fasciitis and metatarsalgia. Orthotics correct biomechanical abnormalities, which cause both plantar fasciitis and metatarsalgia. Orthotics correct the malposition of the foot allowing for reduction in foot pain. Therefore, the requested orthotics are medically necessary to treat the enrollees medical condition.Final Result: The reviewer determined that the requested devices 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 podiatry 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 DecisionDx-Melanoma gene assayFindings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. DecisionDx-Melanoma gene assay is an analysis of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. Researchers reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients who had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data relates to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma gene assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene assay was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the breast. Findings: Three physician reviewers found that there is sufficient support for the services at issue in this patients case. While ultrasound may be beneficial for the evaluation of implant rupture, the utility of that technique is best for patients with saline implants. This patient has silicone implants which are difficult to evaluate with ultrasound due to the dense nature of the material. While ultrasound may have shown extravasated silicone, the possibility of intracapsular rupture would not have been addressed. MRI is the more definitive test in the evaluation of implant rupture and is more sensitive than other breast imaging techniques. Therefore, MRI of the breast was likely to have been more effective 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. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Foundation molecular panel testing. Findings:  Two of the three physician reviewers found Individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. The medical evidence supports the requested services in this clinical setting. In sum, Foundation molecular panel testing is likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan.Findings:  Two of the three physician reviewers found Imaging is utilized in the initial staging of ovarian malignancy, and accurate staging is essential in determining initial treatment. Positron emission tomography/computed tomography (PET/CT) can be used for complete staging of patients with ovarian cancer and can help determine the candidacy of patients for cytoreductive surgery, the standard initial treatment, as well as the need for adjuvant chemotherapy. For staging purposes, PET/CT has demonstrated higher accuracy than computed tomography (CT) alone in multiple studies. Per the records, this patient is a carrier of BRCA1 genetic mutation. The BRCA1 genetic mutation conveys increased risk of multiple malignancies, specifically ovarian, breast and primary peritoneal cancers. PET scanning was indicated in this case for staging purposes of the patients known ovarian cancer. In sum, PET scan 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. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of a 10-year-old male enrollee has requested authorization and coverage for an echocardiogram for treatment of the enrollees chest pain. Findings:  The physician reviewer found that At issue in this case is whether the requested echocardiogram is medically necessary for treatment of the enrollees medical condition.Per Hussain and colleagues, chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than 5% of cases. Most children have normal physical exam findings. Interventions depend upon etiology: bronchodilators for reactive airways disease, anti-reflux medications for gastroesophageal reflux, and non-steroidal anti-inflammatory medications for musculoskeletal pain. When cardiac cause is suspected, a reasonable evaluation would include comprehensive history and complete physical examination, selective laboratory studies including metabolic studies and indicators of cardiac stress, electrocardiogram, chest x-ray, and echocardiogram. In some cases, a period of cardiac monitoring may be indicated. Other patients may benefit from a Holter 24-hour monitor or an event monitor. In this patients case, he initially presented with chest pain that began during physical education class, and with subsequent onset of dry cough. He was evaluated multiple times by all pertinent specialists, with normal testing throughout and examination consistent with costochondritis. Ultimately he was also diagnosed with habit cough after completing a course of prednisone and azithromycin. There is nothing in his history or the submitted documentation that would indicate that an echocardiogram would add any additional useful information. Therefore, the echocardiogram is not medically necessary. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric critical care 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a high frequency chest wall oscillation air-pulse generator system. Findings: Two of the three physician reviewers found that the requested high frequency chest wall oscillation air-pulse generator system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient has very slow and low expiratory volume (likely due to his COPD) for devices such as flutter valve to make a difference, and chest percussion and postural drainage needs a helper, needs to be done frequently during the day, and is poorly tolerated by many. The patient has multiple medical problems and is a very poor candidate for postural drainage. It is also reported that he has no caregiver to provide that therapy. The patient has clearly retained mucous as demonstrated in repeated bronchoscopies. HFCWO devices have the great advantage that they do not require the active participation of the patient to clear airways as opposed to positive expiratory pressure devices, nor do they require a trained adult at home. Due to the patients age, medical conditions, and a home situation that does not have a caregiver who can assist with chest percussion and postural drainage, the use of a high frequency chest wall oscillation device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in pulmonary disease, and all three 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.