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 epidural injections for treatment of the enrollees moderate to advanced degenerative disc disease. Findings:  The physician reviewer found that the requested epidural injections are medically necessary for treatment of the patients medical condition. There is sufficient medical literature supporting the requested services in this clinical setting. In this case, the patient has documented degenerative disc disease on imaging. The patient has underwent an adequate trial of conservative therapy with a multi-disciplinary approach. Based on the clinical records submitted for review, there is adequate support for a trial of epidural steroids after a trial of conservative therapy. Therefore, the requested services are medically necessary for the treatment of the patients medical condition. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lactic acid dehydrogenase (LDH) isoenzyme blood test for evaluation of the enrollees stiffness and joint pain. Findings:  The physician reviewer found the request for LDH isoenzyme blood testing is not medically necessary for evaluation of the patients medical condition. According to the peer-reviewed evidenced based guidelines, LDH isoenzyme test is not a recommended serology in the evaluation and treatment of arthralgia and myalgia. Given the lack of support in the peer-reviewed literature, LDH isoenzyme testing is not supported as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested testing is 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 internal medicine with sub-specialty certification in rheumatology 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 enrollee has requested authorization and coverage for Nutropin AQ NuSpin 10 mg/2mL for treatment of the enrollee who has been diagnosed with idiopathic short stature. Findings:  The physician reviewer found that the documentation submitted supports the medical necessity for the requested medication in this clinical setting. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations (SD) below the mid-parental height percentile; growth velocity is less than 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency.  The submitted records indicate that this patient meets most of the above criteria. Recent predicted adult height is more than 2 SDs below the mean for adult females in the United States and below her genetic potential. Her height prediction of 55 inches qualifies for treatment of idiopathic short stature based on the U.S. Food and Drug criteria. As such, Nutropin AQ NuSpin 10 mg/2mL is medically necessary for the treatment of this patients medical condition. 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 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: Expedited Review Fulfills requirements of (1374.33) (h)(1)(D)The patient has requested authorization and coverage for physical therapy (including aqua therapy, acupuncture and epidural)for treatment of the enrollees medical condition. Findings:  The physician reviewer found that The records in this case propose diverse diagnoses including fibromyalgia, ankylosing spondylitis, and spondylolysis with pars defects. In addition, there is inadequate rationale for acupuncture or an epidural injection provided in the medical records and it is not clear if aquatic therapy is proposed as part of a long-term independent rehabilitation program. Most notably, the request is for physical therapy, but acupuncture and epidural injections are not considered forms of physical therapy. Overall, the records do not support a diagnosis for which specific treatment program be recommended without more detailed clinical information. Accordingly, the requested physical therapy (including aqua therapy, acupuncture and epidural) are not medically necessary for treatment of this patients medical condition. 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. 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: An enrollee has requested authorization and coverage for a breast ultrasound for evaluation of the enrollees breast cancer screening. Findings:  The physician reviewer found that the request for a breast ultrasound is not medically necessary for evaluation of the patients medical condition. Although screening ultrasonography may mildly increase the number of cancers detected, there are numbers of false positives that include suspicious findings which require further evaluation and possible biopsy that turn out to be benign. In general, the best modality to screen for breast cancer is a routine mammogram. It is optimal to compare like studies, and the patient has a long history of negative mammograms. While some patients experience discomfort with the pressure required with mammography, this is a manageable issue that can be managed by altering the degree of pressure, and by the addition of medications. Considering the lack of any palpable abnormalities and the lack of suspicious findings on the craniocaudal views, the requested breast ultrasound has not been established as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center level of care services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the substance abuse residential treatment center level of care services provided were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive or violent. The patient was cognitively intact and not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that support treatment at the residential level of care. The patient was medically and psychiatrically stable. The patients medication management was extremely uncomplicated and there were no changes. The records note that medication assisted treatment was discussed during the course of treatment. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in his treatment plan. Although the patient continued to struggle with his emotions and required further treatment to help develop and solidify coping skills, this did not require the structured environment of a residential setting and could have been stepped down to a lower level of care. As such, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for treatment of the enrollees osteoarthritis, left knee. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of Synvisc injections for the treatment of pain in patients with osteoarthritis of the knee. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses (total 20,049 patients) comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. This patient presents with worsening left knee pain with associated swelling and slight giving way. He was status post left knee arthroscopic partial medial meniscectomy. There was reported radiographic evidence of left knee medial compartment osteoarthritis, and operative findings of chondromalacia patella. The patient failed to improve with recent and prior corticosteroid injections and medications. Pain precluded participation in postoperative rehabilitation for functional restoration. Therefore, Synvisc injections are medically necessary for treatment of this patients left knee osteoarthritis. 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 lumbar spinal fusion for treatment of the enrollees moderate to severe two level stenosis at L2-4. Findings:  The physician reviewer found that The medical records document that the patient has spinal stenosis above the level recommended for fusion at the L2-4 levels. However, there is no spinal instability, fracture, or tumor present to support an indication for spinal fusion. The role of fusion, in the absence of a degenerative deformity, is uncertain. Thus, the requested lumbar spinal fusion is not medically necessary for treatment of his spinal stenosis. Final Result: The reviewer determined that the requested surgery 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 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 two acupuncture treatments per week for the first six weeks and one acupuncture a week for eighteen weeks. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested services in this clinical setting. The patient has many conditions that are commonly helped by acupuncture treatment. However, she has had an unknown total amount of acupuncture in the past with at least 11 sessions within the last year with no improvement in her condition. The request for thirty acupuncture treatments is not supported by medical evidence. Most studies for acupuncture recommend short term treatment.  For example, acupuncture is an effective short term treatment for patients with chronic neck pain, but there is limited evidence for long term effects. For chemotherapy-induced nausea and vomiting, results of 11 trials differed according to modality with acupressure appearing effective for first day nausea, electroacupuncture appearing effective for first day vomiting, and noninvasive electrostimulation appearing no more effective than placebo for any outcome. Also, studies show that acupuncture is not clinically significant than sham-acupuncture or placebo for neck pain. Studies for low back pain are generally limited to approximately 12 sessions over the course of eight weeks.  There is limited evidence for extended treatments over the course of approximately half a year. The patient has had short term treatment for her condition with at least 11 sessions in the past year. The records do not demonstrate that these treatments have provided improvements. As such, acupuncture treatment twice a week for six weeks and then once a week for 18 weeks are not medically necessary for treatment of this patients medical condition. 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. Credentials/Qualifications: The reviewer is board certified in oriental 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 Anser ADA testing for evaluation of the enrollees ulcerative colitis. Findings:  The 3 physician reviewers found that there is a lack of sufficient medical evidence to support the effectiveness of Anser ADA testing compared to conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels. In sum, there are a lack of controlled studies showing that use of these test results improve long-term health outcomes for patients with ulcerative colitis compared with conventional management.  As such, the Anser ADA testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary  A gender-neutral enrollee has requested a reimbursement for a reduction mammoplasty. Findings:  The physician reviewer found that A gender-neutral enrollee has requested a reimbursement for a reduction mammoplasty. The Health Plan has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees gender dysphoria and were not reconstructive in nature. There is support in the medical literature for the services at issue in this clinical setting. The patient had undergone bilateral breast reduction to reduce the female appearance of the breasts in order to treat gender dysphoria. The records support that this patient had evidence of breasts that were consistent with the female gender.  The patient does not identify as either male or female. Instead, the patient  identifies as gender-neutral. As such, a female appearance of the breasts would be considered an abnormal body structure for someone who identifies as gender neutral. Based on the documentation provided, this patient has gender dysphoria associated with adult female breasts.  The patients preoperative photographs are more consistent with the female gender.  Therefore, the reduction mammoplasty was medically necessary for treatment of this patients gender dysphoria.With regards to whether the services at issue were reconstructive in nature, this patients breast development constituted an abnormal body structure for someone who identifies as gender-neutral. The patients breasts should not be consistent with adult female breasts. As such, the patients breasts can be considered a developmental abnormality for a non-binary person. The patients breast development should be more consistent with an adult non-binary person. Based on the postoperative photographs, there was a significant breast reduction which was consistent with a nipple sparing mastectomy. Reduction mammoplasty is generally performed to improve function, but may also be done to approximate a more normal appearance. Although this case does not specifically address traditional indications for breast reduction, the reduction mammoplasty offered more than a minimal improvement in this patients appearance. For these reasons, the reduction mammoplasty performed was reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturnedCredentials/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.