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 aquatic rehabilitation physical therapy for treatment of the enrollee, who is diagnosed with juvenile osteochondrosis of tibia and fibula of both legs (Blounts disease). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. The patient had undergone surgery, and the recent clinical documentation did not identify that this patient would be unable to perform land based physical therapy to address any remaining deficits.  However, despite this patients ability to walk on her affected limb, with full range of motion and there was no tenderness at the osteotomy site, she had tenderness over the medial distal tibial physis. The patient was also showing signs of decreased endurance. The documentation supports that her disease is exacerbated by compressive forces. As such, the aquatic therapy would be reasonable to address her symptoms of pain during extended periods of ambulation. Peer reviewed literature has stated that it is important to identify treatment modalities to help mitigate the complications of surgery and care should be assessed for each individual patient. Therefore, after review of the clinical documentation and peer reviewed literature, aquatic rehabilitation physical therapy is medical necessary for the treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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 113 hours per month of one-on-one applied behavioral analysis (ABA) therapy, 14 hours per month of supervision and 12 hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 113 hours per month of one-on-one ABA therapy, 14 hours per month of supervision and 12 hours per month of parent training are medically necessary for treatment of the patients medical condition. In this case, the patient has made progress in many areas, but continues to have significantly problematic behaviors in the areas of self-injury, stereotyped repetitive behavior and elopement. His maladaptive behaviors makes it increasingly difficult for him to be successful in more generalized environments. Decreasing ABA therapy in the context of extreme self-injury is not to be in the best interest of the patient. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Given the clinical documentation provided for review and support in the peer-reviewed literature, 113 hours per month of one-on-one ABA therapy, 14 hours per month of supervision and 12 hours per month of parent training are medically necessary for treatment of the patients autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 reimbursement for digital breast tomosynthesis performed Findings:  The physician reviewer found that the patient who was asymptomatic with respect to her breasts.  On the date of dispute, the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted.  There was evidence of a nodule which was described as benign-appearing, stable and smooth.  Her breasts were heterogeneously dense. The Health Plan has denied reimbursement for the digital breast tomosynthesis portion of the examination on the date of dispute.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, the patients breast tissue was described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used on the date of dispute was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the service at issue was 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,& 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 reimbursement for digital breast tomosynthesis.  Findings:  Two physician reviewers found that according to a study, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prostate saturation biopsy performed.Findings:  The physician reviewer found that the patient  was found to have elevated prostate-specific antigen (PSA) and enlarged prostate.  Per the records, he was also noted to have abnormal 4K test.  The patient underwent prostate saturation biopsies under anesthesia.  Biopsy results revealed evidence of chronic prostatitis, but no malignancy was noted.  The Health Plan has denied reimbursement for prostate saturation biopsy performed  on the date of dispute.  Per the Health Plan, the services at issue were investigational for the evaluation of this patient.There is a lack of support for the services at issue in this clinical setting.  This patient had an increased risk of prostate cancer per screening test and underwent saturation biopsy. Currently, the recommended procedure is transrectal ultrasound with guided biopsy of suspicious areas and random 12 core biopsies.  Saturation biopsies are typically reserved for those patients with negative initial 12 core biopsies and persistent PSA elevation.  Saturation biopsies were not indicated as the initial diagnostic procedure.  In sum, prostate saturation biopsy performed on the date of dispute was not 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 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 & 3 are board certified in urology and are actively practicing. The reviewers are expert sin 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services provided on 8/15/16. Findings:  The physician reviewer found that the patient reported low back pain with movement. The patient was evaluated in urgent care without any diagnostic testing. A screening history was performed including vital signs, but there was no evidence that a physical exam was performed. The patient was felt to have musculoskeletal back pain. The patient was discharged home with recommendations for over-the-counter analgesics, stretching, and heating pad. The patients parent is requesting reimbursement for the urgent care services provided on 8/15/16. At issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided on 8/15/16 were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with low back pain with movement. According to Nigrovic Although back pain may be a sign of a more concerning problem, especially in children younger than 10 years, most episodes of back pain in children are not serious and resolve without treatment. In addition, the patient had normal vital signs and no diagnostic testing was performed. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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 reimbursement for the bilateral digital breast tomosynthesis. Findings:  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the bilateral digital breast tomosynthesis performed has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: the physician reviewers 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 reimbursement for digital breast tomosynthesis performed.Findings: The physician reviewer found that the patient who was asymptomatic with respect to her breasts.  However, the patient has a remote history of breast cancer.  On the date of dispute, the patient underwent a routine screening and surveillance mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Surgical clips were identified. Her breasts were described as primarily fatty withscattered fibroglandular elements.  The patient has requested reimbursement for the breast tomosynthesis portion of the examination but the Health Plan has denied reimbursement.  Per the Health Plan, digital breast tomosynthesis performed on the dated of dispute was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, on the basis of breast density, one could not justify the superior effectiveness of tomosynthesis. But in terms of surveillance in patients who have had breast cancer, studies have demonstrated that when digital breast tomosynthesis was applied in a study, screening sensitivity had improved. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. Moreover, a study allowed avoidance of unnecessary biopsy. Therefore, digital breast tomosynthesis performed on the date of dispute was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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 & 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 reimbursement for the digital breast tomosynthesis performed.  Findings:  The physician reviewer found that the patient is asymptomatic who underwent a screening mammogram including tomosynthesis. The exam revealed heterogeneously dense breast tissue. The patient has requested reimbursement for the digital breast tomosynthesis performed. The Health Plan has denied this request as investigational. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms especially in patients with dense breast tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D imaging only. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. This patient was diagnosed with multiple mental health concerns which affected her activities of daily living.  She was admitted to the RTC at a time when she was showing behaviors which were dangerous to herself and to others. Prior to RTC level of care, the patient tried and failed multiple different avenues of outpatient care and care at less restrictive levels. Her behaviors were escalating and had not abated with treatment at these less restrictive levels. While at the treatment facility, the patient started to respond positively to therapy and the structure of the program. Over time, she began to implement the lessons she was learning which allowed her to modify her own behaviors. She was learning to be successful at behavioral management, a discipline that was absent at the time of her admission at RTC. The submitted records indicate that this patient was benefitting from the structure of the program. As noted in the documentation provided, by the time of her graduation, her anxiety was well managed and controlled with current medications, Buspar in particular.  Her behavior had settled. She was no longer a danger to others and she was no longer exhibiting self-injurious behaviors. She was no longer pulling her hair out and she was calmer. She learned skills, including self-efficacy. The patient was subsequently able to establish positive relationships at home and with friends, though this was indicated to still be a bit of a struggle for her at the time of her discharge. The patient had reported that she was going to continue to work on maintaining positive relationships. As such, the records show that this patient benefited from RTC services. Therefore, the services at issue were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.