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

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient behavioral health services for treatment of his behavioral health condition. Findings:  The physician reviewer found that although inpatient care was initially indicated, the medical record does not support the medical necessity of continued inpatient level of care.  The nursing notes indicated that the patient remained symptomatic, but not distressed.  Although the patient remained symptomatic, the record demonstrates that the acute psychiatric syndrome which initially prompted the admission had resolved. There are no physician notes documenting acute symptomatology.  The physician noted the patient had improved and was tolerating medications well. In sum, the inpatient behavioral health 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 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi, Daklinza and ribavirin for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza with ribavirin for 12 weeks.  Per the guidelines, only interferon-eligible patients can be treated with Sovaldi, peg-interferon, and ribavirin.  This patient is interferon-ineligible due to a pre-existing medical condition.  For these reasons, the requested treatment with Sovaldi, Daklinza, and ribavirin is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are 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 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:  An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition. Findings: The physician reviewer found that an MRI is supported if additional imaging is necessary or internal derangement is suspected. The American College of Radiology imaging criteria for non-traumatic knee pain state that the initial imaging examination for non-traumatic knee pain is radiography. An MRI examination for non-traumatic knee pain is indicated when the pain is persistent and conventional radiographs are non-diagnostic or when additional information is necessary before instituting treatment. Therefore, in this patient, the MRI is medically necessary as adjunctive diagnostically and potentially to affect treatment.  Regarding the requested knee surgery, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for knee osteoarthritis generally recommend conservative treatment of osteoarthritis of the knee including weight loss for patients with body mass index greater than or equal to 25, self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engaging in physical activity consistent with national guidelines. The AAOS does not recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.  Peer-reviewed evidence based medical guidelines do not support arthroscopic surgical treatment of knee osteoarthritis and support knee joint replacement for select patients with severe osteoarthritis failing conservative treatment. This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness. However, the specific surgical procedure has not been identified in detail. Therefore, the requested right knee surgery is not considered medically necessary.  All told, the medical records demonstrate the medical necessity of an MRI for more definitive evaluation of this patients medical condition; but, the medical records do not support the medical necessity for knee surgery.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Specifically, an MRI of the right knee is medically necessary. Therefore, the Health Plans denial should be partially 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 placement in an acute inpatient rehabilitation facility for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a mobility deficit that is adequately ameliorated by an assistive device.  She does not show a need for occupational therapy or speech therapy.  She has a continued need for physical therapy, but at an outpatient or skilled nursing facility level of care.  The medical records do not document an indication for intensive multidisciplinary therapies in an acute rehabilitation facility.  All told, the requested placement in an acute inpatient rehabilitation facility is not medically indicated 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.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 inpatient hospitalization for treatment of his behavioral health condition.   Findings: The physician reviewer found that although inpatient care was initially indicated, the medical record does not support the medical necessity of subsequent inpatient hospitalization. The patient had a positive marital session; he was neither suicidal nor homicidal. The patient was tolerating his medications, one of which was reduced. The patient remained free of suicidal ideation and continued to improve. His affect was bright. His family was actively involved in his treatment. The patient was receptive to continuing his treatment in a less restrictive setting. In sum, the patient remained symptomatic and in need of ongoing specialty care. However, the record indicates that the acute psychiatric syndrome which prompted admission initially had resolved at this point and the services at issue were not medically necessary for treatment of the patients behavioral health 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 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 intensive outpatient program services for treatment of his behavioral health condition. Findings: The physician reviewers found that based on the submitted records, IOP level of care was not medically necessary. The patient was not a danger to himself or others; he was cognitively intact; he showed no violent tendencies; he was no longer psychotic; and he was not manic. Moreover, the records indicate that the patient was medically stable and capable of caring for his activities of daily activities.  For these reasons, the services at issue were not and are not medically necessary for the treatment of this patients medical condition.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 physician reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the hip and knee for evaluation of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. In this case, a trial of conservative management before obtaining the requested MRI of the knee is indicated. As discussed by Miller, An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films.  Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms.  Patients with persistent or recurrent unexplained pain after 3-6 weeks of conservative treatment may require an MRI and may require referral to an orthopedist as a next step in the evaluation. However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. In regards to MRI of the hip, the patient had a hip x-ray which demonstrated only mild acetabular spurring, which is typical for a patient his age. In addition, hip replacement is not indicated and delaying an MRI of the hip until after a trial of conservative treatment is in the patients best medical interest. Given the above, the requested services are not indicated for the evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy for treatment of the enrollees language delay. Findings: The physician reviewer found that the article by Law and colleagues speech therapy interventions are effective for articulation disorders and expressive language disorders.  The authors also noted improvements in mean length of utterance and in expressive language on standardized testing.  The review by the physician and colleagues recommends continuing to screen for speech and language delay in children under age 5.  The authors found that the PLS-4 was the gold standard in most articles.  However most of these studies used a cut off of more than 1.5 standard deviations below the mean or 25% to qualify for services.  This review again found that expressive language disorders improve with speech therapy while also improving quality of life.  The research supports, total language or expressive language, are better scores to look at when determining who qualifies for services.  This patient had a total language score that qualifies him for speech services.  In sum, the request for speech therapy is medically necessary.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 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that 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 (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this clinical setting, the patient has breasts that have been described as being extremely dense. 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. For the reasons provided above, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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:   All three reviewers are board certified in diagnostic radiology and 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Omega-3 Acid Ethyl Esters for treatment of his medical condition. Findings: The physician reviewer found that  Omega-3 Acid Ethyl Esters is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested services. Omega-3 fatty acids have been demonstrated in numerous studies to be of potential benefit in IgA nephropathy. In addition, the side effect profile is good and it is considered the standard of care in this clinical setting. In sum, the requested services to be utilized in the management of the patients medical condition are medically necessary given the support in the evidence based literature.  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 physician reviewer is board certified in internal medicine with sub-specialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient behavioral health services for treatment of her behavioral health condition. Findings: The physician reviewer found that although inpatient care was initially indicated, the medical record does not support the medical necessity of subsequent inpatient services. The patient was tolerating medications and medical therapy. Her vital signs were stable and she was not enduring any withdrawal symptoms. The patient's thought process and content were unremarkable. She had supportive family and was active in her treatment. She was assessed as being appropriate for an outpatient dialectical behavior therapy program with continuing ambulatory medical therapy. There was no physician note to review, but the nursing documentation was reassuring as was the psychiatric note.  In sum, the patient remained symptomatic and in need of ongoing specialty care. However, the record indicates that the acute psychiatric syndrome which prompted the initial admission had resolved. Thus, the services at issue were not medically necessary for treatment of the patients behavioral health 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 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 parent of an enrollee has requested a partial hospitalization program for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that per the submitted documentation, the patients condition was assessed using the Child and Adolescent Level of Care Utilization System (CALOCUS).  She was assessed in six different dimensions, ranging from risk of harm to acceptance and engagement of treatment.  In each dimension, she scored at a fairly low level of intervention, an indication that her risks of harm to self or to others were low. For these reasons, the partial hospitalization program services were not medically necessary in the treatment of this 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy for treatment of his medical condition.  Findings:  Three physician reviewers found that proton beam radiation therapy has been shown to be well suited to treat targets near critical structures, especially at the base of the skull. However, until proton beam radiation therapy is more fully developed and tested, it will be difficult to establish whether proton beam radiation therapy may be equivalent to photon intensity modulated radiation therapy (IMRT) in treating full head and neck cancer. At this time, further clinical data through prospective clinical trials are needed regarding cases in which the target is the primary volume located near critical structures. There are dosimetric advantages to using proton therapy over IMRT in many situations. However, in this clinical setting proton beam radiation therapy is not likely to be superior to IMRT outside of compelling dosimetric data. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any standard treatments.  Final Result: Three 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:   All three reviewers are board certified in radiation oncology and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested neuropsychological testing for evaluation of her medical condition. Findings: The physician reviewer found that the clinical standard in determining the need for neuropsychological testing is to perform in-office cognitive assessments such as the mini mental status exam and/or the MoCA. Scores that are low or borderline low would suggest that more detailed testing should be conducted. In this case, there is a lack of evidence showing that in-office testing has been conducted which would demonstrate the need for a neuropsychological testing. While neuropsychological testing should be done after traumatic head injuries, it is customary to do so within two to six months of the injury. In this case, years have elapsed since the patient suffered a traumatic head injury.   For the reasons provided above, the request for neuropsychological testing is not clinically indicated for this patient.  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 physician 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.