Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services on an emergent basis or urgent basis for treatment of her medical condition.  Findings: The physician reviewer found that the review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention. Upon review of the submitted medical records, the patient presented with blunt head and chest trauma with multiple orthopedic fractures. She underwent several emergency orthopedic surgeries.  She was stabilized relative to her abdominal, chest, and head injuries in the ICU, and treated for a deep vein thrombosis. She subsequently underwent additional orthopedic surgeries.  The staged treatment of the patients leg, hip, and arm fractures is an extension of her emergency treatment to avoid serious impairment and dysfunction. The continuation of care with the initial orthopedic surgeons was indicated for optimal continuity of care in the setting of staged orthopedic trauma surgery without delay. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. 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 eye movement desensitization and reprocessing therapy for treatment of the enrollees post-traumatic stress disorder (PTSD) and pain disorder. Findings: The physician reviewer found that there is a lack of evidence to show that this patient had objective functional improvement from the eye movement desensitization and reprocessing (EMDR) versus cognitive behavioral therapy (CBT). At the time that she underwent EMDR, she was attending multiple group therapies and she was in individual therapy. In addition, the patients symptoms are not well delineated in the records provided for review. Some of the classic symptoms of post-traumatic stress disorder (PTSD) include hypervigilance, nightmares, and flashbacks, none of which are described in notes provided for review. Rather, she reports depression, anxiety, and anger. Based on these findings, there is a lack of medical necessity for the requested EMDR twice per week 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the enrollees breast cancer screening.  Findings: Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the examination had been performed using the two dimensional technique alone.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.Credentials/Qualifications: All three 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: The parent of an enrollee has requested pelvic floor physical therapy for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that Pelvic floor physical therapy has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Encopresis is a challenging condition to treat, especially in the pediatric population with behavioral issues. In addition, the identification of specific types of constipation is challenging in the pediatric population, as in this case, where a digital rectal exam was refused. In this clinical setting, empiric approaches for treatment become reasonable and appropriate. As such, pelvic floor training is both appropriate and likely to yield a positive outcome for treatment of the patients encopresis. Therefore, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in pediatric gastroenterology 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: An enrollee has requested reimbursement for residential treatment services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders.  This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes.  Notwithstanding, the patients alcohol use was central to her daily routine and contributed to her significant impairment across multiple domains of functionality.  The patient was not able to stay sober with Alcoholics Anonymous.  The patient had failed a course of psychiatric treatment in the outpatient setting.  The patient lived alone while the patient's residence approached inhabitability due to hoarding.  The patient had limited social supports.  The patient's past history of poor adherence suggested insufficient motivation.  In this clinical setting, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards.  Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. 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 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 residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation demonstrates that the patient was not at risk of severe withdrawal. The patient experienced post-acute withdrawal syndrome which was mild to moderate. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. He was not a danger to self or others.  Thus, treatment in a setting with 24-hour supervision, in the absence of unstable psychiatric illness or the potential for harm to self or others, was not medically necessary.  The patient could have been treated at a lower level of care in an ambulatory or outpatient setting. 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 authorization and coverage for chiropractic services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that This patient has received extensive chiropractic care, but he has not made significant improvement.  Despite continued frequent chiropractic visits, his pain levels do not improve and sometimes worsen.  There is a lack of evidence indicating that chiropractic treatment is helping the patient improve his condition.  This is a chronic injury, and chiropractic care is not considered active care.  There is a lack of further clinical improvement to be expected from ongoing therapy.  The records do not document objective functional improvement.  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 chiropractic care 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 a six-month-old enrollee has requested Nutramigen with Enflora LGG formula for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation supports the requested formula in this clinical setting. There are a variety of clinical syndromes and manifestations that would justify use of alternative formulas.  Syndromes such as enterocolitis, proctocolitis, and enteropathy, as well as severe atopic dermatitis, are all significant manifestations of cows milk protein allergy early in infancy.  The presentation may include vomiting, bloody diarrhea, abdominal distention, anemia, failure to thrive, eczema, and malabsorption.  Since cows milk sensitivity may be associated with sensitivity to soy, soy-based formulas are not indicated.  The literature supports the use of amino acid-derived formulas in severe cases. Casein hydrolysate formulas such as Nutramigen are medically indicated for cows milk protein allergy.  In sum, the requested Nutramigen with Enflora LGG formula is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested formula 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 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, breast tomosynthesis revealed an interval change when compared to prior studies. Areas of asymmetry are better evaluated with tomosynthesis than with conventional 2D mammography. As such, the tomosynthesis at issue was helpful for evaluation in this clinical setting. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested methadone and Fentanyl patches for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that in this clinical setting, the recommendation to taper the patients pain medications are well supported by the medical literature. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting (Raffa, et al).  Moreover, the submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. In addition, the submitted documentation does not indicate an optimization of all non-opioid medications (Mendlik and Uritsky). Rather, quite large doses of opioids are being used without a clear rationale for such a high dose despite research to show its dangers. In this patients case, tolerance has taken place since the start of the narcotics. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The addition of more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation. However, studies have shown that down regulation will transpire and then the patient is only back to where they started in terms of their pain perception. Patients are worse off since they now have a much higher opioid tolerance level. There is also the possibility of opioid induced hyperalgesia. Finally, the requested medications are not considered evidence based treatments for fibromyalgia. Physical exercise should be considered another treatment option over opioids. Therefore, the recommendation to taper the patients pain medications is medically appropriate.  For all these reasons, methadone 10 mg (up to 6 tablets as needed) and Fentanyl patches 100 mcg (2 patches every 48 hours) are not medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested medications 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc One injections for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity for the Synvisc One injections. The peer-reviewed medical literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with advanced osteoarthritis of both knees. She had failed to respond to other conservative treatment including anti-inflammatory medications, physical therapy, and activity modification. The patient had undergone prior viscosupplementation series with marked pain reduction and documented functional improvement. Pain had recurred and resulted in significant functional difficulty in walking. The patient was attempting to avoid or delay bilateral total knee replacement. Therefore, the Synvisc One injections were medically necessary for treatment of the 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 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for arthroscopic surgery for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Evidence-based medical guidelines and peer-reviewed literature support surgical management of femoroacetabular impingement when conservative treatment has failed and there is no evidence of severe osteoarthritis or cartilage degeneration.  In this case, the patient has failed over one year of comprehensive conservative treatment including physical therapy, chiropractic care, medications, and intraarticular steroid injections.  The patient has significant left hip pain and functional limitations.  There was clinical examination evidence of impingement.  X-rays findings are reported with Tonnis grade 1, an alpha angle of 86 degrees, and small lateral osteophytes on the femoral head consistent with a cam deformity.  Imaging demonstrated a labral tear, with no severe chondral damage.  In this patients case, there are clinical and imaging findings reflective of the symptomatic pathology and indications for the arthroscopic procedure requested.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings:  The physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: Two of three reviewers determined that the diagnostic procedure 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 number one, two, and three are board certified in diagnostic radiology and 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.