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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested breath hydrogen or methane test for evaluation of the enrollees dyspepsia.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patients symptoms and medical work-up are reassuring for the absence of an inflammatory, progressive, or life-threatening condition.  The medical records suggest a functional condition akin to irritable bowel syndrome (IBS).  While small intestinal bacterial overgrowth (SIBO) may exacerbate symptoms of IBS, lactulose breath testing is not a reliable means of determining whether SIBO is present or whether treatment of SIBO is liable to lead to symptom improvement.  There is a lack of standardization for interpretation of breath tests, with inconsistent criteria for which breath hydrogen and methane parameters constitute a positive result.  Additionally, there is a lack of correlation between breath hydrogen or methane production on testing and the presence of abdominal pain and IBS phenotype.  In sum, there is a lack of support for the requested services in this clinical setting.  All told, the requested breath hydrogen or methane test is not medically indicated for the evaluation of this patient.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 reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested substance use disorder residential treatment for treatment of the enrollees substance use disorder and depression. Findings: The physician reviewer found that the records provided for review document that this patient was not at risk for withdrawals and showed no post-acute withdrawal symptoms. The patient was not a danger to herself or others and she was psychiatrically stable. Her Addisons disease did not require monitoring at the residential level of care. The patient was highly motivated and engaged in treatment. The patient was future oriented as demonstrated by her level of aftercare planning of activities to prevent relapse. She was aware of her triggers and developed insight and coping mechanisms. Her living environment was stable and she had a sober support system in her 12 step group. The patient showed good progress and no longer required treatment in a 24-hour residential setting. All told, the substance abuse residential treatment center services were not medically necessary for treatment of this patients substance use disorder.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) for evaluation of the enrollees right knee pain.  Findings: The physician reviewer found that the patient has been evaluated with two MRI exams and arthroscopy. The arthroscopy revealed degenerative changes and a stable root tear of the medical meniscus, which the provider noted is not amenable to arthroscopic repair. The patient has been told she does not need a follow-up MRI exam by the provider and there are no red flags to support an indication for follow-up imaging. All told, the requested MRI for further evaluation of this patients right knee pain is not supported as medically necessary.Final Result: The reviewer determined that the requested diagnostic procedure 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: 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 enrollee, who was asymptomatic. Findings: Two physician reviewers found that the current medical evidence supports the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested gene testing for evaluation of the enrollee, who has been diagnosed with attention deficit/hyperactivity disorder.  Findings: Three physician reviewers found that the submitted records do not demonstrate the superior effectiveness of the services at issue.  Specifically, the standard of care of attempting a second stimulant medication would have provided similar outcomes compared to gene testing results in this case.  Given that he had only attempted two medications prior to the testing, and only one was a stimulant, there is a lack of clinical justification based on substantial medical research to endorse genetic screening tests prior to attempting another medication for attention deficit/hyperactivity disorder.  Thus, gene testing was not likely to have been more efficacious than other methods of evaluating this patient.Final Result: Three 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: All three physician reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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 Harvoni 90-400 mg tablets for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested 12 week course of Harvoni 90-400 mg tablets is supported as medically necessary for the treatment of this patients hepatitis C infection.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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Two physician reviewers found that the submitted documentation supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.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 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 authorization and coverage for a portable oxygen and oxygen conserving device for treatment of the enrollees chronic obstructive pulmonary disease (COPD). Findings:  The physician reviewer found that the accepted criteria for oxygen therapy according to the Centers for Medicare and Medicaid Services (CMS), includes a partial pressure of oxygen (pO2) of 55 or lower, an oxygen saturation of 88% or lower, a pO2 in blood of 56-59, or an oxygen saturation of 89% and congestive heart failure (CHF), pulmonary hypertension, pulmonary heart disease, or a hematocrit greater than 56%. A pO2 of 60 or an oxygen saturation of 90% does not support an indication for oxygen. The providers notes reveal that this patient already has a home oxygen system and a portable system. The only oxygen saturation measurements were 94% and 95% on room air during office visits. These findings do not meet the CMS criteria for oxygen. Thus, the requested portable oxygen and oxygen conserving device are not medically necessary for treatment of this patients COPD. Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in pulmonary disease 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 coverage of Oasis, a special wound product for treatment of the enrollees post-surgical back wounds.  Findings: Two physician reviewers found that chronic wounds can remain unhealed after three or more months of treatment in 40-60% of patients. The molecular environment of chronic wounds exhibits numerous changes that impede healing. High levels of inflammatory cytokines are associated with chronic inflammation, and high levels of matrix metalloproteinases (MMPs) degrade extracellular matrix (ECM). Degradation of the ECM interferes with the dynamic and reciprocal cell-ECM interactions that are essential in every step of wound healing. Oasis is an intact matrix naturally derived from porcine small intestinal submucosa (SIS). SIS has been applied to chronic wounds in an attempt to address the ECM deficits and stimulate the cell-ECM interactions that are necessary for healing to occur. In randomized, controlled trials, SIS has been found to significantly increase the percentage of wounds healed and the healing rate compared to standard of care alone. As a naturally-occurring ECM, Oasis supports the adherence, proliferation, migration, and differentiation of numerous cell types. The bioactivity of Oasis includes releasing growth factors, minimizing the destructive activity of MMPs, and induces angiogenesis to support new blood vessels in growth. Oasis is biodegradable and can be well incorporated into tissue. Based on these considerations, treatment of this patient with the special wound product Oasis, was likely to be more beneficial than any available standard therapies for treatment of this patients chronic wounds.Final Result: Two reviewers determined that the device at issue was 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 certified in dermatology 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 authorization and coverage for speech therapy at the frequency of three times per week (30 minute sessions) for treatment of the enrollees pragmatic language disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested therapy. Speech therapy focusing on pragmatic language skills was effective for school aged children with ASD to provide improvements in social interactions. Speech therapy and social skills groups were both effective for addressing the pragmatic language problems. Evaluating pragmatic language skills is more difficult than evaluating other language disorders. The in-Plan evaluation which utilized OWLS-2 is adequate for detecting expressive language or receptive language disorders, but not pragmatic language problems. The in-Plan evaluation did not adequately assess the more subtle pragmatic language problems found in children with ASD. The out-of-Plan speech and language evaluation found the patient to have significant difficulty with both narrative comprehension and oral narration, language processing and pragmatic language challenges. Based on the documentation submitted for review, speech therapy is medically necessary to treat the patients pragmatic language disorder. For the reasons stated, speech therapy at the frequency of three times per week (30 minute sessions) are medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapy 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 developmental and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Ritalin 300 mg a day (10 mg, 6 pills 5 times a day) for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that there is a lack of evidence based, peer reviewed literature to support the requested Ritalin 300 mg a day (10 mg, 6 pills 5 times a day) for the treatment of this patient. There is no true pharmacological precedent to support the use of amphetamines, high dose or otherwise, as antidepressants with sustained response over time. More evidently, doses of this nature have been associated with cardiovascular and cerebrovascular risk as well as tachyphylaxis. Moreover, the submitted documentation does not show that this patient has tried and failed all other conventional methods of treatments. The options of bupropion and modafinil were discussed with the treating provider in July 2016, but the patient was against trying these new medications. Therefore, given the lack of support in the medical literature and based on standard guidelines, the requested Ritalin 300 mg a day (10 mg, 6 pills 5 times a day) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The 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: 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. The Health Plan has denied digital breast tomosynthesis as investigational/experimental for evaluation of the patient. Findings: Three physician reviewers found that the patient had a digital breast tomosynthesis performed as part of her routine screening mammography.  The patient's status is post lumpectomy of the right breast along with radiation and chemotherapy in 2006. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The digital breast tomosynthesis was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening.Final Result: Three 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 physician reviewers are 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: An enrollee has requested authorization and coverage for neurofeedback three times per week, eye movement desensitization and reprocessing (EMDR) twice per week and one on one psychiatric therapy for treatment of the enrollees brain injury. Findings:  The physician reviewer found that The use of neurofeedback and EMDR are beneficial and medically appropriate in patients who have a history of neurological and psychiatric complications. There is notable evidence in the literature which suggests that neurofeedback and EMDR are effective for treatment of patients who are diagnosed with PTSD. Moreover, neurofeedback and EMDR are an appropriate non-invasive alternative for treatment of a wide range of neuropsychiatric disorders.  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 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.