Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested open treatment of rib fractures requiring internal fixation for treatment of his rib fractures. Three physician reviewers found that the open treatment of rib fractures requiring internal fixation was likely to be more beneficial for treatment of the patients medical condition than available standard modalities. In this clinical setting, standard pain management was unsuccessful. Due to the patients uncontrolled pain, he underwent open treatment of rib fractures requiring internal fixation. With surgery, pain was controlled and pneumonia, the most frequent complication of rib fractures was avoided. In addition, the study by De Moya and colleagues confirms a significant reduction in the requirement for analgesia after surgical repair. In sum, the open treatment of rib fractures requiring internal fixation was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy given the patients uncontrolled pain, unstable chest wall, and worsening CT scan. Final Result: Three reviewers determined that the services at issue were 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: One reviewer is board certified in general and thoracic surgery with sub-specialty certification in vascular surgery and is actively practicing. Two reviewers are board certified in general and thoracic surgery 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 an office/outpatient visit (CPT code 99215) and office consultation with an orthopedic medical group (CPT code 99245) for treatment of his herniated disc.  The physician reviewer found that evidence based medical peer-reviewed literature supports surgical evaluation and treatment of lumbar disc herniation as well as pain management for treatment of epidural scarring. This patient presents status post L4-5 laminectomy and repeat laminectomy with persistent low back and radicular pain with significant myelopathy. There is current imaging evidence of a new disc herniation at the L5-S1 level with annular tear extending into the neural foramen and associated moderate neuroforaminal narrowing. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial, including epidural steroid injection, medication management, and physical therapy, and failure has been submitted. Current pain management is limited to medication management. The patient has requested a second spine surgery opinion and this is supported by the treating provider. Given the significant functional weakness and age of the patient, a second spine surgery opinion based on current imaging evidence is medically appropriate and reasonable at this time. Thus, the requested office/outpatient visit (CPT code 99215) and office consultation with an orthopedic medical group (CPT code 99245) is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 mental health residential treatment services for treatment of her behavioral health conditions.  The Physician Reviewer found that modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, harmonized relationships and mental wellness.  Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescents with anxiety and depression represents a challenging endeavor.  In this patients case, the record does not substantiate the need for residential programming.  The patient was struggling with the developmental stage of identity formation which was complicated by a formidable anxiety and affective burden coupled with an underdeveloped sense of self.  During the psychological assessment the provider indicated that the patient may benefit from a therapeutic program outside of the home environment.  This treatment plan was reasonable as the patient had recently discharged from the acute level of care for the third time in five months.  The residential wilderness program appeared to adequately address this need.  According to the psychosocial assessment, the patient had been without suicidal thoughts for the two months during the wilderness program and had made therapeutic progress.  Additionally, good self-control was listed as one of her strengths.  The records do not demonstrate that the patient and family had the opportunity to capitalize on the therapeutic momentum generated by the wilderness program in the community setting.  This is important as treatment outcomes are typically optimized in the community setting.  Additionally, the medical records from the residential facility do not describe any behaviors, symptomatologies, interventions or medication management that would require treatment in a 24-hour supervised setting, while the psychiatric notes did not include an integrated summary or justification for the necessity of the placement.  All told, mental health residential treatment services were not medically indicated for the treatment of this patient.  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 subspecialty 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 sacroiliac joint fusion for treatment of her sacroiliac joint pain.  Three physician reviewers found that SI joint fusion is not the standard of care for the treatment of degenerative back pain and SI joint disorders. In addition, the medical records submitted for review do not demonstrate that this patient has had SI joint trauma, tumor or infection. Fusion surgery for degenerative SI joint conditions has not been established in the medical literature and more long-term outcomes research is needed to establish the safety and efficacy of the procedure. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than conservative measures. 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 orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested stereotactic radiosurgery (SRS) for treatment of his cluster headaches.  Two physician reviewers found that the submitted records do not adequately define the patients headache syndrome. There is a lack of documentation of the duration, frequency and severity of the patients headaches. Additionally, the patients medication attempts are not well documented, as details regarding the dose, duration, combination of medications trialed and treatment response are not included in the submitted records. As such, it has not been established that the patient exhausted standard therapies prior to pursuing treatment with SRS. Given the lack of controlled studies supporting the safety and long term benefit of SRS for the management of cluster headaches, there is insufficient evidence demonstrating that SRS was likely to have been more beneficial for treatment of the patients medical condition than available standard therapies in this setting, which based upon the records provided, do not appear to have been exhausted.  Final Result:  Two reviewers determined that the services at issue were 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 neurology 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 Norco for treatment of her fibromyalgia. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Norco has not been established. According to the documentation submitted for review, the patient is requesting 1-2 tablets of Norco daily. Such narcotics and at the doses prescribed is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. Additionally, the dose of Norco poses a risk for acetaminophen toxicity. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Moreover, the medical literature reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. For the reasons provided, the patients request for Norco is not medically necessary. 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 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:  The parent of an enrollee has requested a magnetic resonance imaging (MRI) of the head/brain with constructive interference steady state (CISS) sequences and cerebrospinal fluid (CSF) flow through the aqueducts for evaluation of the enrollees possible aqueductal stenosis.  Findings:  The physician reviewer found that while this patient does not appear to have evidence of increased intracranial pressure based on a single static neuroimaging measurement, the growth and attainment of neurocognitive and motor milestones is largely dependent on the health of oligodendrocyte maturation/myelination during the first one to two years of postnatal life. A single head computed tomography (CT), while reassuring for no evidence of active hemorrhage, is inadequate to evaluate CSF flow dynamics, which in turn reflect the overall health of developing white matter. Thus, the requested MRI scan of the head/brain with CISS sequences and CSF flow through the aqueducts for further evaluation is medically necessary for evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatric 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested breast implant replacement surgery for treatment of breast implant deflation.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. Based on the entirety of the documentation submitted for review, the patient had original augmentation mammoplasty for aesthetic concerns, and has suffered known complications. There was no evidence that the initial surgery was performed for reconstructive reasons.  The patient is noted to have some functional compromise related to her implants, as she has pain. Although implant removal could be considered medically necessary, the request for breast implant replacement surgery is not medically necessary.  With regard to the whether the proposed breast implant replacement surgery meets reconstructive surgery criteria, the patient presents with a capsular contracture and a ruptured implant which can be considered an abnormal condition. There is some indication that the possible implant rupture may have been due to the previous imaging. However, this is not conclusive as the implant is not obviously ruptured on evaluation of the photographs. In addition, the requested surgery is not being performed to improve function or create a normal appearance to the extent possible. Implant replacement would not likely resolve the patients functional concern, but could lead to a recurrence of the condition. In addition, there is no evidence that the initial augmentation was performed for reconstructive reasons. The planned procedures are performed to correct previous aesthetic intervention. This implies a baseline relatively normal appearance. Thus, the corrective procedures are planned for returning to an improved appearance relative to normalcy. In addition, the photographs submitted for review show a relatively normal appearance. Finally, the proposed surgery may improve the appearance of the patient, but would tend towards improvement on normalcy. Therefore, the requested breast implant replacement surgery does not meet reconstructive surgery criteria.Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of his severe persistent asthma.  Two physician reviewers found that in this patients case, the requested services are likely to be more effective than other available treatment options. Based on the medical records submitted for review, the patient meets the criteria for severe persistent asthma. Bronchial thermoplasty is an accepted modality for reduction in exacerbations of severe persistent asthma. It has been shown to reduce hospitalizations, reduce emergency room (ER) visits and reduce exacerbations. Bronchial thermoplasty treatments also improve a patients quality of life and this patient would benefit from this procedure. Therefore, for the reasons provided above, the request for bronchial thermoplasty is likely to be more beneficial than other treatment alternatives in this patients case.  Final Result: Two reviewers determined that the requested services are 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: One reviewer is board certified in internal medicine and pulmonary disease and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: 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.  Two physician reviewers found that in this patients case, the services at issue were likely to have been superior over other modalities.  The technique has been associated with a significant decrease in callbacks and increased detection of small cancers when employed as part of the usual screening.  This improvement is based upon the unique tomographic capability of tomosynthesis.  All told, breast tomosynthesis was likely to have been more beneficial to the patient than digital mammography 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. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested a home birth with a certified professional midwife for medical treatment of her pregnancy.  Findings:  The physician reviewer found that the medical literature noted concern regarding the increased risk of neonatal death with home birth.  Per the current medical evidence, planned home birth is associated with a twofold to threefold increased risk of neonatal death as compared to planned hospital birth.  As noted by the medical literature, hospitals and birthing centers are the safest setting for births in the United States.  All told, the requested home birth with a certified professional midwife 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 obstetrics and gynecology 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 requested an inpatient hospital stay for treatment of the enrollees gastroenteritis, dehydration, acidosis, and hypoglycemia. Findings:  The physician reviewer found that, the patient was noted to have persistent emesis and diarrhea at the time of presentation. She was severely dehydrated on initial emergency department evaluation. According to the medical literature, severe dehydration and intractable vomiting are indications for hospital admission. Given that this patient had severe dehydration and persistent vomiting, inpatient therapy with intravenous and oral hydration was warranted. Current clinical practice guidelines suggest that discharge may be possible once sufficient rehydration has occurred, intravenous fluids are not required, oral intake equals or exceeds losses, medical follow-up is available, and adequate family teaching has occurred. In this case, the patient received intravenous fluid up until the day of discharge and was noted to continue to have significant stool losses. For these reasons, the inpatient hospital stay was medically necessary on the dates of service in question 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 pediatrics and pediatric critical 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.