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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a LeFort 1 osteotomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The patient has a maxillofacial skeletal deformity as demonstrated by both physical and imaging examinations.  The records document a malocclusion which cannot be corrected with orthodontics alone.  Functionally, she also has a subjective history of difficulty with mastication.  The requested surgery should result in improved musculoskeletal and dento-osseous relationship, as well as improved mastication and swallowing.  All told, the requested LeFort 1 osteotomy is medically indicated for the treatment of this patient. 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 oral and maxillofacial 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested gene testing (molecular profiling) for the evaluation her medical condition.  Findings:  Three physician reviewers found that according to the documentation submitted for review, relapse was not identified and the patient currently has no evidence of disease. The timing of the molecular profiling was premature without any evidence for disease relapse. Furthermore, if the patient had relapsed disease, profiling of tissue from years ago would not have helped direct targeted therapy of the relapse. In sum, the relapsed lymphoma tissue would have been the one to analyze since new mutations could have been accumulated since autologous hematopoietic stem cell transplant previously.  All told, the services at issue were not 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 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 reviewers are board certified in internal medicine with sub-specialty certification in medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment center services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that review of the submitted documentation reveals the patient met the American Society of Addiction Medicines (ASAM) criteria for treatment at the residential level of care (LOC).  In order to qualify for residential LOC, the patient had to only meet the criteria in two dimensions. This patient met them in three dimensions. The patient continued to exhibit symptoms of bipolar disorder, specifically his delusional thinking and his severe anxiety, produced at least a moderate level of interference to his recovery.  The patient still did not show that he would be able to take responsibility for his recovery.  Upon review of the submitted documentation, this patient would relapse in an outpatient setting. All told, the services at issue were medically necessary for treatment of this patients behavioral health conditions.  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: Experimental/Investigational
Decision: Upheld 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 the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer.  Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature.  Therefore, breast tomosynthesis was not likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two 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 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 has requested bariatric surgery for treatment of her medical condition. Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  Clinical notes do not document serious comorbid conditions such as hypertension, diabetes or sleep apnea.  The Health Plans requirement that this patient with a BMI of 36 have at least one significant obesity-related disease complication prior to approval of bariatric surgery is medically appropriate.  There is a lack of support for the requested services in this clinical setting.  All told, the requested bariatric surgery 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 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 a gastric bypass for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. Although this patient is morbidly obese and has failed dietary efforts, she does not meet criteria for the requested procedure for failure to document attendance to a weight loss program of at least three sessions per month for six months. In addition, she does not have documentation of six monthly physician supervised dietary efforts. For the reasons stated, the requested services are not medically necessary in this clinical setting. 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 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:  The parent of an enrollee has requested Zomig for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients medical condition. While all triptans, intranasally administered or perorally administered work through the same mechanism, it is quite possible the intranasal sumatriptan may work in some patients when the oral formulation does not. The key is to administer it early enough during the development of the headache.  Thus, intranasal Imitrex should be trialed first and if it fails for this patient, then other triptans may be considered. Given the above, Zomig has not been established as medically necessary for treatment of the patients medical condition. 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 neurology with special qualification in child 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an MRI of the cervical spine and an MRI of the lumbar spine for treatment of his medical condition.   Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedures. The patient can benefit from the anatomical studies of an MRI of the cervical spine and lumbosacral spine. The submitted clinical records document a history of neck pain with pain radiation into the upper extremities and low back pain with pain radiation into the lower extremity with previous MRI imaging of the cervical spine and the lumbar spine. The clinical records also document a change in the level of pain proximate to the request for repeat anatomical studies. Repeat studies are appropriate and indicated at this time in order to assess the extent of any incremental structural changes at the cervical spine and lumbosacral spine. Moreover, there is no documentation of any specific contraindications to MRI imaging such as ferromagnetic metal in the body or about the eyes or a pace maker. For these reasons, the requested procedures are medically necessary in the evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested procedures are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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 low back and cervical spine surgery for treatment of his medical condition. Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  Relative to the cervical spine, this patient reports continued severe neck pain radiating to the middle of his back with bilateral arm numbness and weakness.  He reported a history of non-specific surgery for these symptoms, without improvement. The most recent imaging of the cervical spine documented cervical cord compression and nerve root compromise. There is no documentation of current clinical findings or conservative treatment relative to the cervical spine. A recent electromyography/nerve conduction study did not evidence cervical radiculopathy, but did document findings consistent with carpal tunnel syndrome. A specific cervical surgery request, including the type of surgery and operative levels, was not documented in the available records. There is insufficient medical history and current clinical examination and recent imaging evidence in the available records to support the medical necessity of cervical spine surgery.  Relative to the lumbar spine, this patient presents with low back pain and bilateral lower extremity radiculopathy. Significant functional difficulty was reported in sitting, standing, walking, and activities of daily living. Neurologic examination documented dermatomal hypoesthesia and minimal myotomal weakness. There is imaging evidence of mild multilevel degenerative disc disease with no central canal stenosis and mild to moderate neural foraminal stenosis. There was right lateral recess stenosis. However, there are no clinical examination findings correlated with imaging at specific lumbar levels to support anterior fusion and positive decompression at these levels. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion.  Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Therefore, the requested low back surgery is not medically indicated for the treatment of this patient.  All told, the requested low back and cervical spine surgery are not medically necessary 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 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:  The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that it is difficult to differentiate autism and attention deficit hyperactivity disorder (ADHD). Many children with ADHD will have some difficulties with social interactions due to not paying attention and missing social cues. The in-Plan developmental-behavioral pediatrician separates these two symptoms and notes the impact of the language delays on all of his behaviors. The patient had a positive autism diagnostic observation schedule (ADOS) but that report did not take into account the significant impact of ADHD on eye contact and social awareness nor the impact of his language processing difficulties. In addition, there is some evidence in the medical literature that the ADOS is an imperfect evaluation tool (Zander, et al). The article by Zander and colleagues shows that the ADOS scores across settings were not always consistent and especially when there were co-occurring problems such as ADHD or language based problems. Given the entirety of the clinical documentation submitted, the most recent evaluation by the in-Plan developmental-behavioral pediatrician adequately fits the patients diagnosis of ADHD with no clinical signs of autism. As such, ABA therapy is not clinically indicated for this patient.  Final Result: Two reviewers 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: One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatric and is actively practicing. One reviewer is board certified in child neurology and is 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 BRCA1 and BRCA2 testing.  Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The guidelines supported previous BRCA testing for this patient due to her age at previous diagnosis of breast cancer.  Subsequently, when she was seen for genetic counseling, the provider noted that this mutation was still considered a variant of uncertain significance and therefore of unknown importance either for the patient or her family members.  It is not clear from this consultation why another round of BRCA testing would be important in clinical decision making.  The requested services would not assist in the decision as to whether to continue her current medication, and she has already had surgery.  All told, BRCA1 and BRCA2 testing is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that 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 internal medicine with sub-specialty certification in medical oncology 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: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography.  In addition, any mass could possibly be better characterized with tomosynthesis. Given the reasons above,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation of uterine fibroids for treatment of her medical condition. Findings: Two physician reviewers found that the submitted medical records do not demonstrate the superior effectiveness of the requested services.  Options for minimally invasive alternatives for the treatment of uterine fibroids include myomectomy and uterine artery embolization.  The Acessa device is a new minimally invasive treatment for uterine fibroids that uses radiofrequency energy to destroy fibroid tissue.  However, this treatment has not been thoroughly evaluated for long-term clinical efficacy in a randomized study. There is a lack of peer-reviewed studies in the medical literature that evaluate the fertility outcomes of patients undergoing this procedure. It is not considered standard of care in this clinical setting.  Thus, the requested radiofrequency ablation of uterine fibroids has not been established as more effective than other treatment alternatives.  Final Result: Two 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 physician reviewers are board certified in obstetrics and gynecology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested ambulance services on an emergent or urgent basis for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought ambulance transport on the date in question. In this case, the patients parent called 911 due to nausea, vomiting and the patient becoming unresponsive. Most likely the patient had a vasovagal (neurocardiogenic) syncope and recovered spontaneously prior to EMS arrival. In addition, the patient had already been treated for recent infectious illness and he developed the vomiting which had persisted for a protracted period of time. In this clinical scenario, it is an appropriate parental concern for possible dehydration, electrolyte imbalances, and other serious conditions which may be manifested by an alteration in the level of consciousness. Thus, the patients symptoms were of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did meet prudent layperson criteria for ambulance transport.  Result:  The reviewer found that the patients symptoms met prudent layperson criteria for ambulance transport services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in emergency medicine and is actively practicing.   The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.