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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the initial treatment services could not have reasonably been conducted at a less restrictive setting because the patients prominent occupational, financial and parenting stressors had not resolved.  She remained symptomatic, documentation noted that she was making limited progress in her therapy groups, and was described as agitated, anxious and depressed in group.  The provider described the patient as dysphoric and anxious.  In sum, the patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting. Thereafter the patient made slow but steady progress.  The patient still struggled in the mornings and expressed her dislike of being alone; however, progress notes indicated that she felt better: she was more motivated; she had more energy; and her mood improved.  The records also reflect that her anxiety and OCD symptoms had decreased. At this time, she was sleeping better and her family had been involved in her treatment and was supportive. The records show that she was tolerating her medications well and had a modest dose reduction of one of her medications. Based on the documentation provided, discharge to a less restrictive setting at this point would have been safe, appropriate and consistent with good medical practice.  Upon review of the patients documentation, the patient initially benefitted from partial hospitalization program services.  However, partial hospitalization program services provided thereafter were no longer medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  Patients with cirrhosis are high priority for treatment.  This patient is ineligible for ribavirin due to his wifes pregnancy.  The U.S. Food and Drug Administration (FDA) approved prescribing information for ribavirin states that it is contraindicated in the male partners of women who are pregnant, and that extreme care must be taken to avoid pregnancy during therapy and for six months after completion of treatment.  Due to the severity of liver disease, the risk of decompensation of cirrhosis, and the high priority of cirrhotic patients for treatment, delay in treatment is against current guidelines.  The guidelines only recommend one therapy for cirrhotic treatment-naive, ribavirin-ineligible genotype 2 patients: Sovaldi/Daklinza for 16 weeks. For these reasons, Sovaldi and Daklinza are medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or to others.  She was medically stable.  She was cooperative and respectful.  There was no indication that returning her to her home environment would lead to decompensation.  The records do not demonstrate the need for structure of a 24-hour nature, and she could be managed at a lower level of care.  In sum, residential treatment was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested psychiatric intensive outpatient program services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that according to the documentation submitted for review, the patient continues to exhibit agitation and head banging behaviors. In addition, the patients medications are being actively adjusted. The patient has been responding positively overall to interventions, however these will likely need to be skills that are taught to the family to carry forward as the patient transitions to a lower level of care. The study by Vismara and colleagues provided a 12 week, 1 hour per week, individualized parent-child education program to toddlers newly diagnosed with autism. Parents learned to implement naturalistic therapeutic techniques from the Early Start Denver Model, which fuses developmental- and relationship-based approaches with Applied Behavior Analysis into their ongoing family routines and parent-child play activities. Results demonstrated that parents acquired the strategies by the fifth to sixth hour and children demonstrated sustained change and growth in social communication behaviors. Thus, there is support demonstrating that parents of autistic children who have been taught behavioral intervention skills results in lasting behavioral improvements in autistic children. Thus, continued psychiatric intensive outpatient program services are indicated. The time allows for the patient to transition to a lower level of care as he spends more time with family on a daily basis and the utilization of ABA skills at home with the patient.Final Result: The reviewers determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Revlimid for treatment of his medical condition. Findings: Three physician reviewers found that the current medical evidence supports the requested medication in this patients case.  In the study by Fowler and colleagues, 50 patients with follicular lymphoma were treated with Rituxan and Revlimid. Of the evaluable patients, 87% had a complete response and 11% had a partial response. Toxicity was quite manageable. Thus, this combination must be considered highly active.  The study by Leonard and colleagues also demonstrated good activity with this combination, even in those with prior therapy.  In sum, Revlimid is likely to be more effective than other treatment options.Final Result: Three reviewers determined that the requested medication 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 internal medicine with sub-specialty certification in medical oncology 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 lumbar spinal fusion for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. According to the documentation submitted for review, the patient does not have neurogenic claudication or radiculopathy resulting in significant functional impairment or severe/progressive symptoms of motor loss, neuroclaudication, or cauda equina syndrome. In addition, the standard of care requires a recent complete history and clinical exam prior to recommending any form of treatment. Moreover, lumbar fusion for chronic non-specific low back pain without radiculopathy is not indicated. Based on the clinical documentation provided, lumbar spinal fusion is not medically necessary for treatment of the 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 neurological 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 Ketamine in liquid nasal spray for treatment of his behavioral health condition.  Findings:  Three physician reviewers found that Ketamine is an N-methyl-D-aspartate (NMDA) antagonist that has shown promise for dramatic improvement for those suffering from depression. Despite its promise, and reported success in this case, the treatment remains controversial. First, Ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of bipolarity. There are many unknowns regarding the antidepressant effect of Ketamine, not to mention its risk of treatment-induced hypomania or full-blown mania for those with bipolar disorder. There is a lack of evidence-informed practice guidelines regarding pre-treatment screening and patient selection criteria, intra-treatment recommended observational metrics, dosing schedules and treatment duration, and post-treatment follow-up. Final Result: Three reviewers determined that the requested medication is 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 psychiatry 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.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural distortion, particularly in cases of extremely dense or heterogeneously dense tissue.  This advantage has been associated with a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis was likely of more benefit to this patient than had the exam been done with two-dimensional imaging alone.  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 reviewers are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient level of care for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  The patient continued to have agitated aggressive behavior as his meds continued to be readjusted and he was prepared for discharge.  Discharge planning was actively taking place as the patient awaited transfer to a lower level of care. The services at issue during the dates of service in dispute were for appropriate and safe discharge planning.  All told, inpatient level of care was medically indicated for the treatment of this patient.  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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: 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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.   It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been superior over other treatment options.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Afirma gene test for evaluation of her thyroid nodules.  Findings: Three physician reviewers found that, while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma Thyroid  FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, the Afirma gene test was likely to be more beneficial for the patient than any available standard therapy.  Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Otezla for treatment of her plaque psoriasis. Findings:  The physician reviewer found that this is a case of plaque psoriasis on 10% of the body to involve the elbows and nails per the medical records. The patients history is also complicated by hyperlipidemia on medication and heart disease. The records indicate that the patient has failed topical medications. Furthermore, the records also indicate that she has hand psoriasis in addition to the nails make injecting anti-TNF agents difficult and painful. The patient has tried the requested medication and has noted improvement.  As such, the request for Otezla is medically necessary. 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 certifications in rheumatology, allergy and immunology 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 shoe inserts for treatment of her plantar fasciitis.  Findings:  The physician reviewer found that per the submitted documentation, the prescribed custom orthotics (shoe inserts) to treat this patients heel pain are medically necessary. Custom tri-planar orthotics (shoe inserts) have been used to treat plantar fasciitis for many years. Studies have shown that the use of orthotics is considered one of the mainstays of plantar fasciitis treatment and the standard of care for this ailment. Medicare guidelines state that a device can be considered medically necessary if it is deemed to be safe and effective, appropriate for the patients condition, not mainly for the convenience of the physician or patient. The medical information enclosed in this case documents that the patient has been treated with over-the-counter orthotics, local steroid injections to symptomatic heel, stretching, and icing. In this clinical setting, the next course of treatment would be custom orthotics.  All told, the requested shoe inserts are medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested device 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 podiatry 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 tongue reduction surgery for treatment of his medical condition.   Findings:  Two physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health.  Continuous positive airway pressure (CPAP) therapy has demonstrated excellent efficacy and low morbidity.  There are also traditional upper airway surgical procedures which target the anatomic component of obstruction.  Per the medical evidence, adult patients with mild to severe obstructive sleep apnea can be successfully treated with submucosal radiofrequency tongue base ablation.  This patient had obstructive sleep apnea and cannot tolerate CPAP, the gold standard in the treatment of obstructive sleep apnea. He had an enlarged base of tongue.  Reduction of the base of tongue should improve his nighttime breathing and sleeping.  Therefore, tongue reduction surgery was likely to have been more effective than other treatment options.   Final Result: Two 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:   All three reviewers are board certified in otolaryngology 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.