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 inpatient hospitalization for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  According to article researchers regarding care of postoperative cystic fibrosis (CF) patients Postoperative pain management is critically important in the CF patient population. Pain control is especially important in patients with CF to encourage coughing, deep breathing, and minimize pulmonary complications. Patients should have early access to chest physical therapy and early activity and mobilization as well. Patients requiring home oxygen or noninvasive positive pressure ventilation, such as [bilevel positive airway pressure] (BiPAP), must be monitored carefully postoperatively for respiratory failure as evidenced by increased work of breathing, retention of carbon dioxide, and hypoxemia. Patients requiring BiPAP should have immediate access to their equipment. Patients with moderate to severe pulmonary disease should be admitted for overnight monitoring of their recovery from surgery and anesthesia. This patient has extenuating circumstances that requires a higher level of care. The patient has a cardiac condition that puts him at additional risk from anesthesia during the procedure and following the procedure from pain medication. Pain medication, especially given through IV can suppress the patients respiratory drive and cough and exacerbate his pulmonary condition. All told, inpatient hospitalization was medically necessary in this clinical setting.  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 cardiology 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 anastrozole for treatment of his medical condition. Findings:  The physician reviewer found that anastrozole is an inhibitor of the conversion of testosterone to estradiol; as such, it has been used to improve testosterone levels in cases in which the testosterone/estradiol ratio is decreased. Researchers reported that treatment with anastrozole led to normalization of the patient's testosterone, luteinizing hormone and follicle-stimulating hormone levels, suppression of serum estradiol levels and normalization of spermatogenesis and fertility. A study indicates `Some men with severely defective sperm production commonly have excess aromatase activity, reflected by low serum testosterone and relatively elevated estradiol levels. Aromatase inhibitors can increase endogenous testosterone production and serum testosterone levels. Further, a study reported that patients who receive testosterone therapy may find that the effect of testosterone lasts longer when an aromatase inhibitor is administered. While the proposed use of anastrozole is considered off-label in this setting, the above cited evidence is sufficient to support the use of this medication to help with the patients testosterone/estrogen ratio. As such, the requested anastrozole is medically necessary for treatment of the patients medical condition.  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 endocrinology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent basis or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a foot injury that was sustained a significant time period earlier.  Although the patient rated his pain above average, there was no history of a break in the skin or puncture wound. In addition, there were no signs of inflammation or possible infection. There was no sign of vascular or nerve injury. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with foot injury with delayed presentation. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment for treatment of her behavioral health condition.  Findings:  The physician reviewer found that residential treatment was medically necessary for treatment of the patients medical condition. According to the medical literature, Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Based on the longitudinal history and medical documentation, the patient likely would have relapsed and required re-admission in the absence of residential programming. Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically necessary for treatment of the patients behavioral health 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment program services for treatment of his behavioral health condition.   Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. At the time of admission, the patient was not in active withdrawals and his symptoms were mild at best. He was medically and psychiatrically stable. He was not cognitively or physically impaired. Moreover, his medication management did not require residential level of care. He demonstrated motivation and was an active participant. Although his sober support system was not a strong one and he was at risk for relapse, this in and of itself is not a reason to keep a patient at a higher level of care in the absence of  unstable psychiatric illness or the potential for harm to self or others. In sum, the patients treatment could have been provided at a lower level of care along with community support such as a 12-step group with a sponsor. Thus, the patient does not require 24 hour supervision at the residential level of care.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested liver elastography for evaluation of her hepatitis C.  Findings:  Three physician reviewers found that the liver elastography performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Elastography is widely-accepted as a community-recognized non-invasive test of choice when liver biopsy is undesired. The technique demonstrates greater accuracy, sensitivity, and specificity for predicting and discriminating minimal or no fibrosis from extensive fibrosis, as well as in correlating treatment response in patients such as in this case with chronic hepatitis C infection. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgery to remove an ovarian cyst for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has had a stable presumed ovarian cyst for many years.  It is unilocular, and she has a low CA-125, making the likelihood of ovarian cancer very low.  She has some pain, but has other potential etiologies for abdominal pain including adhesions and chronic narcotic analgesic use, which can cause bowel motility disorders and chronic pain.  This patient is very high risk to undergo surgery, as the records document obesity, asthma and known extensive abdominal adhesions.  Given the stability of the cyst, the benign nature of the ultrasound findings, and the co-existing medical problems that make her very high risk for surgery, the requested surgery to remove an ovarian cyst 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:   An enrollee has requested Botox injections for treatment of his medical condition.  Findings:  The physician reviewer found that the patient has a history of bruxism and migraines.  The records noted that at baseline there was constant daily pain in the head and jaw.  Botox treatments have been noted to result in subsiding of disabling headaches and muscle spasms, and the patients quality of life has been improved.  He has failed numerous prior treatments, including medications, physical therapy, oral appliances, and biofeedback.  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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested peroral endoscopic myotomy (POEM) for treatment of her medical condition.  Findings:  Three physician reviewers found that pneumatic dilation has been proposed for treating spastic disorders, and some success has been reported.  A caveat to this success is that it is unclear whether or not the patients benefited by pneumatic dilation would not be more properly categorized as having spastic achalasia or achalasia with esophageal compression, emphasizing the need for accurate manometric classification.  Researchers observed that pneumatic dilation was associated with a lower treatment response in patients with spastic achalasia compared with patients with achalasia with esophageal compression.  Botulinum toxin injection is a pathophysiologically attractive approach to treating patients with spastic disorders, and therapeutic trials suggest it can reduce chest pain.  Recently, POEM has been introduced to treat achalasia and several cases have been reported of jackhammer esophagus successfully treated by extended POEM.  However, powered prospective data is lacking to determine the role of POEM in the management of patients with spastic disorders.  Thus, the requested services are not likely to be of greater benefit than other treatment options. 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 internal medicine with sub-specialty certification in gastroenterology 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 home speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that according to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, socialization, and behavior.  Specifically, speech sound disorder not only greatly reduces intelligibility, it has also been associated with later reading disability.  Speech sound disorders refer to any combination of difficulties that impact speech intelligibility, including perception, motor production, and phonological representation of speech sounds and segments.  Articulation disorders are those that impact the form of speech sounds and are associated with structural and motor-based problems.  Phonology disorders impact the way speech sounds function within a language. Treatment approaches have traditionally focused on either articulation or phonology.  Articulation approaches are typically selected if the problem is thought to be motor-based, and phonologic approaches tend to target specific sound error patterns.  The medical literature supports speech therapy intervention for young children with speech sound disorders.  This patient was receiving services through the school district prior to starting kindergarten.  The private school that he now attends has acknowledged his need for speech therapy, but is not able to provide it. Because of his family situation, he is unable to attend speech services outside of the home.  In the absence of school-based services and clinic based services, the means for this patient to receive the necessary intervention is through home-based services.  All told, the requested home speech therapy is medically indicated for the treatment of this patient. 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 pediatric critical care medicain 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 a computed tomography (CT) scan of the chest for evaluation of his medical condition. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  Previously, a CT scan revealed what was thought to be benign pulmonary nodules.  In a patient at high risk, the medical evidence supports routine follow-up CT scans at regular intervals.  This was recommended by the radiologist per the report at the time of the previous CT scan.  Thus, it is medically appropriate to obtain a CT scan of the chest at this time.  The records do not show that the patient was evaluated with regular CT scans over the period of time since the previous CT scan.  All told, the requested CT scan of the chest is medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the 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. This applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1 patients who have failed interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline 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. The guidelines also recommend Viekira Pak, although ribavirin needs to be used for genotype 1a and not genotype 1b. However, in this case, the laboratory testing could not differentiate. In addition, AASLD guidelines cite data showing decreased survival with delayed treatment. Treatment is required, and none has been approved.  For these reasons, the requested treatment with Harvoni 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.