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

Nature of Statutory Criteria/Case Summary: An enrollee has requested orthopedic surgeon for evaluation of the enrollees low back pain.  Findings: The physician reviewer found that this patient presents with a significant flare-up of his chronic low back pain. The patient has reported persistent severe left-sided low back pain radiating into the left leg with numbness. The patient has been evaluated with initial treatment by a physical therapist and a chiropractor without benefit. X-rays demonstrated degenerative disc disease at L2-3, L3-4 and L4-5. The patient was previously diagnosed and treated by an orthopedic surgeon for lumbar degenerative disc disease and radiculopathy with physical therapy, home exercise, and epidural steroid injection with benefit. The American College of Environmental and Occupational Medicine (ACOEM) guidelines recommend non-prescription medication or appropriately selected anti-inflammatory medications, activity modification, and use of heat/cryotherapies for initial treatment. Primary care providers can effectively manage low back problems conservatively. Strengthening and stabilization exercises are not recommended until acute low back pain has subsided. If symptoms persist without improvement, further evaluation is recommended. Given this patients history of chronic low back pain and failure of more than six weeks of self-care methods and initial physical medicine treatment, referral for an orthopedic consult is reasonable. Therefore, the requested referral to an orthopedic surgeon is medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested referral 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic testing for FH/Gene/Tier 2 analysis/hereditary leiomyomatosis and renal cell cancer (HLRCC) for evaluation of the enrollees risk for cancer. Findings: The physician reviewer found that this patient is at 50% risk of having inherited HLRCC as her father is known to have the condition. The family mutation is known to be N340K. As noted in the medical literature, HLRCC is a cancer predisposition syndrome. Patients with this condition are at risk for cutaneous leiomyomata, which are at risk for becoming leiomyosarcoma. Uterine leiomyomata are present in almost all females with HLRCC. These are also at risk for transformation to leiomyosarcoma. Renal cell carcinoma occurs in about 10%-16% of patients with HLRCC with a median age of detection at 44 years. Early diagnosis is important for those at risk for inheriting HLRCC. Genetic testing to determine if this patient has inherited the familial HLRCC will determine if further screening is necessary. Thus, single site genetic testing for the N340K mutation is medically necessary as patient is at 50% risk for having this mutation. However, full tier 2 testing is not medically necessary. Consistent with this finding, a portion of the testing at issue was medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that this portion of the testing at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in genetics 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 center (RTC) services for treatment of the enrollees anorexia nervosa. Findings: The physician reviewer found that based on the records provided for review, no aspect of this patients medication management, individual or group therapy required treatment at the RTC level of care, and all treatment goals could reasonably have been met at a less restrictive, less intrusive level of care, such as outpatient care. The documentation including the intake evaluations and multiple progress notes throughout the course of treatment document the patients mild symptoms and denial of any risk of harm to herself or others. In the psychiatric progress note dated is noted that her mood is super happy and she continues to have ongoing panic attacks twice since admission. The physician was detoxing from alcohol, benzodiazepines, and opiates after reportedly drinking a pint of whiskey daily for six months. She noted she had been clean and sober for 17 days prior to admission and had been prescribed Xanax. The patient was tearful during the initial evaluation and discussed that she is struggling with bulimia and anorexia and is a laxative abuser. No suicidal or homicidal ideas were reported and no psychosis was reported. The patient continued to have regular flashbacks and PTSD symptoms. The patient was started on prazosin 1 mg nightly, Effexor 112.5 mg daily, gabapentin 600 mg three times daily, Vistaril 100 mg as needed for anxiety three times daily, and trazodone 100 mg three tablets nightly as needed for insomnia. In a nursing progress report was noted she was alert and oriented. On that date, her mood was of five out of 10 and anxiety was eight out of 10. In the psychological addendum, it was noted that she was not having any negative behaviors and she remained positive and hopeful towards recovery. She was attending 12 step meetings, and continued to take trazodone 300 mg nightly for sleep. All told, the patient did not require the supervision, support, and treatment provided at the RTC level of care through discharge as she could have been safely and adequately treated in a less restrictive treatment setting. Thus, the RTC services provided were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Adderall extended release for treatment of the enrollees autism spectrum disorder, anxiety, and attention deficit/hyperactivity disorder (ADHD). Findings: The physician reviewer found that as noted in the medical literature, ADHD is a common developmental disorder. According to the American Academy of Child and Adolescent Psychiatry, up to 65% of children with ADHD will continue to have impairing symptoms into adulthood, and the condition commonly co-occurs with autism spectrum disorder. Per the American Psychiatric Association (APA), stimulants such as methylphenidate and amphetamine salts are the two major categories of pharmacological treatment for ADHD and are considered the first-line medication treatments for the disorder. The clinical effect of these medications is generated by neurotransmitter enhancement in the prefrontal cortex of the brain. Adderall XR is a psychostimulant medication composed of 50% immediate-release beads and 50% delayed-release beads designed to mimic the effects of two doses of immediate release Adderall given four hours apart. Adderall does not serve critical psychiatric functions such as treating depression, bipolarity, suicidality, aggression, anxiety, substance use, or psychosis. Adderall is a potent medication, which means it has the potential for abuse and can worsen anxiety. Further, Adderall is a positive ionotrope, which means it can make the heart pump harder and faster. In this case, there is evidence that the stimulant is contributing to hypertension and tachycardia. As such, a dose reduction is safe, appropriate and consistent with good medical practice. The patients provider offered a meeting to discuss an alternative medication, atomoxetine, which is approved by the United States Food and Drug Administration (FDA) for adult ADHD. Further, the patient has consulted with another provider for a second opinion. The risk of continued Adderall therapy at 40 mg daily outweighs the benefit considering the cardiovascular sequelae coupled with the availability of standard alternatives and reasonable access to specialty services. All told, the requested Adderall XR 40 mg is not supported as medically necessary for treatment of this 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 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: The parent of an enrollee has requested acupuncture for treatment of the enrollees abdominal pain. Findings: Two physician reviewers found that this patient has been referred for treatment with acupuncture to possibly help with abnormal gut sensations during feedings. According to the providers notes, this is the presumed reason the patient is uncomfortable during feeding, but this is not an indication for acupuncture. Acupuncture has not been demonstrated to improve patients in this clinical setting. Further, there is a lack of documentation that abnormal gut sensations are the cause of the patients pain. There is no indication in the medical records provided for review that standard testing has been performed to rule out other causes of pain. Thus, the requested acupuncture is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested service 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 physician reviewers are board certified in pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of implants is not an indication for tomosynthesis. However, the patients breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, 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. Therefore, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Mekinist and Tafinlar for treatment of the enrollees poorly differentiated adenocarcinoma with mixed neuroendocrine and acinar cell features.  Findings: Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested medications.  Mekinist is a new drug that has been approved for use in melanoma that has the BRAF V600E mutation.  It is often combined in such use with Tafinlar.  This combination is approved for use in BRAF V600E positive melanoma.  There have been studies of this combination or Mekinist alone, in other cancers that are also BRAF V600E mutation positive.  The results have been disappointing.  There is a lack of data available demonstrating usefulness of these drugs in pancreatic cancer.  It is becoming clear that a mutation alone does not select for efficacy; primary site plus the mutation appear to be important.  Thus, the presence of a BRAF mutation does not necessarily predict for response to Mekinist.  There is controversy as to whether at this point in time the results of molecular target analysis can be used to select therapy generally.  All told, Mekinist and Tafinlar are not likely to be of greater benefit than other treatment alternatives.Final Result: Two reviewers determined that the requested medications 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested one-on-one applied behavioral analysis (ABA) services for treatment of the enrollees autism.  Findings: The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. Mohammadzaheri and colleagues noted that ABA is helpful for school children with autism spectrum disorders for aggressive, disruptive and tantrum behaviors. In this case, the patient presents with maladaptive behaviors that include aggression, tantrum and self-injurious behaviors. Given the patients elevated safety issues, aggression and self-injury, a reduction in ABA hours is not indicated for this patient. Therefore, the ABA providers recommendation of the continuation of 40 hours per week of one-on-one ABA services is medically necessary for treatment of the patients autism spectrum disorder.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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage of digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, breast Tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) supervision services for treatment of the enrollees autism spectrum disorder. Findings: The physician reviewer found that the request for of ABA supervision services have been established as medically necessary for treatment of the patients autism. In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior and ABA services can be utilized to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism. Therefore, ABA therapy supervision services are medically necessary for treatment of the 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 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: The parent of an enrollee has requested applied behavioral analysis (ABA) direct services for treatment of the enrollees autism spectrum disorder.  Findings: The physician reviewer found that ABA therapy is medically indicated for children with autism spectrum disorders. In this case, the patient has received a high level of ABA services. However, he has not yet met his behavioral goals and he continues to have a high level of maladaptive behaviors. There is a lack of evidence provided that shows he has made enough progress to allow for a reduction in ABA hours. In addition, the patients maladaptive behaviors including aggression, non-compliance and vocal protest require a high level of ABA services. The ABA providers recommendation of 40 hours per week of ABA therapy and supervision are medically necessary in this clinical setting.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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for breast implant removal surgery on an emergent basis. Findings:  The physician reviewer found that there was no emergent medical condition noted in the records submitted for review. The patient presented with breast implants that were reported as too large and heavy and interfering with her daily function. However, the need for emergency surgical treatment is not supported by the medical records provided for review. The operative note does not describe an emergency medical condition. Moreover, there is insufficient evidence that autoimmune disorders are caused by silicone or saline implants. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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.