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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested positron emission tomography (PET) scan for evaluation of her medical condition. Findings: Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The patient has had progression of disease while on intensive chemotherapy.  In general, liver metastases can be followed with sequential routine contrast enhanced CT scanning of the abdomen.  However, there is considerable variability in the best approach to diagnosing and following bone metastases.  Routine bone scintigraphy will often produce confusing results during therapy.  A lytic bone metastases might be relatively photopenic at the early stage, and after successful therapy, as the bone is reconstituting and osteoblastic activity develops, the scintigraphic findings might actually suggest worsening rather than improvement.  PET/CT scans offer the ability to image the entire body as opposed to routine CT scans which must be directed to specific body regions.  Considering that this patient has had multiple sequential PET/CT scans, the most efficacious method would be continuing to perform a PET scan for comparison.  In sum, the requested PET scan is likely to be more effective than other methods of evaluating this patient.Final Result: Two reviewers determined that the requested services are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested abdominoplasty for treatment of her medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The records document abdominal diastasis recti in the setting of an umbilical hernia.  The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty.  There is insufficient documentation from the treating providers to support a functional deficit directly related to the rectus diastasis.  Although there is some indication that muscle plication may affect intractable lower back pain, the current medical evidence suggests that nonoperative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication.  In this patients case, records from the treating providers do not document a functional deficit directly related to the diastasis recti.  All told, the requested abdominoplasty 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Synvisc injections for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. The evidence based literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with severe osteoarthritis of both knees. He has undergone two prior viscosupplementation series with positive results documented in terms of pain reduction, improved function, and reduced medication use. He is currently reporting progressively worsening and function-limiting knee pain. Therefore, the requested Synvisc injections 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 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: 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 the radiologist to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  This advantage has been especially useful in patients with extremely dense and heterogeneously dense tissue.  Therefore, the addition of breast tomosynthesis to the usual two-dimensional views was likely of more benefit for the patient than had the examination been done with two-dimensional technique 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the evaluation of her medical condition. Findings:  Three physician reviewers found that the ability to separate overlapping structures enables visualization of an occult tumor which might otherwise have been missed. While the lack of interval change when compared to prior mammograms is reassuring, tomosynthesis does offer the ability, in dense breasts, to better detect early recurrence. Given the above, 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 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 breast tomosynthesis for evaluation of her breast cancer screening. 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. In this particular patient, an abnormality was detected that warranted further imaging.  Breast tomosynthesis provides the ability to separate overlapping structures and to better characterize calcifications. As such, breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast tissue 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 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: An enrollee has requested Botox injections for the treatment of his medical condition.   Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The medical records note short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), which is a rare condition.  There is a lack of standardized or proven therapies for SUNCT.  Treatment for this condition is off-label.  OnabotulinumtoxinA is indicated for prevention of chronic migraine, and has decades of safety data available. It is believed to exert its therapeutic effect by inhibition of pre-synaptic neurotransmitter release.  This patient has been diagnosed with SUNCT and has failed therapy with previous medications. He has had marked relief with Botox, and therapeutic response has been confirmed by pain recurrence upon wear off.   All told, the requested Botox injections are 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 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: 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  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 of greater benefit than other methods of evaluating this patient.  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 erts 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 Dexcom G4 Platinum Continuous Glucose Monitor, including transmitter, receiver and sensors for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested equipment in this patients case.  Malik and colleagues noted that for patients with hypoglycemia following bariatric surgery, continuous glucose monitoring is a valuable tool, revealing the episodes in the natural environment and can also be used to monitor treatment success.  The Dexcom G4 Platinum Continuous Glucose Monitor is of particular benefit for the prevention and detection of hypoglycemia.  In this patients case, the records suggest an emerging condition called post gastric bypass hypoglycemia.  The Dexcom G4 will be able to monitor her glucose levels continuously, and alarm her when a glucose fluctuation is occurring so that she may take action and prevent severe hypoglycemia. This offers an advantage over conventional fingersticks with which the time in between testing is blind and patient may not realize that she has hypoglycemia until the glucose is very low.  All told, the requested Dexcom G4 Platinum Continuous Glucose Monitor, including transmitter, receiver and sensors are medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment 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, diabetes and metabolism 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 an enhanced external counter pulsation (EECP) for treatment of her chest pain.  Findings:  The physician reviewer found that there is a lack of support for the requested service in this clinical setting. EECP is indicated for the treatment of patients with angina refractory to conventional therapy which would include coronary artery bypass graft (CABG), PCI/Stenting, as well as maximally tolerated anti-ischemic therapy. The records provided do not support intractable angina. In addition, the provider recommended appropriate cardiovascular evaluation stating that the patients ischemic burden would need to be identified to determine whether additional intervention would be required. For these reasons, the requested service is not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested service 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 internal medicine with sub-specialty certification in cardiovascular disease 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 air ambulance transportation for treatment of his medical condition. Findings:  The physician reviewer found that the air ambulance transportation has not been established as medically necessary in this clinical setting. Per the documentation submitted, a definitive diagnosis of an acute myocardial infarction was not made. In addition the ECG provided for review was not definitively diagnostic of an acute myocardial infarction.  CPK MB levels are often inaccurate in the diagnosis of a myocardial infarction and have been largely abandoned given the widespread availability of troponin levels. The discharge summary does not indicate that it did not have the capability to appropriately evaluate and treat the patient. In sum, there is a lack of evidence supporting the services at issue as medically necessary for the treatment of the 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 internal medicine with sub-specialty certification in cardiovascular disease 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 inpatient chemical dependency services for treatment of his behavioral health conditions. Findings: The physician reviewer found that the documentation submitted for review does not support inpatient chemical dependency services. According to the documentation submitted, the patient has come to value the concept of treatment. He expressed motivation and willingness to engage services. He has access to specialty programming in the outpatient setting. In addition, the absence of significant co-morbidity supports a less restrictive setting. The patient had unremarkable mental status examinations. There was no evidence of withdrawal, suicidality, psychosis or bipolarity. Moreover, the patient had supportive family and had demonstrated the ability to achieve and maintain sobriety in the absence of a 24-hour treatment facility. Finally, the patient had no prior history of chemical dependency treatment in a less restrictive setting such as community programming, outpatient specialty care, intensive outpatient services or partial hospitalization. This is significant given that modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Also, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the requested services are not medically necessary for treatment of the patients behavioral health conditions.Final Result: The 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: The physician 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 residential treatment center services for treatment of the enrollees behavioral health condition. Findings: The physician reviewers found that the residential treatment center services provided were and are medically necessary for treatment of the patients medical condition. The patient appears to be very fragile. The patients main stressor is dealing with peers in the school setting. The patient has had very little experience outside the residential treatment center level of care to gauge his reactions to the normal stressors of his home environment. As confirmed, by details provided by the patients parent, he is not yet ready for discharge to a lower level of care. The patient is not equipped to handle these stressors and would likely decompensate when expected to do so. Discharge at this time would likely require re-admittance to an acute care facility, thus undoing the gains the patient has made so far. This patient needs to continue in the residential treatment program in order to solidify his gains and slowly transition back home without fear of regression and relapse. Given the above, the services at issue were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewersdetermined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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.