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

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer 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 patients case, the records noted heterogeneously dense breast tissue.  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, digital breast tomosynthesis performed on the date of dispute was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the service 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: Physician reviewers 1, 2 & 3 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: An enrollee has requested reimbursement for residential, substance use disorders, rehabilitation, adult and geriatric treatment provided .Findings:  The physician reviewer found that The documentation provided for review supports the medical necessity of the residential treatment in dispute. The American Psychiatric Association (APA) states that 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. In this case, the patients alcohol use disorder was complicated by co-occurring depression and anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, that anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes . The patients alcoholism was central to her daily routine and contributed to her significant impairment across multiple domains of functionality. Despite an alcohol-related arrest and facing occupational and legal uncertainty, she demonstrated minimal motivation for recovery at the outset. The patient lived alone and was estranged from her family. The patient was unable to achieve sobriety in her environment. The patient was struggling with anxiety and depression despite outpatient psychiatric services. The patient had significant medical comorbidity as well. During the disputed time frame, the patient was engaged in active treatment. The patient was prescribed an anti-craving medication in addition to the full array of non-pharmacologic interventions afforded by the setting. Based on the documentation submitted for review, the services at issue were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. Accordingly, the residential, substance use disorders, rehabilitation, adult and geriatric treatment provided during the dates of dispute16 was medically necessary for the patients medical condition. Final Result: The reviewers 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for monthly intravenous immune globulin (IVIG) therapy for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that the documentation does not detail all the various medications the patient has tried and failed or what was considered drug failure. In addition, the records do not indicate focal neurologic findings, imaging findings, or tests in support of progression of disease while on current therapy. Further, IVIG is not U.S. Food and Drug Administration (FDA) approved for treatment of MS and the current peer-reviewed publications do not support IVIG as a routine therapy for MS. Melzer and Meuth noted that MS and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) represent chronic, autoimmune demyelinating disorders of the central and peripheral nervous system that share some fundamental pathogenic elements. However, the authors noted that treatments do not provide uniform effects across both disorders. 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 physician reviewer is board certified in neurology with sub-specialty certification in pain 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:The parent of an enrollee has requested authorization and coverage for 108 hours per month of direct applied behavioral analysis (ABA) therapy, 13.5 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 108 hours per month of direct ABA therapy, 13.5 hours per month of supervision and two hours per month are medically necessary for treatment of the patients medical condition. A study evaluated the relationship between ABA treatment intensity and treatment outcomes. The authors found a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made good progress in a relatively short period of time, but he continues to have significantly problematic behaviors in the context of adaptive delays. The peer-reviewed literature supports 25 or more hours of weekly ABA to ensure optimal outcomes. Final Result: The reviewers determined that the requested services at issue 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that digital breast tomosynthesis  is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In this clinical setting, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms over 12 years. Accordingly, the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. 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 authorization and coverage for abdominal hernia repair with panniculectomy for treatment of the enrollees abdominal hernia and excess lower abdominal skin. Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The American Society of Plastic Surgeons (ASPS) consider a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms as reconstructive. A study analyzed a series of massive panniculectomies greater than 10 pounds following massive weight loss and investigated the outcomes achieved. The researchers state The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. In this case, a panniculectomy was recommended to treat the patients intertrigo and improve her lower abdominal appearance. Although the patient has evidence of intertrigo, she has not been documented to have failed reasonable conservative dermatologic management.  In addition, the size of her pannus, is relatively mild and does not support a significant functional deficit. Based on documentation submitted for review, the request for an abdominal hernia repair with panniculectomy has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Three physician reviewers found that Tomosynthesis is approved for clinical use by the U.S. Food and Drug Administration (FDA) and by the Centers for Medicare and Medicaid Services (CMS) for reimbursement. 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 advantage it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. In this case, post lumpectomy architectural distortion would be expected and the addition of tomosynthesis provides added confidence in separating post-operative distortion from recurrent cancer. Thus, the addition of tomosynthesis was likely of greater value to the patient than had her exam been done with 2D imaging alone. Accordingly, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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. 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examinationFindings:  Two physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis to be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging. Thus, the addition of 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 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. 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: An enrollee has requested authorization and coverage for Forteo for treatment of the enrollees osteoporosis.Findings:  The physician reviewer found that in review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested medication. According to the National Osteoporosis Foundation guidelines for severe osteoporosis, sequential treatment with anabolic therapy followed by an antiresorptive agent is generally preferred to concomitant combination therapy. Forteo is an anabolic agent approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Forteo reduces the risk of vertebral fractures by about 65% and nonvertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy. Prolia is an antiresorptive agent that decreases the risk of spinal fractures by 68% and hip fractures by 40% and is indicated for the treatment of osteoporosis in men and women at high risk for fracture. Early studies have shown that the use of antiresorptive agent prior to or concomitant to Forteo blunt the beneficial effects of Forteo. It has been demonstrated that sequential monotherapy of Forteo followed by an antiresorptive agent is more effective than monotherapy with an antiresorptive agent alone. It has been shown that the greater effect of Forteo occurs after one year of therapy, and the benefit is maintained when followed by an antiresorptive agent. Moreover, when a patient presents with severe bone loss and compression fractures, Forteo for one or two years followed by an antiresorptive agent is recommended. The reverse order may have blunted results, and it is not as effective. Final Result: The reviewers 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for of 35 hours per week of one-on-one applied behavioral analysis (ABA) therapy for treatment of his autism. Findings:  The physician reviewer found that the request for 35 hours per week of one-on-one ABA therapy, is medically necessary for treatment of the patients medical condition. Researchers studied 726 children ages 1.5 to 12 years old receiving behavioral intervention services. The study indicated a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made progress, but he continues to have significantly problematic behaviors in the context of language delays and persistent vocal stereotypy. The patient is currently receiving 22 hours per week of direct one-one-one ABA therapy, which is less than what is typically recommended for optimal response. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board (BACB) state that typical comprehensive ABA programs range from 30-40 hours of treatment per week. In this clinical setting, the request for 35 hours per week of one-on-one ABA is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services at issue 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility level of care for treatment of the enrollees skin condition. Findings:  The physician reviewer found that the medical literature indicates that inflammatory demyelinating polyneuropathies are well known to cause significant functional impairments. The chronic variants are known to cause fatigue and have a progressive course lasting months, affecting participation in rehabilitation efforts and functional recovery. In this patients case, the patient had had a slow recovery following his initial collapse.  His functional status had plateaued to the point that further care at a custodial level was recommended. Prior to an initial discharge for late November 2016, there were incidental indications of a rash, possibly pruritic. However, the documentation shows no indication that the rash was severe or medically concerning. A providers note on 12/7/16 indicated a skin examination that was within normal limits.  On 12/8/16, a providers record noted some mild rash and orders were written for a lotion to be applied daily due to dry skin and anti-itching medication to be administered as needed. There were no indications that this rash was significant enough to warrant further investigation. There were no referrals made for a dermatology consultation and no documentation that the rash required more significant treatment. There is a lack of clinical documentation supporting a delay in discharge from the facility. 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 physical medicine and rehabilitation 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.