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

Nature of Statutory Criteria/Case Summary: An enrollee has requested outpatient counseling services twice per week for four months for treatment of his medical condition.   Findings:  The physician reviewer found that this patient has been diagnosed with generalized anxiety disorder, panic disorder and social anxiety. He continues to be in psychotherapy treatment which has been helpful per the subjective report. Data regarding treatment of anxiety disorders suggests that the key targets for improvement in treatment adequacy include regular follow-up of patients with a generalized anxiety disorder medication and access to psychotherapy. The patients preference should be considered in the choice of treatment and drug treatment should be continued for up to one year after remission. If psychotherapy or drug treatment is not adequately effective, then the treatment should be switched to the other form, or to a combination of both. In this case, the patient does not want to take psychotropic medications for anxiety. Psychotherapy can be continued alone. However, the request for outpatient counseling treatment twice per week for four months is excessive and therefore not medically necessary.  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.  Qualifications/Credentials: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of his behavioral health condition. Findings: The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, residential treatment center services were not medically necessary for this patient. The submitted documentation demonstrates that the patient was not experiencing post-acute withdrawal symptoms and he was not a danger to self or others. The medical records show he was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive indicators to warrant residential level of care.  He endorsed motivation for recovery.  The progress notes indicate that he was cooperative and compliant with care.  He lived with someone who was sober and supportive. There was no evidence that the patient would not respond to treatment at a lower level of care.  He did not require 24-hour supervision in a residential setting and could have been treated in an intensive outpatient program (IOP). Studies support that IOP level of care can be as effective as inpatient level of care in the treatment of alcohol and drug addiction. As such, residential levels of care services were not medically necessary for management and treatment of the patients behavioral health 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.Qualifications/Credentials: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc hyaluronan injections for treatment of her medical condition.   Findings: The physician reviewer found that the patient has bilateral degenerative osteoarthritis of the knees with secondary varus deformity. The rationale for the use of hyaluronan includes the concept that proinflammatory mediators and MMPs that stimulate chondrocytes to syntheses endogenous hyaluronic acid and proteoglycans will be affected positively by the injection of hyaluronic acid. However, the basic science rational for hyaluronan effecting arthritis of the knee has not been confirmed. Long-term tissue reaction to break down products of hyaluronan as well as acute reactions should also be considered along with the weak support provided by well-designed double blinded studies.  Therefore, due to the lack of clinical evidence supporting the use of hyaluronan injections for treatment of osteoarthritis of the knees, Orthovisc hyaluronan injections are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the injections 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 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 the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this 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.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the services at issue.  A follow-up examination was indicated due to the findings seen on a previous screening examination which included breast tomosynthesis.  However, the patient did not need a repeat tomosynthesis examination since the area of concern could have been targeted with ultrasound and conventional views. The repeat tomosynthesis was not of greater value to the patient than ultrasound and two-dimensional images.  Therefore, the breast tomosynthesis screening at issue was not likely to have been more efficacious than other methods of evaluation.  Final Result: Two 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 physician reviewers are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested a computed tomography (CT) scan for evaluation of his medical condition. Findings: The physician reviewer found that the records indicate this patient underwent evaluation with a CT scan. The size of the nodules did not exceed 4 mm in diameter and the patient would be classified as low risk. Also, no known malignancy was evident. The Fleischner Society criteria for following these nodules would likely be no follow-up, or if recommended, a follow-up CT would be appropriate at one year after detection. The British Thoracic Society advises against any routine follow-up in cases such as this. Thus, the follow-up CT at four months after original detection of multiple small subpleural nodules in a low risk patient was not medically necessary.  Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Qualifications/Credentials: The physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Belsomra for treatment of his medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Most hypnotics have not been studied for long-term control of insomnia. However, extended-release zolpidem has been studied for this indication (Krystal, et al). The study by Krystal and colleagues found that the efficacy of three to seven nights per week dosing of zolpidem extended-release 12.5 mg for up to six months provided significant and sustained improvements in sleep onset, sleep maintenance, next-day concentration, and morning sleepiness. In this case, the documentation submitted does not demonstrate a trial of a benzodiazepine agonist such as zolpidem or zaleplon have been tried. Baclofen belongs to a different drug class, and there is no known cross-reactivity between the two classes in precipitating migraine headaches. Furthermore, non-pharmacologic options such as cognitive behavioral therapy for insomnia (CBTI) that have not been documented as trialed in this case. Given that there are effective and safe options available; Belsomra has not been established as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the medication at issue was not and 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 neurology with sub-specialty certification in sleep 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lipoprotein testing for evaluation of his medical condition. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Primary prevention guidelines for the management of cardiac risk and dyslipidemia that have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.    Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing was not 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 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested air and ground ambulance services on an emergent or urgent basis.  Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition. Based on the records provided the patients presentation was not consistent with the above definition of an emergency medical condition. Her medical condition was not precarious as prior to her flight she was at home without monitoring of physiologic parameters. In addition, the patient denied any pain or discomfort. There is a lack of clinical documentation demonstrating that the patient presented with symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. 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 at issue did not meet prudent layperson criteria for emergency care.  Moreover, it has not been established that criteria for urgently needed services were met on the date in dispute. The patient presented status post left hip surgery. The medical records from the air ambulance report that she was picked up at home without monitoring of physiologic parameters. Once in the ambulance she denied pain or discomfort. There is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation during the date in dispute the patient did not meet prudent layperson criteria for urgently needed services. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 a sacral laminectomy, spinal dorsa graft and osteoplastic reconstruction of dorsal spinal elements following a primary intraspinal procedure of her lower back.   Findings:  The physician reviewer found that there is evidence based medical peer-reviewed literature that supports the use of microsurgical resection of Tarlov cysts as safe and effective treatment for symptomatic Tarlov cysts. Studies indicate that symptomatic Tarlov cysts are extremely rare. Burke and colleagues completed one of the largest published studies on patients with Tarlov cysts who were treated microsurgically. They studied 23 adults who were treated with laminectomy, microsurgical exposure and/or imbrication, and para-spinous muscle flap closure. The data suggested that patients with symptomatic Tarlov cysts may benefit from open microsurgical treatment. Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study was warranted and reported underway. Another study reviewed by Xu and colleagues documented the outcomes of 15 patients with symptomatic sacral perineural cysts who were managed by three different modalities. Six patients underwent microsurgical cyst fenestration and cyst wall imbrication. Seven patients underwent a modified surgical procedure, during which the cerebrospinal fluid leak aperture was located and repaired. Two patients were treated with medication and physical therapy. They concluded that microsurgical operation should be a treatment consideration in patients with symptomatic sacral perineural cysts. Furthermore, the surgical procedure with partial cyst removal and aperture repair for prevention of cerebrospinal fluid leakage seemed to be more simple and effective. This patient presents with persistent pain and progressive neurological dysfunction attributable to the Tarlov cysts, and unrelated to her fibromyalgia. The submitted clinical exam findings and signs/symptoms are consistent with imaging evidence of very large Tarlov cysts arising from the S2 and possibly S3 nerve roots, and corroborated by electrodiagnostic findings of a lack of sural nerve response. Moreover, reasonable conservative treatment has been tried and has failed. Given the progressive neurologic dysfunction, the requested surgical intervention is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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:   The parent of an enrollee has requested Lupron Depot for treatment of the enrollee's gender dysphoria. Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient has been receiving support from a licensed mental health professional. The patients therapist has assessed the patient with gender dysphoria. The patient has been experiencing early pubertal changes that have resulted in an increase of his gender dysphoria. There is no evidence of any psychiatric comorbidities that would interfere with his diagnostic workup or treatment. All told, the patient is an appropriate candidate for hormone therapy. As such, the requested Lupron Depot is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in endocrinology 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 Lyrica for treatment of his medical condition.  Findings:  The physician reviewer found that Lyrica has a U.S. Food and Drug Administration (FDA) indication for treatment of fibromyalgia. In the medical literature, Pauer and colleagues reported that Lyrica demonstrated modest efficacy in pain, global assessment, and function in patients with fibromyalgia at 450 mg per day, and improved sleep across all dose levels, but it did not provide consistent evidence of benefit at 300 and 600 mg per day in this study.  Mease and colleagues noted that patients in all Lyrica groups showed statistically significant improvement in endpoint mean pain score and in patient impression of global change (PGIC) response compared with placebo. Compared with placebo, all Lyrica treatment groups showed statistically significant improvement in assessments of sleep and in patients impressions of their global improvement. However, this patients medical records do not support a diagnosis of fibromyalgia or indicate any other neuropathic pain condition. As such, the requested Lyrica is not supported as medically necessary for the 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 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.