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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scans of the brain, neck, thorax, abdomen and pelvis with contrast. As noted by the National Imaging Associates (NIA), CT imaging is not used to evaluate for occult malignancy unless there is an imaging or clinically strong suspicion of malignancy, such as diffuse adenopathy, or identifiable mass on physical examination. This patient has a chronic cough and chest pain that was evaluated with two chest x-rays and a CT of the thorax. The bones and soft tissues of the thorax including the ribs and thoracic spine would have been visualized on the CT of the chest even without contrast. A past chest x-ray showed a small nodular density overlying left upper lobe. However, there was no evidence of a nodule on the CT scan performed on the same day, or on the repeat chest x-ray later performed. The provider noted that the latter x-ray showed no abnormality, as the nodular density visualized over the left upper lobe on the first chest x-ray, was shown to be an artifact due to superimposed normal structures. Thus, there is no imaging finding or clinical suspicion supporting an indication for a repeat CT of the chest. Further, the records do not support the requested CT scans of the brain, neck, abdomen, or pelvis. Specifically, there are no records from a pulmonologist, otolaryngologist, or cardiologist noting the patients symptoms require advanced imaging that has not already been performed. All told, the requested CT scans of the brain, neck, thorax, abdomen and pelvis with contrast are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: The patient requested a referral for magnetic resonance neurography (MRN). Findings:  The physician reviewer found that in this case, the patient has a history of lower extremity pain of uncertain etiology. EMG/NCS, MRI of the lumbar spine, and MRI of the lumbar plexus were normal or non-diagnostic. The patients neurological examination was also normal. In this setting, it would not be expected that performance of a repeat imaging study of the same anatomic region with MRN would lead to any new findings. Published medical literature does not support the clinical utility of MRN in this clinical setting. Specifically, it is unclear how MRN imaging would lead to improvements in the management of the patients care. Overall, the medical evidence does not suggest that the requested service will yield data beyond that obtained with imaging already performed. Therefore, the requested MRN is not medically necessary for the evaluation of this patient.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 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 patient has low back pain that has been present since November 2018. The patient rated his back pain as seven out of 10. On that date, physical examination findings indicated no focal neurologic deficits. The patients symptoms have persisted despite treatment with physical therapy and non-steroidal anti-inflammatory drugs. Magnetic resonance imaging of the lumbar spine demonstrated a L5-S1 disc bulge and facet arthropathy without neural compression. At issue in this case is whether a visit with a neurosurgeon specialist is medically necessary for the treatment of this patients medical condition. Referral to a neurosurgeon specialist is recommended in cases of low back pain that is severe and persists longer than 12 weeks, even when there are no red flags on examination. In this case, the patients physical examination was within normal limits with no focal neurologic findings. The provider noted that the patients low back pain has persisted out of proportion to the imaging results and physical examination findings. Moreover, a course of conservative therapy has not produced improvement. Thus, a referral to a specialist in diseases of the back, such as a neurosurgeon, is the next logical step in evaluation and management of the patients low back pain. Accordingly, the requested visit with a neurosurgeon specialist is supported as medically necessary for evaluation of this patients low back pain. Final Result: The reviewer determined that the requested service 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 family practice 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

Patient has tried and failed conservative treatment, including corticosteroid injections that only provided short-term relief and was able to decrease her use of antiinflammatories. She has benefitted from viscosupplementation with Euflexxa in the past and the provider has recommended repeat Euflexxa injections into both knees. At issue is whether Euflexxa knee injections are medically necessary for treatment of this patient.According to Maheu and colleagues, intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. Viscosupplementation may offer one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis symptoms, overall gain in quality of life, and substantial delay in time to total knee replacement. The clinical benefits of intra-articular hyaluronic acid on knee osteoarthritis may include lubrication and shock absorption of the joint, and the re-establishment of joint homeostasis. In this case, the patient has a history of significant benefit from prior Euflexxa injections. Given this support, the requested Euflexxa injections for both knees are medically necessary for treatment of this patients osteoarthritis of the knees.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient was admitted for detoxification and treatment for diagnoses including alcohol use disorder and anxiety disorder. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate the patient was admitted with a history of substance use. She was not exhibiting withdrawal symptoms during the disputed timeframe. The patient did not report significant medical issues that were affecting treatment. She did not have plan or intent of self-harm and did not engage in self-harm behaviors during the admission. The patient did not describe suicidal thoughts or psychosis. She expressed motivation for treatment on numerous occasions. The patient expressed the need for continued treatment and expressed an understanding of her struggles with substance use. She was insightful in her therapy sessions. The progress notes do not reflect aberrant behaviors. The records indicate that the patients overall function was good. There was no indication of problems with activities of daily living.  The patient was not experiencing behavioral issues, aggression, or oppositional behaviors.   In addition, the evaluations based on the The American Society of Addiction Medicine (ASAM) and the Level of Care Utilization System (LOCUS) scores, the services at issue were not medically necessary. In sum, residential treatment center services at issue were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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 patient is diagnosed with alcohol use disorder, severe dependence. He was admitted to an intensive outpatient program (IOP). He participated in group psychotherapy and assignments. The patient was noted to show good insight and did not have any co-morbid physical or medical issues. He was not experiencing any acute or potential dangerous withdrawal symptoms. He reported low cravings and declined medication assisted treatment. Based on review of records, the patient denied any suicidal or homicidal ideation and did not have any auditory and or visual hallucinations or psychosis. He was not showing any medical or physical issues that required monitoring. There was no report of this patient requiring assistance with activities of daily living (ADLs). The patients wife was supportive and his home was a sober environment. The patient was cooperative with care, was involved in his treatment, participated in his treatment plan and attended 12-step groups. Applying the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS), the IOP services that were provided were not medically necessary. In terms of risk of harm, the records support a score of one due to a lack of current suicidal ideation and no self-harming behaviors. Regarding functional status, the records support a score of one due to minimal impairment with no identifiable stressors. The records support a score of two for addictive and psychiatric comorbidity due to overall medical stability. In terms of level of stress of the patients recovery environment, the records support a score of one due to a stable living situation. The records support a score of one for his level of support for the recovery environment due to family support and availability of treatment resources and some difficulty with family relationships. Regarding treatment and recovery history, the records support a score of two due his significant response to treatment. In terms of engagement and recovery status, the records support a score of one due to cooperation in treatment, insight into the need for treatment, along with insight into his treatment needs. Thus, the patient has a composite score of nine, which correlates with treatment in a community-based outpatient clinic setting. Given this finding, the patient was a candidate for treatment in a less restrictive treatment setting than IOP, and could have been safely and adequately treated in the outpatient venue. Final Result: The reviewer determined that the requested services 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 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 patient has been diagnosed with an autism spectrum disorder. He has reportedly been receiving applied behavioral analysis (ABA) therapy. The patient has requested authorization and coverage for 36 hours of ABA therapy per month. Findings:  The physician reviewer found that the Behavior Analyst Certification Board (BACB) guidelines indicate that discharge will be reviewed when the patient has achieved treatment goals, no longer meets diagnostic criteria, does not demonstrate progress, the family does not want to continue services, or the family and provider are not able to reconcile important issues. The provider indicates that discharge criteria will be discussed when the patient has met all treatment goals. This patient meets the diagnostic criteria of autism and is still making progress on treatment goals. Based on this information, he does not meet discharge criteria.  It is premature to begin discussing discharge, including reducing an already low number of requested service hours. The Vineland 3 is a normative based assessment that compares adaptive functioning skills to individuals of the same age. Based on the patients Vineland score, he is functioning in all areas at the level of a six-year-old or younger and obtained scores that are 4 or more standard deviations from the mean. This information suggests that the patient is performing significantly discrepant from their same-aged peers and needs significant support. Given the level of deficits displayed and the need for improvement in several domains, reduction in service intensity is not medically appropriate.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 a board certified psychologist 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 patient has requested reimbursement for computed tomography (CT) of the heart without dye with calcium test. Findings:  The physician reviewer found that the records provided for review document that this patient has some coronary risk with dyslipidemia, no anginal quality symptoms, no history of heart disease and a normal cardiovascular physical examination. In this circumstance, guidelines to evaluate and manage dyslipidemia are available and endorsed by several national organizations. These guidelines currently do not recommend screening coronary computed tomography (CT) angiography or screening coronary calcium scanning. Outcomes in patients evaluated with coronary CT angiography have not been shown to be improved compared to outcomes achieved with treatment based on clinical risk and basic lipid profile results alone. Thus, the CT of the heart without dye with calcium test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of the 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is 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 enrollees parent has requested authorization and coverage for ABA services, including 40 hours per week of direct therapy (24 hours in school and 16 hours in home), 30 hours per month of supervision and six hours per month of parent training, for six months. The submitted documentation supports the medical necessity of the requested services. In this case, a lack of progress, and subsequent increase in interfering behaviors, coincided with the patient attending kindergarten and an interruption in services for approximately two months at the start of the school year. The purpose of supporting the patient in the educational setting is to provide training on social interactions with peers. The Behavior Analyst Certification Board (BACB) indicates that services are provided in multiple locations, including school settings, to promote generalization and maintenance of treatment gains. In this case, it has been observed that a decrease in service intensity has led to an increase in problem behavior and slow progress. This patients Vineland Adaptive Behavior Scales, Third Edition scores were discrepant from her same-age peers. Specifically, the patients total composite was greater than one standard deviation below the mean, and the socialization domain was two standard deviations below the mean. ABA therapy is the most evidence-based treatment for children and adults on the autism spectrum. One of the ABA strategies identified among the evidence is naturalistic teaching, which utilizes ABA therapy in naturally occurring contexts, such as the school. The school environment grants the patient natural opportunities to evoke, generalize, and maintain the desired behavior. Therefore, the requested ABA services, including 40 hours per week of direct therapy (24 hours in school and 16 hours in home), 30 hours per month of supervision and six hours per month of parent training, for six months are medically necessary 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested coverage for magnetic resonance imaging (MRI) of the knee. At issue in this case is whether MRI of the knee is medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that MRI is the optimal modality to evaluate internal derangement in the knee. Plain x-rays are of limited value because the menisci and ligaments are not visible on plain x-rays. X-rays can show findings such as a mass or a congenital abnormality. A MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on x-ray. The incidence of abnormal findings such as meniscal tears is high in asymptomatic patients. Therefore, MRI findings must be carefully correlated with clinical signs and symptoms. Obtaining a MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions and unnecessary surgery. The medical evidence does not support the requested service in this clinical setting. Therefore, the requested MRI of the knee is not medically necessary for the treatment of this patient. 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an office consultation with a pain management specialist. The American Academy of Family Physicians guidelines state that providers should provide patient-centered care to those with chronic pain or dependence on opioids, and should work with other health care professionals to provide multidisciplinary care. The management of chronic pain is complex and often benefits from consultation with specialists in pain management strategies. In this case, the patient has multiple sites of pain that require further evaluation and treatment by pain management. The enrollee has been evaluated by neurosurgery and found not to be a candidate for surgical intervention. Therefore, the requested office consultation with a pain management specialist is well supported by medical literature as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in family 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.