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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI). Findings:  The physician reviewer found that this patients mammographic density was described as heterogeneously dense, not extremely dense, on the mammogram report. There were no equivocal findings on the mammogram to warrant a follow-up MRI or ultrasound of the breasts, and the radiologists recommendation was a one-year follow-up mammogram, not MRI examination as stated by her oncologist. There are no genetic predispositions to breast cancer documented in the records, such as BRCA mutation. The history of prior breast cancer is not considered an indication for postoperative screening breast MRI. All told, bilateral breast MRI performed was not medically necessary for the evaluation of this patient. Final Review: The reviewer determined that the services at issue were 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 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: The enrollee has requested authorization and coverage for Humatrope 5 mg for treatment of the enrollees septo-optic dysplasia and associated panhypopituitarism.Findings:  The physician reviewer found that The request for Humatrope 5 mg is not medically necessary for treatment of the patients medical condition. The patient has documented panhypopituitarism and should continue on full pituitary replacement as determined by his provider. However, there is a lack of documentation supporting brand name Humatrope as medically necessary. The Health Plans formulary medication such as Nutropin is medically appropriate in this clinically setting. As such, the requested medication has not been established as medically necessary for treatment of the 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 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 authorization and coverage for screening colonoscopy and esophagogastroduodenoscopy. Findings:  The physician reviewer found that Guidelines from the American College of Gastroenterology (ACG) and guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) for Barretts esophagus recommend EGD with biopsies for dysplasia screening every three to five years in patients with non-dysplastic Barretts esophagus, as in this case. Per the records, this patient had an endoscopy previously. Thus, repeat EGD is not warranted for Barretts esophagus surveillance at this time. Additionally, ASGE guidelines for appropriate use of endoscopy do not support repeat EGD for reflux or epigastric pain as evaluation had already been performed, and the symptoms had not been documented as refractory to proton pump inhibitor for at least four weeks. The colonoscopy is not supported by ASGE guidelines for evaluation of symptoms such as bloating or pain. Additionally, the recommended interval for repeat colon cancer screening would be at least five years.  Both the American Cancer Society guidelines for colon cancer screening and the joint guidelines issued by the ACG, ASGE, and American Gastroenterological Association Institute (AGA) recommend screening colonoscopy every five years in patients with colorectal cancer or adenomatous polyps in any first-degree relative younger than 60 or if non-hyperplastic polyps are found in the patient, or every 10 years if the first-degree relative is diagnosed at age 60 or higher or if hyperplastic polyps are found. The age at which the enrollees mother was diagnosed is not provided, but the patient had hyperplastic polyps on the prior colonoscopy, so colonoscopy would not be supported at this time. For these reasons, the EGD and colonoscopy are not medically necessary for the evaluation 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 internal medicine with sub-specialty certification in gastroenterology 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 Euflexxa injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical evidence supports hyaluronic acid injections in the knee as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome, or osteochondritis dissecans. The peer-reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee, but states that application in sports-related chondropathy has yet to be fully assessed. The ideal indication in the knee appears to be moderate femorotibial osteoarthritis without swelling. This patient presents with bilateral anterior knee pain, left greater than right, with popping and clicking in the left knee. Her symptoms are worse with colder weather, climbing ladders, climbing hills, going up/down stairs, and with heavy lifting. Clinical examination findings have been consistent with imaging evidence of patellofemoral chondromalacia and degenerative joint disease. Current evidence-based medical guidelines and literature do not support the use of Euflexxa injections in the treatment of patellofemoral osteoarthritis. The current evidence does not support the requested services in this clinical setting. Therefore, the requested Euflexxa injections are not medically necessary 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 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: An enrollee has requested authorization and coverage for a monthly injection of Simponi 50 mg for treatment of the enrollees psoriatic spondylitis. Findings:  The physician reviewer found the request for a monthly injection of Simponi 50 mg is not medically necessary for treatment of the patients medical condition. According to the records submitted for review, there is a lack of documentation demonstrating that the patient has tried and failed both Humira and Enbrel. Based on the medical records provided for review and lack of failure of Humira or Enbrel, the requested medication is not supported as medically necessary for treatment of the patients psoriatic spondyloarthropathy. 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 internal medicine with sub-specialty certification in rheumatology 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 reimbursement for the substance abuse residential treatment center (RTC) services for treatment of the enrollees substance abuse and depression. Findings:  The physician reviewer found that The patient was not in withdrawals on admission, and was not placed on any type of withdrawal protocol. She was not a danger to herself or others, nor was she aggressive or violent. She showed no self-harming behaviors. She was cognitively intact and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. She was not psychotic, delusional, or manic. There was no evidence of a high degree of impulsivity, agitation, depression, or any other significant symptom that would interfere with her care. She was medically and psychiatrically stable. Her medication regimen was not complex and could have been started and monitored in an ambulatory setting. She participated in her care and required further treatment to help develop coping skills and relapse prevention. However, this also could have been carried out on an ambulatory basis. The patient did not require the structured environment of residential treatment center (RTC) level of care. All told, the substance abuse RTC services were not medically necessary for treatment of this patients behavioral health issues Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that The documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patients post acute withdrawal syndrome were not at a level, which required 24 hours per day, seven days per week monitoring. The records document that her vital signs were stable. She was not a danger to herself or to others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. The patient was medically and psychiatrically stable to the extent that she did not need 24 hours per day, seven days per week monitoring.  There were no other significant symptoms that would interfere with her care such as mania or psychosis.  No new problems had arisen and medications were essentially unchanged.  Her clinical institute withdrawal assessment for alcohol was a six.  Relapse education and the development and solidification of coping skills against triggers could have been provided at a lower level of care and she could have been stepped down to partial hospitalization program. Therefore, the residential treatment center services were not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 reimbursement for residential treatment for treatment of the enrollees alcohol dependence/related disorder, severe. Findings:  The physician reviewer found that The residential treatment provided were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients post-acute withdrawal symptoms were not severe in nature.  The patient was not a danger to himself or others, nor was he aggressive or violent. The patient was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. The patient was medically and psychiatrically stable. There were no changes in his medications since admission. There were no psychiatric progress notes to support a severity that would require ongoing residential level of care. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and appeared to be working the program. The patient was cooperative and participating in his treatment plan. His living environment was safe and sober, and the discharge plan was for IOP. The patients substance use disorder was recidivistic in nature and he did require further treatment. However, this could have occurred in an ambulatory, lower level of care. As of the dates in dispute, the patient no longer required the 24-hour structured residential setting. As such, the services at issue were not medically necessary for 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 psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for topical solution Jublia (efinaconazole) for treatment of the enrollees onychomycosis. Findings:  The physician reviewer found that The submitted documentation fails to support the medical necessity of the requested medication in this clinical setting. According to the record, this patient has not failed at least one course of an oral antifungal. There are no fungal cultures to support the indication for Jublia. There is also no documentation provided to support the clinical complaint of pain. Additionally, a review of the documentation provided indicates that the patient has no contraindications to oral antifungal therapy.  For these reasons noted above, topical solution Jublia (efinaconazole) is not 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 podiatry 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 enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility services provided. Findings:  The physician reviewer found that The request for skilled nursing facility services provided from the date in question, forward were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is status post intracranial hemorrhage. The initial skilled nursing facility services provided were medically appropriate. However, the patient has made little progress with skilled therapies, and continued skilled rehabilitation services are not clinically indicated for this patient. Further care can be provided in a custodial level setting. Thus, as of the date in question, the documentation does not support skilled nursing facility services as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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 authorization and coverage for microvascular decompression (MVD). Findings:  The physician reviewer found that the request for MVD is medically necessary for treatment of the patients medical condition. There is sufficient medical literature supporting the requested surgery in this clinical setting. MVD surgery for trigeminal neuralgia provides a low-risk treatment for cranial nerve hyperactivity-compression syndromes, which are associated with severe, disabling facial pain and spasm. In addition, studies note that MVD is likely the most effective therapy for patients with trigeminal neuralgia. In this case, the patient presents with medically refractory trigeminal neuralgia with persistent pain. As such, the requested surgery has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 neurological 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: An enrollee has requested reimbursement for skilled nursing facility including therapy services and has requested the resumption of skilled nursing facility including therapy services. Findings:  The physician reviewer found that the documentation provided do not support the medical necessity of the services at issue in this clinical setting. Stroke is a leading cause for severe disability in the community, resulting in multiple deficits including community mobility deficits. It is also among a variety of conditions that increase risk of influenza complications. In this case, the patient has chronic mobility deficits, and requires use of mobility aides. The records noted that his baseline is the use of a cane, wheelchair or motorized scooter. Due to the patients baseline condition, his recovery has been protracted. He also became deconditioned due to influenza.  The patient had made modest progress but he continued to require significant assistance for his basic self-care and mobility, including transfers.  As such, the documentation provided support continued care but in a less intensive setting. Therefore, the skilled nursing facility including therapy services provided and the resumption of skilled nursing facility including therapy services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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.