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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of both breasts.Contrast enhanced breast magnetic resonance imaging (MRI) is more sensitive for the detection of breast cancer in the high-risk population, approximately 90% sensitive, than both mammography and ultrasound, approximately 38% individually. Screening breast MRI is recommended in women with a lifetime risk of greater than 20%, women with BRCA gene mutations and their untested first-degree relatives, as well as other high-risk populations. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. In this case, the patients calculated lifetime risk of breast cancer is above 20% and she has dense breast tissue, therefore breast MRI is indicated as additional screening. Accordingly, the requested magnetic resonance imaging (MRI) of both breasts is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.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 patients parent has requested authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy.Findings:  The physician reviewer found that Based on the Council of Autism Service Provider (CASP) guidelines for autism and the ABA Coding Coalition, the essential components of documentation to support ABA services includes the submission of a treatment plan developed from a thorough assessment of the patients skills. This patients caregiver has requested authorization of 20 hours of ABA per week. However, the records do not include documentation of a treatment plan to support the requested ABA services. In addition, the most recent providers notes dated 6/18/20 recommended 15 hours of ABA services per week. Moreover, the patient does not meet the medical necessity criteria outlined by Papatola and Lustig, which states that medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these criteria, the requested 20 hours of ABA services per week fail to meet criteria (a), (c), and (d). Without an authorization request based on a thorough assessment of skill, the requested services have not been shown to meet the essential health needs of the patient. In the absence of this information, the requested services have not been established to be for purposes other than the convenience of the provider or patient, and it is unknown whether they are consistent with the patients diagnosis. Given these findings, the requested 20 hours per week of ABA therapy is not medically necessary to decrease disability and correct or ameliorate the patients behavioral conditions.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 a licensed B.C.B.A, board certified in psychology, 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 knee surgery for the right knee. In a systematic review of the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee, researchers concluded that there was a benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. Researchers noted that while the role of arthroscopic debridement in the painful degenerative knee is controversial, arthroscopy may provide good symptomatic relief and sustained benefits in significantly symptomatic patients, especially in the presence of mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis. In this case, the patient has severe pain from osteoarthritis of the right knee. The documentation reflects mechanical symptoms, such as locking and giving out. Given current medical literature, the requested service is medically indicated. Therefore, knee surgery for the right knee is medically necessary for the treatment of this patient. 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 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 patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder (CPT 73221). Findings:  The physician reviewer found that patients x-rays were consistent with calcific tendinitis. The patients provider recommended an MRI scan for further diagnostic purposes and treatment planning. Disease of the rotator cuff is a common cause of shoulder pain and dysfunction in adult patients. In this case, the patients calcific tendinitis has persisted for at least six months. The standard of care is arthroscopic removal of the calcific deposit and repair with a suture bridge technique if the deposit removal leaves a full thickness defect. The anatomy and physiology of the rotator cuff is complex and unique in each patient. Diagnostic imaging with MRI provides valuable information about the nature of the injury, which is critical to planning surgical intervention. For these reasons, the requested MRI of the left shoulder (CPT 73221) is medically necessary for this patient. 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 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 has requested authorization and coverage for oxycodone. The Centers for Disease Control and Prevention (CDC) guidelines state that, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards (FSMB) guidelines reported that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Based on the CDC and FSMB guidelines, this patients records do not document a current indication for treatment with oxycodone. The patients is noted to have peripheral neuropathy and chronic low back pain, which was being treated with oxycodone, gabapentin, and Flexeril. However, there is a lack of evidence that the benefits outweigh the potential harms to support continued oxycodone treatment in this clinical setting. The patient reportedly tested positive for methamphetamines on a urine drug screen in September of 2020 and he has a previous history of substance use disorder involving methamphetamines and cocaine. Thus, the patient is not considered a good candidate for opioid therapy. Moreover, the patients records do not demonstrate that the patient has exhausted non-opioid treatment options. Given these findings, the requested oxycodone is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in anesthesiology with subspecialty certification in pain management 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

ature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for matrix-induced autologous chondrocyte (MACI) surgery (CPT J7330). Findings:  The physician reviewer found that Based on the arthroscopic findings, the provider recommended that the patient undergo MACI transfer, especially given patients large chondral defect. Focal chondral defects are common in the patellofemoral joint and can significantly impair a patients quality of life. The MACI technique has been improved over 20 years. The first-generation technique included a periosteal patch, which was changed to a type I/III collagen membrane, followed by a collagen membrane seeded with chondrocytes prior to implantation. Current medical literature supports a role for MACI for this patients patellofemoral cartilaginous defects (Hinckel and Gomoll; Chahla, et al.). Based on these findings, the requested MACI surgery (CPT J7330) is medically necessary for 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 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: An enrollee has requested authorization and coverage for Tramadol 50mg for the requested quantity of 120 tablets for a 30-day supply. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. The guidelines state that clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh the risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. The guidelines state that opioid dosage should be maintained as low as possible and continued only if clear and objective outcomes are being met. American Society of Interventional Pain Physicians (ASIPP) opioid prescribing guidelines state that the prescription of opioids at a dosage of less than 40 morphine equivalents a day is considered low dose therapy.In this case, the patient has chronic knee pain that has been managed with tramadol 50 mg every 6 hours as needed, 120 tablets, for the past year. The requested quantity of medication is considered low dose opioid therapy according to ASIPP guidelines, and the providers notes state that the patient has not shown any aberrant or drug seeking behavior and that the patients medications are managing his pain and allowing him to perform his activities of daily living. There is no documentation showing that there have been any irregularities in the patients CURES report, and there have not been any inconsistent urine drug screens documented. Under these circumstances, Tramadol 50mg for the requested quantity of 120 tablets for a 30-day supply is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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 patient has requested authorization and coverage for (1) Otezla 28-day starter pack, and (2) Otezla 30 mg tablets (60 tablets/30 days). Findings:  The physician reviewer found that Otezla (generic name apremilast) is a phosphodiesterase 4 inhibitor. A review of studies suggests that this medication is effective for the treatment of moderate to severe psoriasis. The American Academy of Dermatology guidelines state that apremilast is recommended for the treatment of moderate to severe psoriasis. In this case, the patient presented with a two-year history of dry flaking skin.  On examination, it was estimated to cover approximately 15% BSA. He was started on apremilast. On follow-up one month later, it was noted that the patient had not significantly improved, and he was started on a higher potency steroid. Subsequent follow-up found that the patient had improved on the combination. There is sufficient support for the requested medication in this clinical setting. Therefore, (1) Otezla 28-day starter pack, and (2) Otezla 30 mg tablets  (60 tablets/30 days) are medically indicated for the treatment of this patient.Final Result: The reviewer 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 reviewer is board certified in dermatology 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 stand-up magnetic resonance imaging (MRI). In this case, the patient reports panic attacks in a conventional MRI unit. Given that open configuration MRI units are standard of care for patients with anxiety or claustrophobia, the requested service is medically indicated. Therefore, a stand-up MRI is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services 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 patient has requested authorization and coverage for Odactra 12 standardized quality-house dust mite tablets. Findings:  The physician reviewer found that a study assessing the safety and efficacy of two doses of house dust mite extracts over one treatment year and the subsequent immunotherapy-free year. The authors noted that twelve months of treatment were efficacious and well-tolerated. In a study of 992 adults with house dust mite induced respiratory allergic disease, Demoly and colleagues confirmed the efficacy and safety of sublingual tablets and noted that the treatment effect was present from 14 weeks of treatment onward. Given current medical literature and that house dust mite sublingual immunotherapy is standard of care for the treatment of chronic allergic rhinitis, the requested medication is medically indicated. Therefore, Odactra 12 standardized quality-house dust mite tablets are medically necessary for the treatment of this patient. Final Result: The reviewer 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 reviewer is board certified in allergy and immunology 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 authorization and coverage for virtual colonoscopy/computed tomography colonography of the abdomen and pelvis. Findings:  The physician reviewer found that the American College of Radiology (ACR) guidelines for virtual colonoscopy states that the indications for a computed tomography colonography examination include screening examination in individuals who are at average or moderate risk for developing colorectal carcinoma. The U.S. Preventive Services Task Force recommends computed tomography colonography as a colorectal cancer screening test and stated that, if colonoscopy is not available or is unacceptable to a patient, recommended alternative strategies include flexible sigmoidoscopy every five to 10 years or CT colonography every five years. The documented disadvantages of computed tomography (CT) colonography versus colonoscopy include radiation exposure, missed flat lesions, and the need for subsequent colonoscopy to evaluate positive or equivocal findings (Pickhardt, et al). This patients records do not include documentation to support an indication for virtual colonoscopy in lieu of standard colonoscopy. For these reasons, the requested virtual colonoscopy/computed tomography colonography of the abdomen and pelvis is not medically necessary for this patient.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 board certified in internal medicine with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continued speech therapy. The requested continued speech therapy is medically necessary for treatment of the patients medical condition and should be used to transition the patient to applied behavioral analysis (ABA) therapy. The available records do not support that the patient is making measurable progress with speech therapy and utilization of speech therapy sessions by the patient has been suboptimal. Speech therapy for six months will permit transition to ABA therapy and ameliorate deterioration in behavior and regression of previously acquired speech skills. Behavioral and developmental regression during the COVID-19 pandemic has been described by many parents of children with autism spectrum disorder. Researchers concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal patients with developmental disabilities. Researchers found that treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech and language, occupational, and physical therapies. Given these findings, continued speech therapy is medically necessary to decrease disability and correct or ameliorate the patients behavioral conditions.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 board certified in neurology with special qualification in child 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.