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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa with ribavirin 400 mg  100 mg tablet for 24 weeks. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. However, the patient has satisfied this recommendation with two treatments, including a failed treatment with Viekira Pak, an NS5A inhibitor. After failure of an NS5A inhibitor such as Viekira Pak, AASLD/IDSA guidelines state that Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. The provided information does not establish the presence of cirrhosis or any of the AASLD/IDSA listed severe extrahepatic manifestations of hepatitis C. Limited data is available regarding the efficacy of Epclusa and ribavirin after failure of Epclusa . For these reasons, Epclusa with ribavirin 400 mg  100 mg tablet for 24 weeks is not supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one 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: The parent of an enrollee has requested reimbursement for residential treatment services provided for disputed dates  and prospective authorization and coverage for residential treatment services. Findings:  The physician reviewer found that as noted in the practice guidelines, RTC is considered the highest level of psychiatric care available. Medical necessity guidelines indicate that psychiatric symptoms must be present to the degree that this level of care is needed. The available records do not indicate that this patient had severe psychiatric symptoms but rather continued substance use and associated depressive symptoms due to substance use. The progress notes indicate that the patient was cooperative in treatment. The patient used substances throughout IOP treatment and has failed RTC in the past as well as outpatient treatment on numerous occasions. It appears that the desire for RTC is due to isolation from substances for brief sobriety. The patients family appears to be engaged in substance use and this has been a detriment to the patients sobriety. However, it is unlikely that RTC level of care services will have any benefit on the patients substance use due to numerous failures of this type of treatment as well as apparent minimal commitment to behavioral change on the part of the patient or family. Further, repeated RTC treatment is not indicated or evidence-based. Family therapy is therefore essential to the patients success in the future due to the patients family systems issues. All told, residential treatment services provided and  prospective coverage for residential treatment 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 psychiatry with sub-specialty certification in child and adolescent 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: an enrollee has requested authorization and coverage for magnetic resonance imaging of the lumbar spine without dye. Findings:  The physician reviewer found that this patient presented with a sudden onset of severe low back pain with lower extremity giving way. Clinical examination documented positive nerve tension signs and hyporeflexia. The patient failed to improve despite initial conservative treatment, including steroid injection, oral steroid, opioid pain medication, neuropathic medications, and activity modification. The treating provider opined the patient had an L4/5 or L5/S1 herniated nucleus pulposus.  Final Result: The reviewer determined that the requested procedure is 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 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 inpatient treatment and weekly talk therapy for treatment of her behavioral health condition. Findings:  The physician reviewer found that The requested services are not medically necessary for treatment of the patients medical condition. In this case, inpatient treatment is not medically necessary for treatment of the patients medical condition. The medical records do not support inpatient level of care services. She has recently started an IOP program and has attended less than 10 sessions of this program. She appears to have some emerging engagement with her treatment providers. Continued treatment in this program is medically reasonable and appropriate for this patient. The medical literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of anorexia nervosa. Without a specific medical complications or need for refeeding, inpatient admission is typically not recommended for treatment of anorexia nervosa (Hay, et al). Moreover, the request for weekly talk therapy is not a specific type of treatment. Based on the documentation submitted for review, the patient is receiving several hours of individual and group psychotherapy weekly through her IOP which is medically adequate. 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 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 and prospective authorization and coverage for intensive outpatient services provided.  Findings:  The physician reviewer found that in aggregate, the patients weight fluctuated within a mean weight which did not put the patient at imminent risk of having to be stepped up to a higher level of care.  The patient's eating disorder behavior did not seem to vary much over time.  The patient had improved as to meal plan compliance and reached the 100% mark.  The patient was not a danger to self or others. The patient maintained employment, which was a motivating factor.  The patient was engaged in group and individual therapies.  The patient was at 86% of ideal body weight. Although weights had taken a downward trend, the patient stabilized out and was medically stable.  The patient's parents were supportive.  Although the patient continued to struggle with emotions and eating disorder behavior urges, the patient did not require multiple hours per day, and multiple days per week at an IOP setting. The patient could have maintained treatment at an outpatient level of care. 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 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: an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided. Findings:  The reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains. However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness. In this case, the patients substance use was dominating daily routine and causing functional impairment across multiple domains.  The patient has chronic, serious addictive illness. The patient was using intravenous heroin, consuming alprazolam and ingesting an opioid plant material, heroin and cocaine. The patient had a comorbid psychiatric diagnosis of generalized anxiety disorder and a poor self-concept. The patient had recently failed two successive supervised detoxifications. Thus, a conservative residential treatment stay was indicated. A review of the record, indicates that the patient was struggling with anxiety, depression, shame and craving around the time of service denial. It appears that the services have helped with the consolidation of treatment gains while developing a transition plan for treatment in a less restrictive setting. Based on the longitudinal history and medical documentation, the patient would promptly relapse and require re-admission in the event of a premature discharge from residential programming. Thus, the services and setting are safe, appropriate and consistent with good medical practice. Further, the services provided have been for active treatment delivered in accordance with a treatment plan, and are reasonably expected to bolster his resilience, improve his condition and prevent a more serious episode of illness. Final Result: The reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for occupational therapy at the frequency of four times per week for treatment of her autism spectrum disorder, optic nerve coloboma and myopia. Findings:  The physician reviewer found that the request for occupational therapy at the frequency of four times per week has been established as medically necessary for treatment of the patients medical condition. While the evidence for sensory based OT is emerging, recent studies suggest clinical benefit. Researchers systematically reviewed 27 studies to identify, evaluate, and synthesize the effectiveness of sensory integration intervention on the ability of children with difficulty processing and integrating sensory information to engage in desired occupations and to apply these findings to OT practice. The authors concluded that using sensory integration may provide beneficial outcomes when addressing sensorimotor skills, motor planning, socialization, attention, and behavioral regulation and reading-related skills. In this case, the patient has a complicated medical picture which includes autism spectrum disorder, optic nerve coloboma, myopia, astigmatism for which she wears glasses and hearing loss for which she utilizes bilateral hearing aids. Each of these conditions contribute to significant sensorimotor deficits, making the activities of daily living such as self-feeding increasingly difficult. This fact, coupled with an increasingly restricted diet due to the aforementioned sensory deficits in the context of multiple food allergies that include nuts, wheat/gluten, dairy, coconut, apples, red dye Number 40, and citrus fruits necessitates increased OT services on a weekly basis. Therefore, OT at the frequency of four times per week is medically necessary to ensure increasing levels of independence in the patients activities of daily living, improved transitions and diversified dietary options.  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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of leg vein (heat treatment). for treatment of her bilateral leg pain. Two physician reviewers found that there is clinical support for the efficacy of the requested services in this clinical setting.  Moreover, there is sufficient documentation with respect to the severity of this patients symptoms and her failure of conservative efforts to relieve these symptoms.  The patient had a reasonably recent assessment of lower extremity arterial perfusion. There is documentation of leg edema as well as varicose veins.  There is documentation of reflux at the saphenofemoral junction with a significantly enlarged accessory saphenous vein. The treating provider had assessed that correction of that reflux would be a benefit to the patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in vascular surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that In the peer-reviewed medical literature, it was 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. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that, in the peer-reviewed medical literature, studies 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, the breast tomosynthesis performed was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Evidence based peer reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A study concluded that hyaluronic acid (Orthovisc) was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Orthovisc injections have been found to be safe and effective, allowing delay of total knee replacement. In this case, the patient has been diagnosed with right knee osteoarthritis. Clinical examination findings were consistent with radiographic evidence of significant right knee tricompartmental osteoarthritis. Moreover, this patient has failed to adequately respond to other conservative treatment, including anti-inflammatory medications, physical therapy, and exercise. Prior viscosupplementation injections were performed with significant benefit allowing resumption of normal activities, including pain free running, and ability to avoid surgery. Therefore, Orthovisc injections are medically necessary for the treatment of this patients medical condition.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis to be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging. Thus, the addition of tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewers are board certified in diagnostic radiology and is actively practicing. The reviewers are expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral breast tomosynthesis performed for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that the patient presented with an area of palpable concern in one of his breasts. Once a palpable mass is noted, it is imperative to identify and characterize the mass or to be reasonably confident that a biopsy is not necessary. While male breast carcinoma is unusual, it does occasionally occur, and it is not unreasonable to perform tomosynthesis in this clinical setting. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.