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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a computed tomography (CT) scan of the left leg for evaluation of lumbar myofascial pain syndrome (MPS) of her left leg. Findings:  The physician reviewer found that the patient has requested a CT scan for evaluation of her chronic leg pain; however, there is limited medical literature to support this request. Imaging, especially computed tomography, has no significant role in the diagnostic workup for this patient. As noted by Childers and colleagues, Myofascial pain syndrome (MPS) is a painful disorder characterized by distinct sensitive spots in a palpable taut band of skeletal muscle fibers that produce local and referred pain. These palpable areas are referred to as myofascial trigger points (MTrPs) (Childers, et al). The symptoms are dull achy pain exacerbated by direct pressure over the trigger points. Unfortunately, there are no specific diagnostic or laboratory tests to confirm this diagnosis. As such, a CT scan is not likely to be clinically useful in the diagnosis and/or management of this patient's myofascial pain. All told, the efficacy of CT scans for evaluation of myofascial pain syndrome is not well established and therefore, the requested CT scan is not medically necessary in this patients case. Final Result: The reviewer determined that the requested service is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested medical treatment for his medical condition. Findings:  The physician reviewer found that the medical treatment at issue was medically necessary for treatment of the patients medical condition. Patients who have had a relatively prolonged period of disease control following their initial chemoradiotherapy and whose overall condition is good may be candidates for retreatment with a platinum-based combination. In this case, the patient received weekly chemotherapy with cisplatin, docetaxel, and cetuximab and radiation therapy. This treatment was medically necessary and is the standard regimen for non-pharyngeal head and neck cancer with recurrent disease according to the National Comprehensive Cancer Network (NCCN) guidelines. In addition, patients with head and neck cancer with one or a limited number of distant metastases at presentation or relapse may benefit from aggressive treatment that includes eradication of all known sites of disease. Radiation to the patients liver metastases would be considered for curative intent given his limited metastatic site of disease. All told, the medical treatment at issue was medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in medical oncology and hematology 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 residential mental health and substance abuse treatment services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the documentation submitted for review supports the medical necessity of the residential mental health and substance abuse treatment services in dispute. According to the American Psychiatric Association (APA) Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Considering the patients history of abuse and post-traumatic symptoms, the feasibility and appropriateness of discharge to a sober living environment was questioned by the clinical team. In the absence of residential programming, the patient would have more than likely returned to a pathological and self-defeating pattern of alcohol consumption if she was discharged. The comprehensive services being provided have been delivered in accordance with an individual treatment plan. The services address not only her addictive illness, but her anxiety, depression, pain and family issues as well. Further, the services remain reasonably expected to improve the patients condition and prevent a more serious episode of illness. Finally, the duration of residential care remains consistent with community practice standards. Considering the patients clinical presentation and the peer-reviewed literature, residential placement was a safe, appropriate disposition consistent with good medical practice. Accordingly, residential mental health and substance abuse treatment services were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer 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: 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 parent of an enrollee has requested inpatient mental health services for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the records provided for review indicate that the inpatient treatment was not medically necessary. The notes do not indicate the patient met medical necessity criteria for inpatient mental health services. No aspect of her medication management or therapy required the inpatient mental health level of care, and all treatment goals could reasonably have been met at a less restrictive, less intrusive level of care, such as outpatient care. In none of the documentation including the intake evaluations and multiple progress notes was there any note that would suggest ongoing inpatient level of care treatment was necessary or appropriate given the patients mild symptoms and denial of any risk of harm to herself or others. Very few medication management changes were made, and they were minor adjustments that could have been conducted in an outpatient setting. For these reasons, the requested inpatient mental health 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Suboxone for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Suboxone is a combination medication containing a partial opioid agonist with a full opioid antagonist.  Suboxone is U.S. Food and Drug Administration (FDA) approved for opioid dependence.  The records indicate that Suboxone has been prescribed for chronic pain.  The current medical evidence does not support the requested medication in this clinical setting.  Other alternatives for pain management are more effective in opioid dependent patients.  All told, Suboxone is not medically indicated for the treatment of this patient. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested mental health intensive outpatient program (IOP) services for treatment of her medical condition. Findings:  The physician reviewer found that as in all conditions, the least restrictive level of care is preferred, and the determination of the ideal care setting is best made by the providers most familiar with the clinical situation and treatment needs. With that in mind, both the patients psychiatrist and therapist have recommended continued treatment at the IOP level of care. During her IOP programming thus far, the patient has been engaged in active treatment using evidence-based therapies delivered in accordance with an individual plan of care targeting her conditions. The IOP setting is reasonably expected to both improve the patients condition and prevent a more serious episode of illness.  The IOP setting represents a safe and appropriate placement consistent with accepted medical practice in this setting.  As such, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.   Final Result: The reviewer 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: 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of his medical condition.  Findings:  Two physician reviewers found that standard therapies for early stage prostate cancer include prostatectomy, interstitial brachytherapy and IMRT. Proton therapy is also an option, though this treatment option has not been demonstrated to confer a substantial advantage over IMRT. This patient has high risk disease due to his substantially elevated PSA level. For high risk disease, the need for SBRT is not well-established in the literature. Most studies that included patients with high risk disease have enrolled small numbers of patients. In addition, the American Society of Radiation Oncology (ASTRO) model policy does not support the need for SBRT in high risk patients. All told, the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a magnetic resonance imaging (MRI) of the abdomen (pancreas) for evaluation of his medical condition.  Findings:  The physician reviewer found that in the peer-reviewed medical literature, Del Chiaro and colleagues reported that while some cystic lesions of the pancreas show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). Schmid and Siveke found that in most cases, cystic lesions are detected incidentally by computed tomography and magnetic resonance imaging (MRI) performed for other reasons. Thus, the literature seems to support the use of CT or MRI for pancreatic imaging for mass. This patients follow-up CT showed no pancreatic mass, thus the requested MRI is not medically necessary for further evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested diagnostic procedure is 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: An enrollee has requested Botox injections for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has diagnoses of cluster and migraine headache per the medical records.  There is no indication of headache frequency or prior medications other than verapamil and indomethacin.  Data regarding Botox for headaches shows good success at doses of 155 to 195 units for patients with chronic migraine.  However, data regarding treatment for cluster headaches is more mixed, and typically when used for this diagnosis it has been after trials of several standard preventive medications such as lithium, topiramate and valproic acid, and more typically at doses as used for chronic migraine.  The provided records do not support the medical necessity of Botox treatment for this patients condition.  All told, the requested Botox injections are not medically indicated 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 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:  An enrollee has requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. The patient was noted to be experiencing post-acute withdrawal symptoms in the form of sleep disturbance, anxiety, and nightmares. However, these symptoms are consistent with a diagnosis of PTSD. The patient was not a danger to herself or others. She was medically and psychiatrically stable. There were no documented emotional, behavioral, or cognitive issues that would preclude her from continuing her recovery at a lower level of care. She was motivated for relapse prevention. Her recovery environment in terms of her relationships with family, was not conducive for her overall well-being. However, she was seeking sober living which would be supportive and not undermining to her recovery. Although she continued to struggle with her emotions and required further treatment to help her develop coping skills, she no longer required 24-hour monitoring in the residential setting. Therefore, the requested residential treatment center 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 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 individual therapy with a licensed clinical social worker once a week for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the request for individual therapy with a licensed clinical social worker once a week is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient is documented to be cooperative and pleasant with no psychomotor agitation. Her thought process is linear and her cognition is normal. Her insight and judgment are also noted to be good. The records revealed that this patient is more relaxed and not showing dysphoria. In addition, a therapy note reported that her compliance with treatment has been excellent. In sum, her mental status shows no distress or abnormality that requires weekly individual therapy. Based on the medical records provided for review, individual therapy with a licensed clinical social worker once a week has not been established as medically necessary. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The additional three dimensional imaging allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, offers increased cancer detection, and allows better characterization of possible masses, spiculation, and architectural distortion. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.