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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested group social skills therapy for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that social skills groups are indicated for children with autism spectrum disorders. However social skills groups are primarily indicated for school age children who are not receiving applied behavior analysis (ABA) services. The primary goals of the social skills groups are social competence, social communication and emotion recognition. In this case, parental concerns include non-compliance, repetitive behaviors, disruptive and aggressive outburst behaviors and public behavior. The requested intervention is not designed to address aggression and non-compliance. Reichow and colleagues (2012) found improvements in communication, cognitive skills, social skills and adaptive skills through the use of ABA.  In reviewing the additional information provided for review, there is a lack of evidence demonstrating that the patient is ready for a social skills group. Once she is more compliant with most adult directions, does not have outbursts and obtains basic conversational skills to be able to respond appropriately in a group then a social skills group may be indicated. In general, many children with autism spectrum disorders in the school age do benefit from social skills groups.  However, there are some basic social skills that need to be learned in a one-on-one setting prior to engaging in social skills groups. Re-evaluation by developmental pediatrician or ABA team for readiness to engage in a social skills group should be done in the near future.  In this case, the most appropriate way to address the parental concerns is through ABA. At this time the goals of building social skills should occur through ABA.  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 pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orencia  for treatment of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested medication in this patients case.  Orencia is approved for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors.  This medication appears to be most effective in certain subsets of rheumatoid arthritis patients.  In this case, the patient most likely has an overlap of systemic lupus erythematous and seronegative rheumatoid arthritis.   The requested Orencia 125 mg is 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 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: An enrollee has requested whole breast ultrasound for evaluation of her medical condition. Findings: The physician reviewer found that automated whole breast sonography has not attained widespread acceptance which may be related to an element of operator dependence. According to Berg and colleagues Automated whole-breast ultrasonography (US) offers the potential for complete documentation; however, real-time adjustment of scanning pressure, focal zones, and gain are often needed to appropriately analyze lesion features. The issue of operator dependence is a major concern when considering widespread use of whole-breast US. In sum, while automated whole breast ultrasound has been developed as a screening tool, there is a lack of widespread consensus concerning which, if any, additional studies are recommended to evaluate a patient with dense breasts. Therefore, whole breast ultrasound is not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive non-cirrhotic genotype 1a patients should be treated with Harvoni. The guidelines report that Harvoni for eight weeks is appropriate in patients with viral load of below 6,000,000 IU/mL. These guideline recommendations are based on multiple randomized clinical trials.  The guidelines cite study data reporting that delay in treatment is associated with decreased survival. For these reasons, the requested Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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 Harvoni for 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive, non-cirrhotic genotype 1a patients should be treated with Harvoni, or with Viekira Pak and ribavirin for 12 weeks. The guidelines report that Harvoni for eight weeks is appropriate in patients with viral loads below 6,000,000 IU/mL. These guideline recommendations are based on multiple randomized clinical trials. There are no reported current medical contraindications to the alternatives Viekira Pak or ribavirin, although caution must be used in men whose partners are planning pregnancy.  In sum, treatment of hepatitis C is supported in this case, but the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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 anesthesia services during an endoscopy for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The patient had a low ASA preoperative physical status classification score. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in clinical practice given a low preoperative physical status classification score, such as in this case. Given the above, 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 anesthesiology with sub-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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary: An enrollee has requested sacroiliac joint fusion for treatment of his medical condition. Findings:  Two physician reviewers found that there is a lack of support for the requested services in this patients case.  This patient has had surgical procedures to address both low back pain and left hip osteoarthritis, two common conditions which can mimic sacroiliac joint pain.  The diagnosis is crucial determining whether or not a patient will respond well to the procedure.  Based on the submitted records, it is not clear the patient is an appropriate candidate for the requested procedure.  There is a lack of laboratory results to indicate whether the patient has been evaluated for systemic arthropathy.  In addition, there is a lack of imaging results submitted in the records which describe the presence or absence of pathologic findings of the left sacroiliac joint.  Therefore, the requested services are not likely to be superior over other treatment options. 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 orthopedic surgery 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:   The parent of an enrollee has requested speech therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services at this time.  Speech services can be helpful for children with language delays to help with behaviors, communication and cognitive learning.  This patient had expressive language score of the 2nd percentile, but total language score of the 3rd percentile.  In this clinical setting, a re-evaluation in six months from the original evaluation is medically necessary.  A repeat evaluation is needed to demonstrate the necessity of the requested services, and the records do not document that this has been done.  All told, the requested speech therapy is not medically indicated for the treatment of this patient at this time. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an office consultation with a plastic surgeon for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has well-documented signs and symptoms of significant macromastia that has failed reasonable conservative management.  She is noted to have failed conservative management of multiple bras, acupuncture, massage therapy, physical therapy and medical management of her chronic rashes.  Multiple medical professionals support a referral for possible breast reduction.  The patient has a well-defined functional deficit of chronic pain and chronic rashes that are likely directly related to her macromastia.  All told, the requested office consultation with a plastic surgeon is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in plastic 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.   It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: Three 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested a shingles vaccine for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate that the patient requires the shingles vaccine.  In a study by Oxman et al, they enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine (zoster vaccine).  The authors found that the zoster vaccine markedly reduced morbidity from herpes zoster and post-herpetic neuralgia among older adults.  In the  Cochrane review, the authors looked at the shingles vaccine and which age group benefitted the most, `Analyses according to age groups indicated a greater benefit in participants aged 60 to 69 years, RR 0.36 (95% CI 0.30 to 0.45) and in participants aged 70 years and over, RR 0.63 (95% CI 0.53 to 0.75).`  The Advisory Committee on Immunization Practices (ACIP) recommends the vaccination for adults who are 60-years-old and over. The Infectious Diseases Society of America (IDSA) recommends that patients who are about to receive immunosuppression should be vaccinated at least 4 weeks before the initiation of immunosuppressive therapy if they do not have a history of zoster vaccination. Although the records state that there is the likelihood of immunosuppression, these records fail to demonstrate that the patient has a diagnosis requiring immunosuppression or definite plans for immunosuppression. As such, the requested shingles vaccine is not medically necessary in this clinical setting.  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 rheumatology and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this case, an area of architectural distortion was noted.   Breast tomosynthesis has been shown to be helpful in evaluating areas of asymmetry or distortion, which is often the only sign of an occult malignancy.  Thus, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  Final Result: Three 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:   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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested elbow manipulation under for treatment of his medical condition. Findings:  Two physician reviewers found that there is a lack of large volume, long-term peer-reviewed outcome studies to support the elbow manipulation under anesthesia for treatment of the patients medical condition. Araghi and colleagues performed a study of 51 consecutive patients who underwent elbow examination under anesthesia. The authors concluded that examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the elbow motion obtained at the time of surgical release. Because this was not a controlled series, the authors opined that additional studies might be conducted to refine those not benefiting from this procedure. In this case, the patient sustained a dislocated radial head fracture with ligament disruption. He underwent open reduction and internal fixation. He was diagnosed with a healed fracture with loss of range of motion. Fluoroscopic examination documented a protruding screw that appeared to block left elbow rotation. Screw removal was recommended and performed along with capsular release and manipulation under anesthesia. There is a lack of compelling rationale presented supporting the manipulation under anesthesia over capsular release and standard post-operative physical therapy following screw removal to regain range of motion. Therefore, the elbow manipulation under anesthesia was 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 services at issue were 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 orthopedic surgery 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.