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 participation in the Stanford Comprehensive Interdisciplinary Pain Program (SCIPP) for treatment of the enrollees degenerative disc disease. Findings:  The physician reviewer found that the Joint Commission standards for pain management supports the efficacy of a multidisciplinary approach to pain management. The study re-enforced this approach citing the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. The medical literature has shown that the multidisciplinary approach is statistically better than no treatment or single specialty treatment.  The benefits of this approach were also found to be longer lasting than either of the alternatives. In this patients case, he was identified as a viable candidate for a multidisciplinary program. As such, this patient may benefit from participating in this multidisciplinary treatment option. All told, the SCIPP program is medically indicated for the treatment of this patient. Final Result: The reviewer determined that I have 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 anesthesiology 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 90-day residential drug rehabilitation for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the medical records, this patient did not have suicidal or homicidal thoughts.  This patient has been unable to maintain abstinence and recovery.  However, he does not appear to be residing in a dysfunctional living environment.  Based on the medical records, this patient does not meet the severity of need for residential drug rehabilitation facility treatment and could be treated in a lesser restrictive setting.  Therefore, the requested 90-day residential drug rehabilitation treatment is 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 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 for Viekira Pak for 12 weeks for treatment of the enrollees 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks.  The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines also cite data showing increased survival with earlier treatment. For these reasons, Viekira Pak for 12 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 continued physical therapy visits for treatment of the enrollees left ankle and foot pain.  Findings: The physician reviewer found that based on the documentation submitted for review, continued physical therapy visits have not been established as medically necessary for treatment of the patients medical condition. According to Hawson, physical therapy can be of benefit for foot and ankle injury in an athlete. However, there is limited medical literature addressing the appropriate dosage of physical therapy. The Centers for Medicare and Medicaid Services (CMS) guidelines provide a framework for determination of the need for continued physical services. The CMS guidelines for coverage of outpatient physical therapy state that There must be an expectation that the patients condition will improve significantly in a reasonable (and generally predictable) period of time and that All services provided are to be specific and effective treatments for the patients condition according to accepted standards of medical practice; and the amount, frequency, and duration of the services must be reasonable. In this case, the patient has non-specific pain as the records do not mention an injury or specific tissue pathology. She has been treated with 12 sessions of physical therapy, which is the standard of care duration for musculoskeletal complaints. The patients strength and pain improved with 12 sessions of physical therapy. However, the patient has not shown any improved range of motion. It is not likely for range of motion to improve substantially with additional physical therapy sessions. The Health Plan recommendation for the patient to continue with a home exercise program is medically reasonable and appropriate for this patient. In sum, continued physical therapy visits are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested therapy 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees 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.  In this patients case, the records noted extremely dense breast tissue.  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 effective than other modalities for evaluating this patient.Final Result: Three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has substance abuse residential treatment center services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the residential level of care.  The patient was motivated for sustained sobriety.  He had supportive friends and family and safe housing.  He denied any cross-addiction with other substances, while his co-occurring insomnia, hypertension and depressive symptoms did not require service delivery in a venue more restrictive than the outpatient setting.  There was no evidence in the record that the patient had previously engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate at the time.  All told, substance abuse residential treatment center services were not medically indicated for the treatment of this patient.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: The parent of an enrollee has requested authorization and coverage for a minimum of 35 hours per week of applied behavioral analysis (ABA) therapy necessary for treatment of the autism. Findings:  The physician reviewer found that ABA therapy is medically indicated for treatment of the patients medical condition. One study found that children with autism who started ABA at an earlier age with intensive ABA hours were more likely to have an optimal outcome. ABA therapy has been effective for treatment of the patients autism. He has made progress in communication, executive function and adaptive skills. Although he does continues to have whining and tantrum. Treatment planning should include parent training goals to address the patients maladaptive behaviors. In this clinical setting, the Health Plans authorization of 107 hours per month of direct ABA therapy, 10 hours per month of supervision and eight hours per month of parent training are medically reasonable and appropriate. Therefore, the requested minimum of 35 hours per week of ABA therapy is not medically necessary for treatment of this patients autism. 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-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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Aubagio 14 mg for treatment of the enrollees multiple sclerosis. The Health Plan offers Copaxone, Tecfidera or a beta-interferon (Avonex or Rebif) for treatment of the enrollees medical condition and has denied Aubagio 14 mg as not medically necessary. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication for treatment of this patients MS. The medical literature does not indicate a preference or superiority of Aubagio over interferon or Tecfidera for the treatment of MS. This patient was diagnosed with MS in 1999. The patient was treated with Copaxone. The patient was on Copaxone until 2007 when the medication was discontinued.  The records do not report that this patient had tried other medications for treatment. There were no specific contraindications to using interferon or Tecfidera noted in the submitted medical records. Accordingly, Aubagio 14 mg for treatment of this patient is not medically necessary.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multi-parametric magnetic resonance imaging (MRI) of the prostate (MRI pelvis with and without contrast - RX should specify: mpMR prostate with & without contrast) for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  Three physician reviewers found that the patient presented with signs and symptoms consistent with prostate infection.  The patient presented with elevated prostate specific antigen (PSA). He was treated with ciprofloxacin. The patient has requested multi-parametric magnetic resonance imaging (MRI) of the prostate (-MRI pelvis with and without contrast - RX should specify: mpMR prostate with & without contrast for evaluation of his medical condition). The Health Plan considers the requested services as investigational for the evaluation of the patients medical condition. This patient presented with a symptoms consistent with prostate infection. He was found to have an elevated PSA. Elevated PSAs are commonly found to be elevated with prostate infections. The patient was treated appropriately with ciprofloxacin to treat the infection. There was no evidence in the submitted records to suggest that this patient had prostate cancer other than the elevated PSA. Once the patient is treated for his prostate infection, the patient should be rechecked. If the patients PSA is still elevated, an ultrasound of the prostate and biopsy would be indicated at that time. Multi-parametric magnetic resonance imaging (mpMR) of the prostate is used to establish clinically significant information (i.e. staging and grading) that may influence a treatment approach after prostate cancer has been established through traditional means. However, the standard steps in diagnosing prostate cancer is by performing an ultrasound and a biopsy.  MpMR of the prostate has not replaced that step in diagnosing prostate cancer. As such, the requested services are not likely to be more effective than the available standard options for evaluation of this patient for prostate cancer. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis for treatment of the enrollees lumbosacral spondylosis.Findings:  Three physician reviewers found that the enrollee has a history of knee pain, lumbar radiculopathy, osteoarthritis of the hip, and lumbar disc degeneration. The patient presented to her provider on 2/5/16 and reported pain in the back and upper left leg. The patient described this pain as constant, shooting, worse with activity and better with medications. The pain had begun two months prior to the visit in February. The patient had tried heat, ice, and transcutaneous electrical nerve stimulation. Per the patient, the treatments helped some. Straight leg raise was positive on the left. The patient had pain with extension and flexion of the lumbar spine. A magnetic resonance imaging noted degenerative changes with retrolisthesis and spinal stenosis. On 2/11/16, a lumbar epidural injection was performed. On 3/31/16, the provider notes stated that since the diagnostic facet joint medial branch blocks helped the patients pain more than 80%, he recommended left sided L4, L5, and S1 radiofrequency neurolysis. On 3/31/16, a left sided L4, L5, and S1 radiofrequency neurolysis was performed. The operative report stated the patient responded well to medial branch blocks at L4, L5, and S1. On 4/14/16, a right sided L4, L5, and S1 radiofrequency neurolysis was performed. The operative report stated the patient responded well to medial branch blocks at L4, L5, and S1. The medical literature is clear about how a diagnostic medial branch block should be performed prior to radiofrequency neurolysis, specifically using a pain diary for the day to verify when the local anesthetic wore off. In the documentation available for review, the provider does not document a pain diary for the medial branch block performed prior to the radiofrequency neurolysis. Moreover, radiofrequency neurolysis is not recommended when patients have radicular pain. It was also possible the patient would have had the same relief from a steroid injection alone without having the increased risk from the radiofrequency neurolysis. The submitted records do not mention prior failure from facet injections. Finally, there is no documentation of a home exercise program or physical therapy. Final Result: Three 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 physician reviewers are board certified in anesthesiology 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 reimbursement for magnetic resonance imaging for evaluation of the enrollees headaches. Findings:  The physician reviewer found that evidence based medical guidelines support MRI of the brain in this clinical setting. The National Imaging Association (NIA) clinical guidelines specify MRI of the brain for headaches lasting more than a few minutes when there is associated neck pain. These types of headaches could be related to carotid/vertebral artery dissection.  In this case, the patient presented with a unilateral severe headache which lasted one week. Moreover, the records indicate that while the neurological examination was normal, there was a concern of intracranial pathology. The patient did not have signs of sinus disease and there was no history of infection or trauma reported. Based upon the patients history and the referenced guidelines, the services at issue were medically appropriate. As such, the MRI was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 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 reimbursement for right hip lipoma removal surgery for treatment of the enrollees lipoma. Findings:  The physician reviewer found that there is sufficient support for the procedure at issue in this clinical setting. The mass was noted to be 10 x 6 x 4 cm and the patient reported symptoms as a result of the lipoma. The lipoma was causing significant irritation and functional limitations.  According to the submitted records, conservative treatment was also attempted.  Therefore, the procedure at issue was not cosmetic. Instead, the patient addressed symptoms of pressure which the patient reported impacted her daily function. As such, the lipoma procedure was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the procedure at issue was 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 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.