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 a consultation with a cardiothoracic surgeon. Findings:  The physician reviewer found that the requested consultation with a cardiothoracic surgeon has been established as medically necessary for evaluation of the patients medical condition. Mild cases of palmar hyperhidrosis can be managed medically without surgery by using topical aluminum chloride, oral anticholinergic agents, or iontophoresis. These treatments are only effective in patients with mild hyperhidrosis. In this case, the patient presents with severe hyperhidrosis. She has been treated with Botox injections to the hands which provided temporary relief and was painful. She also developed hand weakness after treatment with Botox. Thus, the standard medical treatments would not be expected to have any significant long-term benefit for this patient with serious severe palmar hyperhidrosis. Her provider recommends treatment with ETS, which is considered a first-line treatment in appropriate patients. Final Result: The reviewer determined that the requested consultation 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 thoracic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings: Three physician reviewers found that primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), CRP, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Final Result: The reviewers determined that the testing at issue was 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a magnetic resonance imaging (MRI) for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the services at issue. Prior to an MRI of the shoulder, a six week trial of conservative treatment is necessary.  Moreover, there is no documentation or notes by the orthopedic surgeon addressing the progress of physical therapy. There is a lack of support for the services at issue in this clinical setting.  The physical therapy had not concluded prior to the MRI of the right shoulder. For these reasons, the MRI was not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested low field magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this patients case.  MRI of the wrist has been a valuable tool in the assessment of the various ligaments of the wrist for at least two decades.  This technique allows for detailed analysis of the bones of the wrist not possible with plain x-rays, as well as detailed analysis of key soft tissue elements such as the triangular fibrocartilage complex and the various ligaments of the wrist which is not possible with other imaging techniques.  MRI of the wrist is a mainstay of imaging evaluation for patients with wrist injuries.  Ejbjerg and colleagues noted that there was essentially no change in the detection of pathology comparing high field and low field magnets.  The advantage of the low field magnets is increased patient tolerance due to positioning, and the use of low field magnets for hand/wrist evaluation has been in place for well over a decade.  In sum, low field MRI was likely to have been of greater benefit 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency room services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with severe worsening back pain and disability. Serious low back pain can lead to paralysis, bowel and bladder dysfunction. Cauda equina syndrome, spinal cord compression, compressive radiculopathy, spinal stenosis, paraspinal infections, vertebral collapse due to osteoporosis and malignancy, and abdominal aortic aneurysm can all occur without trauma. Based on the records submitted, the patients symptoms were of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in causing serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services at issue meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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: The parent of an enrollee has requested the Tomatis Method - auditory integration therapy for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that the Tomatis Method is an auditory integration therapy that has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of medical research demonstrating the Tomatis Method is effective in this clinical setting. The study by Corbett and colleagues found that children not receiving Tomatis Method had better language progress than the children receiving the Tomatis Method. Given the lack of support in the peer-reviewed literature, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any standard therapy. Final Result: Three 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:   One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested two hours per week of occupational therapy for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. There is ample evidence in the peer-reviewed literature that demonstrates occupational therapy can be effective for addressing sensory processing issues for children with autism spectrum disorder (ASD). An overall sensory based intervention can help children with ASD develop coping strategies. In addition, there is sufficient evidence in the peer-reviewed literature that supports occupational therapy as helpful for patients with ASD with learning activities of daily living. According to the documentation submitted for review, the patient continues to require occupational therapy to address decreased sensory processing and difficulty with fine motor skills. Thus, the requested two hours per week of occupational therapy has been established as medically necessary in this clinical setting. Final Result: The reviewer determined that the requested two hours per week of occupational therapy 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 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 partial hospitalization program (PHP) services for treatment of the enrollees eating disorder.  Findings: The physician reviewer found that the medical records provided for review demonstrated that safe and effective care could not have been reasonably provided in a less restrictive setting than PHP and these services remain medically necessary. The patient is obese with a body mass index (BMI) of 43. The patients nearly lifelong pathological eating habits and subsequent obesity negatively impacts her sense of self and physical health. Additionally, she has significant co-occurring psychiatric illness. The patient has made modest progress but has been unable to consolidate meaningful treatment gains thus far during the admission. The provider described the patient as self-critical. The patient was anxious at meal time and taking small bites and with long pauses. The patient was not motivated to eat at home due to not having any consequences and she reportedly binged that night. The following day she was hopeless and suicidal. The services are evidence-based and aimed at optimizing the skills needed to succeed in a less restrictive treatment setting. Further, the services are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Review of the clinical documentation, in context of the relevant peer-reviewed medical literature shows the PHP services were and are medically necessary for treatment of this patients medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Actemra 162 mg/0.9 syringe (tocilizumab) for treatment of the enrollees medical condition. Findings: The physician reviewer found that the medical literature supports the use of tocilizumab in this clinical setting. Tocilizumab is a monoclonal antibody that binds the IL-6 receptor blocking its activation from IL-6 cytokine. This medication is U.S. Food and Drug Administration (FDA) approved for treatment of inflammatory arthritis such as rheumatoid arthritis (RA) and systemic juvenile idiopathic arthritis. The FDA label states that tocilizumab is indicated in RA when the patients disease has progressed while on other medications. In this case, the patient has contraindications to steroids and other medications since they would interfere with her immunotherapy. Nevertheless, this patient needs therapy for acute bouts with arthritis.  Therefore, treatment for this patients medical condition with tocilizumab is medically necessary.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 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 authorization and coverage for oxycodone HCL ER 10 mg, every eight hours for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The records indicate appropriate utilization of the requested medication. The patient has tried and failed multiple non-opioid medications and short-acting opioid medications.  He has demonstrated improved analgesia and function with the requested medication regimen.  There is no documented aberrant behavior or side effects.  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: Physician reviewer number one 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings in the interpretation of mammograms particularly in cases of heterogeneously dense tissue such as in this case. The technique allows radiologists to separate dense glandular elements from underlying architectural distortion/mass in many cases thereby reducing callbacks and increasing the detection of small cancers. 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: Physician reviewers number one, two, and three 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 Harvoni for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that while this patients records may not support advanced fibrosis, current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This guideline applies regardless of fibrosis stage or viral load. In this case, treatment with Harvoni is medically indicated. Therefore, the requested Harvoni for eight weeks is medically necessary for treatment of the patients medical condition.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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the 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. The AASLD and IDSA guidelines recommend that non-cirrhotic treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for the evaluation of her medical condition.  Findings:  Two physician reviewers found that 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. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided above, 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 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.