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

Nature of Statutory Criteria/Case Summary: An enrollee has requested dialectical behavior therapy (DBT) for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that, in this case, the patients complex illness burden, consisting of but not limited to ego fragmentation, clinical depression, auditory hallucinations, dissociation, recurrent suicidality, limited coping skills and self-defeating coping strategies, increases the risk for a poor clinical outcome in the absence of appropriate treatment. Dialectical behavior therapy (DBT) is medically necessary for this patient as the record provides ample evidence of functional impairment stemming from the symptoms of borderline personality disorder. Further, the therapy has been recommended by clinicians familiar with the case while DBT is a trusted evidence-based intervention that benefits those with character pathology. Moreover, DBT is reasonably expected to improve the patients condition and prevent a more serious episode of illness. Therefore, DBT is medically necessary for treatment of the patients behavioral health condition.Final Result: The reviewer determined that the requested 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 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 skilled nursing facility services for treatment of the enrollees lateral tibial plateau compression fracture and a strain of the patellar ligament. Findings: The physician reviewer found that Tibial plateau fractures are complicated injuries, each requiring an individualized initial approach whether surgical or nonsurgical. These fractures can result in significant functional impairments.  The focus of early rehabilitation efforts should be an early range of motion with special attention to full knee extension.  In this patients case, the patient had been in the rehabilitation setting for approximately a month and a half.  She had made no progress with transfers or mobility.  Even if she had been on non-weight-bearing restrictions of one lower limb, some progress with transfers should have been possible.  No progress has been documented even with liberalization of her weight-bearing status to weight-bearing as tolerated.  The records indicate that the patients obesity and diminished functional capacity are precluding meaningful progress with rehabilitation before knee replacement surgery as well.  Further care could have been provided in a less intensive setting of care.  Continued inpatient care would constitute custodial level care.  All told, skilled nursing facility services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewers 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 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 enrollee, who had a history of ductal carcinoma in situ.  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, her breast tissue has been described as dense.  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. Therefore, digital breast tomosynthesis was likely to have been more efficacious than other methods of 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 requested authorization and coverage for physical therapy twice daily. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested physical therapy services. The patient has had physical therapy treatments and is now at eight months status post injury. The patient has already reached a plateau with skilled treatments due to the orthopedic injury that he sustained. Further skilled therapy is not expected to significantly improve his condition. As of 3/18/16 he had range of motion from -15 to 120 degrees. He was making progress with therapy. He remained pain free. On 5/27/16, his provider had recommended a night splint. On 6/2/16, his motion had significantly improved. He had range of motion from about -15/20 to 130 degrees.  Although the patient describes being unable to perform self-stretching, there is no impairment of the right upper extremity. Per the records, he is right hand dominant and his stretching technique can be modified. A splint had been recommended and could be considered as an alternative treatment. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that in this clinical setting guidelines for the management of cardiac risk 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 Lp-PLA2, sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (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. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the advanced lipoprotein testing provided has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary. An enrollee has requested digital breast tomosynthesis for the evaluation of the enrollees risk of breast cancer. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a combination of two dimensional and three dimensional tomosynthesis examination. The current images were compared to a prior mammogram, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis stating that digital tomosynthesis was investigational for the evaluation of this patient. 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 particular patient, she has breasts that have been described as being heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three physician 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 requested authorization and coverage for Percocet 10/325 (three times a day).Findings:  The physician reviewer found that the medical literature does not support the medical necessity of the requested medication regimen in this clinical setting. The Argoff review article noted specifically that for chronic non-cancer pain, short acting and long acting opioid have been found to be effective. However, the review also noted that therapies should be tailored to the individual patient. In the Nicholson article, it was noted that opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerability. In this patients case, the documentation shows that recent visits with her treating provider noted some success with tapering of Percocet. Progress notes dated 8/10/16 noted that the patient was drinking more fluids and feeling better overall.  At that time, the patient was on Percocet 7.5 mg.  Therefore, a higher dose of Percocet is not medically indicated for treatment of this patient. Instead, continued weaning of Percocet is medically appropriate.Final Result: The reviewer determined that  the requested medication regimen 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 Synvisc injections for treatment of the enrollees chronic knee pain. Findings: The physician reviewer found that Evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient was diagnosed with advanced osteoarthritis of both knees. She underwent prior right knee arthroscopic surgery. She has undergone multiple viscosupplementation injections at least three times with pain reduction and improvement in function. She has worsening bilateral knee pain and functional impairment that has failed to respond adequately to other conservative treatments, including medications, activity modification, physical therapy, and bracing. In sum, the requested Synvisc injections are medically necessary for 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested sleeve gastrectomy for treatment of the enrollees obesity.  Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  A psychological evaluation revealed no obvious barriers to surgery, and dietary clearance was also obtained.  However, there is a lack of support for the requested sleeve gastrectomy in this clinical setting.  The patient does not meet standard definition of morbid obesity at this time, including a body mass index of 40 or body mass index of 35 with serious comorbid conditions such as diabetes, hypertension or sleep apnea.  All told, the requested sleeve gastrectomy 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 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 digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  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, her breasts were described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, 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.  Thus, digital breast tomosynthesis was likely to have been more effective than other methods of 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: 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 enrollee, who was asymptomatic.  Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.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 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: 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 breast examination.  Findings: Two physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Thus, the digital tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested 3T magnetic resonance imaging (MRI) for evaluation of the enrollees prostate cancer.  Findings: The physician reviewer found that in the peer-reviewed medical literature, Filson and colleagues reported that MR-ultrasound fusion biopsy allowed for the detection of clinically significant prostate cancer. Kuru and colleagues noted that MRI/transrectal ultrasound fusion has shown encouraging results for detecting clinically significant prostate cancer. Similarly, Valerio and colleagues compared the ability of standard biopsy to diagnose prostate cancer against a novel approach using software to overlay the images from magnetic resonance imaging and ultrasound to guide biopsies towards the suspicious areas of the prostate. The authors found consistent findings showing the superiority of this novel targeted approach, although further high-quality evidence is needed to change current practice. Further, Schoots and colleagues noted that they found evidence to suggest that MRI-guided targeted biopsy benefits the diagnosis of prostate cancer. Thus, the literature does support the use of the requested 3T MRI of the prostate as medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.