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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services including physical therapy and occupational therapy services provided for treatment of the enrollees transient ischemic attack (TIA), epilepsy, and pressure ulcers. Findings:  The physician reviewer found that based on the medical records provided for review, the SNF services including physical therapy and occupational therapy services provided were not and are not medically necessary for treatment of this patients medical condition. Patients require SNF services or skilled rehabilitation services when they are needed on a daily basis and the daily skilled services can be provided only on an inpatient basis in a SNF. The documentation does not reveal that this patient requires SNF services. There is a lack of evidence that the patient requires such SNF services as intravenous or enteral feeding (enteral feeding that comprises at least 26% of daily calorie requirements and provides at least 501 milliliters of fluid per day), tracheotomy aspiration, suprapubic catheter care, treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other SNF need. While the patient may benefit from continued therapy, the documentation does not support that the patient requires these services on a daily basis or only as an inpatient in a SNF. The patient has made slow progress per therapy documentation and has had left-sided weakness prior to this SNF from his stroke. Therefore, the patient is not expected to make measurable gains within a reasonable and predictable period of time. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility and/or activities of daily living, he does not have medical needs that require skilled nursing services to prevent a deterioration in his condition, and the patient does not require skilled therapy to establish a safe and effective maintenance program. Without clear skilled nursing needs the patient does not require SNF services to establish a safe and effective maintenance program. For these reasons, this patient does not require the necessary services on an inpatient basis at a SNF level and care and his current needs can be met at a lower level of care. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 authorization and coverage for viscosupplementation injection for treatment of the enrollees osteoarthritis of knees. 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. Viscosupplementation has been found to be safe and effective. More importantly, viscosupplementation has delayed total knee replacements for patients diagnosed with osteoarthritis. The studies have also shown that viscosupplementation is  more effective than corticosteroid injections. This patient was diagnosed with severe left knee osteoarthritis. He had been treated with corticosteroid injections, medications, and activity modification without sustained relief. He had undergone more than two series of viscosupplementation injections with reported significant sustained relief of his chronic osteoarthritis pain. Therefore, the requested coverage for viscosupplementation injection is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested injection 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 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 reimbursement and prospective authorization and coverage for partial hospitalization program 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.  Prior to dates of service in question, there was no indication that the patient was an immediate risk of harm to herself or to others. The patient completed the detoxification process and did not have severe acute withdrawal symptoms.  She was compliant with medications and treatment. The patient was highly engaged in group therapy sessions, and she was medically stable.  The patient was motivated for change.  She has a history of a five-year period of sobriety which she achieved through attending community Alcoholics Anonymous meetings. The patient had a supportive family that encouraged sobriety.  Although the patient continued to require treatment for her alcohol use disorder, this could have been done in a less restrictive setting such as an intensive outpatient program level of care.  All told, partial hospitalization program services for the remainder of 30 days were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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 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, the records noted heterogeneously dense breast tissue.  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.  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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for custom molded foot orthotics. Findings:  The physician reviewer found that this patient suffers with plantar fasciitis pain, with a biomechanical structural abnormality including a flexible pes cavus foot structure with overpronation upon stance. She is noted to have pain upon palpation to the medial arch bilaterally.  Custom functional orthotics are the standard of care for the treatment of painful plantar fasciitis.  These devices are fabricated from an impression made of the patients foot. They are created to hold the foot in a biomechanically normal or correct position, thereby taking stress off of the plantar fascia and alleviating pain.  Final Result: The reviewer determined that the requested equipment 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 podiatry 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

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. 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. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: the 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 authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees Crohns disease, ulcer and diarrhea. Findings:  The physician reviewers found that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohns disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful. Capsule endoscopy has been proven to be more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis, and capsule endoscopy resulted in a change in management in a significant number of patients based on findings missed by other tests. Capsule endoscopy is a valuable tool in evaluation of patients with Crohns disease and is more sensitive than conventional ileocolonoscopy for the diagnosis of small bowel Crohns disease activity. For these reasons, the requested wireless capsule endoscopy is likely to provide useful diagnostic information in this case, and is 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 requested diagnostic procedure is 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 internal medicine with sub-specialty certification in gastroenterology and 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 authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, 12 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA is supported by the peer-reviewed literature as medically necessary for children with autism spectrum disorder. ABA therapy started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. ABA has been helpful for this patient, as she has made progress in social, play and cognition skills. However, she continues to have maladaptive behaviors including non-compliance, biting and inappropriate grabbing. She is making slow progress with her goals, and has plateaued in other areas. A gradual reduction of services is indicated. As such, 35 hours per week of ABA therapy, 12 hours per month of supervision and two hours per month of parent training is medically necessary and appropriate based on her progress and significant decrease in maladaptive behaviors. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: 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 enrollees breast cancer screening. Findings:  The 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 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, the patients breast tissue was described as being heterogeneously dense. While her mammogram has not changed since the last study, 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. Therefore, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All 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:  Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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 reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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
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. 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 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, the patients breast tissue has been described as being dense. While her mammogram has not changed since the last study, 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. 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 Lyrica for treatment of the enrollees polyneuropathy due to acquired immunodeficiency syndrome (AIDS).   Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. There is a lack of peer-reviewed literature supporting Lyrica in this clinical setting. Simpson and colleagues performed a randomized, double-blind, placebo controlled trial to evaluating Lyrcas efficacy, safety, and tolerability for treatment of painful human immunodeficiency virus (HIV)-associated neuropathy. The authors concluded that Lyrica was well-tolerated, but not superior to placebo in the treatment of painful HIV neuropathy. Factors predicting analgesic response in HIV neuropathy warrant additional research. There is a lack of medical literature showing that Lyrica is more effective than placebo for the treatment of HIV neuropathy. As such, Lyrica is not clinically indicated in this clinical setting. Based on the lack of support in the peer-reviewed literature, Lyrica 50 mg two times daily is not medically necessary for treatment of the patients medical condition.  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 infectious disease 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 laminectomy surgery of the lower back for treatment of the enrollees back pain. Findings: The physician reviewer found that the medical literature supports the use of lumbar laminectomy for patients with spinal stenosis who have failed conservative treatment.  This patient presents with severe axial low back pain radiating into the left posterior leg to the foot with numbness.  The signs and symptoms were consistent with neurogenic claudication. Clinical examination findings correlated with imaging evidence of L1-2, L4-5 and L5-S1 disc herniations with significant central canal stenosis at L1-2 and L5-S1, and reported evidence of nerve root compromise and bilateral foraminal stenosis at L4-5. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. The surgical treatment plans have recommended artificial disc replacement at the L5-S1 level with L4 through S1 posterior spinal laminoforaminotomy and microdiscectomies. Based on the signs/symptoms of neurogenic claudication, imaging evidence of multilevel spinal stenosis, and failed conservative treatment, the requested laminectomy surgery of the lower back is medically necessary 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 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.