Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing for evaluation of the enrollees possible rupture of membranes. Findings:  The 3 physician reviewers found that the AmniSure Test is utilized to aid in the detection of rupture of membranes when a patient reports signs, symptoms or complaints suggestive of rupture of membranes or premature rupture of membranes. It is a rapid, non-instrumented, qualitative immunochromatographic test for detection of amniotic fluid in the vaginal secretions of pregnant women. According to American College of Obstetricians and Gynecologists (ACOG), the diagnosis of rupture of membranes is typically confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of the vaginal fluid or ferning of dried vaginal fluid. According to ACOG, AmniSure testing is considered ancillary to standard methods of diagnosis. Therefore, the AmniSure testing performed 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 3 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. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 authorization and coverage for Combivent Respimat.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medication has not been established. There are numerous formulary bronchodilators available to the patient. There is no documentation that the requested Combivent Respimat (ipratropium bromide and albuterol) is superior to the formulary bronchodilators available to the patient. Ipratropium and albuterol are both available separately as are other bronchodilators. The patient is already taking a long-term adrenergic bronchodilator, in Salmeterol Advair Diskus. In addition, there is a risk of bronchodilator overdose that with increasing doses does not provide any further bronchodilation but may cause tachycardia. Accordingly, Combivent Respimat is not medically 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 pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an intensive outpatient program that meets 12 hours per week but does not require partial hospitalization for treatment of her behavioral health condition. Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity for the requested services in this clinical setting. This patient reported continued binging and purging.  The records do not show that this patient is receiving intensive therapy, either the dialectical behavior therapy (DBT) or cognitive behavioral therapy type, at this time.  It appears that she may be she receiving psychiatric treatment as well as infrequent therapy. However, the medical literature indicates that therapy on a consistent basis along with medication treatment is the most successful treatment options for eating disorders. In a review, the authors show comparisons of four and five day PHP programs and identifies that `among patients who were binging and vomiting at least eight times a month prior to presentation, the post-treatment abstinence rates were lower in the four-day program. Based on the submitted records, it appears that this patient is struggling with adherence to treatment recommendations for group therapy as recommended by her treatment provider. She was also offered IOP services with contracted providers but she declined on the basis that she believed she required more intensive services. However, the documentation indicates that she was referred to a PHP program which is a more intense level of care then the disputed IOP program but the patient had declined. This patient could benefit from a higher level of care for treatment of her eating disorder but there is a lack of support for the requested out of network services. Therefore, the intensive outpatient program that meets 12 hours per week but does not require partial hospitalization is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 11 hours of psychological testing. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested services in this clinical setting. The diagnoses of OCD, PTSD, major depressive disorder, and ADHD do not require psychological testing. They can be determined in the office via clinical interview with the assistance of scales such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Beck Depression Inventory, Beck Anxiety Inventory, and applying Diagnostic and Statistical Manual of Mental Disorders V criteria. The records do not indicate that these have been performed with this patient. The mental status examination is a tool used to assess cognitive function, and there was no indication that the patient suffered from an organic cause of his impulsive, attentional, depressive, obsessional, or suicidal thinking.  It is important to note that the patient was not seen in psychiatric consultation and was not on any psychotropic medications, which may have drastically altered the subjective symptoms reported, the behavioral manifestations, and objective findings by the provider.  Therefore, the request for authorization and coverage of 11 hours of psychological testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for sports hernia surgery. Findings:  The physician reviewer found that the records provided for review document that this patient underwent surgery less than one year ago. Initial postoperative visits indicate persistent pain in left that subsequently improved. Follow-up MRI demonstrated that the osteitis pubis was improved and that the appearance of the adductor longus is improved when compared to previous examination. Given the fact that less than one year has elapsed and there is clinical evidence of improvement, there is no clinical indication for reoperation. Operation for partial tears to the adductus tendon is generally reserved for complete avulsion or chronic tendinopathy failing several months of a well-designed rehabilitation program. Reoperation at this time would carry substantial risk of injury to the local nerves and cord structures of the groin as well as place the patient at risk of a chronic neuropathy. Moreover, operative intervention without the use of mesh in athletic pubalgia is not considered the standard of care. Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that the current medical evidence supports the service at issue in this clinical setting.  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 callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: The 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injections and prospective authorization and coverage for future Botox injections every 12 weeks for treatment of the enrollees migraines. Findings:  Two physician reviewers found that this patient carries a diagnosis of chronic migraine. The submitted medical documentation does not provide adequate information to confirm a diagnosis of chronic migraine.  No information regarding headache frequency or characteristics that would confirm migraine is included in the note.  There is also no information regarding prior preventives, other than propranolol.  Botox has been shown to be beneficial for preventive treatment of chronic migraine, and the records do not confirm this diagnosis.  Final Result: The reviewers determined that the services at issue were not and 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: The Reviewer number are board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis who presented for a breast examination. 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.  But in terms of surveillance in patients who have had breast cancer, studies have demonstrated that when digital breast tomosynthesis was applied in a study, screening sensitivity had improved. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis.  Final Result: The 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 1, 2, and 3 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review indicate that the patient appeared to have reached a baseline status, and there was no reasonable expectation that condition would further improve with continue treatment with residential care. There was no evidence that he was suicidal, homicidal, or had self-injurious behaviors to the point of requiring medical care. Throughout the course of treatment there were minor incidents of self-injurious behavior, but none that required medical intervention or medical consultation. He had long-standing behavioral issues but these did not warrant residential treatment and could have been treated at a lower level of care. Therefore, the patient could have continued treatment at a lower level of care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeomin for treatment of the enrollees piriformis syndrome and right lower leg pain. Findings:  Three physician reviewers found that IncobotulinumtoxinA (Xeomin) and onabotulinumtoxinA (Botox) are approved by the U.S. Food and Drug Administration (FDA) for the treatment of adults with cervical dystonia or blepharospasm. However, there is a lack of peer-reviewed clinical trials and evidence that Xeomin may be useful in the treatment of piriformis syndrome. One study noted that treatments for piriformis syndrome include physiotherapy, steroid injections, and surgery. All told, the requested Xeomin is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication is 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:  The physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for transcatheter closure of patent foramen ovale (PFO) and left atrial appendage. Findings:  The physician reviewer found that the patient has a history of melanoma, renal stones, hyperlipidemia and a cryptogenic stroke.  An echocardiogram was performed and reported a patent foramen ovale (PFO) and normal left ventricular function.  A carotid ultrasound revealed no stenosis.  A cardiology report refers to a brain magnetic resonance imaging that reported an embolic stroke in the left thalamus and right cerebellum. The patient has requested authorization and coverage for transcatheter closure of patent foramen ovale (PFO) and left atrial appendage. The Health Plan denied coverage for the PFO closure procedure. Per the Health Plan the requested procedure is investigational for the treatment of this patient.The superior efficacy of the services at issue has not been demonstrated in this clinical setting. Based on the records provided, the patient had a stroke that was presumably due to paradoxical embolization through a patent foramen ovale.  Generally, current literature does not consistently demonstrate improved outcomes with patent foramen ovale closure compared to medical therapy.  For example, one randomized prospective trial performed by Furlan and colleagues did not demonstrate relative benefit of patent foramen ovale closure when compared to medical therapy.  Another trial with results recently available, also showed no significant benefit of closure of a patent foramen ovale compared to medical therapy alone.  Similar results were found in a third recent manufacturer funded randomized trial .  As such, the use of percutaneous closure devices for treatment of a patent foramen ovale in the setting of a documented transient ischemic attack or cryptogenic stroke should be considered investigational. Except in specific circumstances where alternative therapies (aspirin or warfarin) are not tolerated or when alternative therapies are contraindicated or failed, the requested procedure is investigational/experimental. In this patients case, he has no documented contraindication to aspirin or warfarin anticoagulation. Therefore, transcatheter closure of PFO and left atrial appendage is not likely to be more effective when compared to other standard options for treatment of this patients medical condition.Final Result: The 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All reviewers are 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.