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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for weekly home based occupational therapy and speech therapy for treatment of his brain cancer status post chemotherapy and radiation therapy. Findings:  The physician reviewer found that in the medical literature, researchers provided an analysis of home implemented speech therapy compared with school and clinics. The authors concluded that neither home nor outpatient services were found to be superior to the other. Other researchers compared home and school gait training programs and reported no significant outcome with either setting. Another study found no significance difference between home-based and center-based therapy after one year. This patients records indicate that the patient has had the benefit of speech and occupational therapy weekly sessions at home. However, over three months, the progress reports indicate only modest improvements. The additional records include weekly occupational and speech therapy reports. The occupational report states modest improvement in gross motor skills, balance and self-regulation. The speech therapy reports virtually no improvement over the time frame. Although the speech therapy report mentions in-home therapy, it does not specify a recommendation for in-home therapy. Neither does the occupational therapy report recommend in-home rather than outpatient treatment. Further, his parents concern regarding the overstimulation of the outpatient setting was not apparent when the patient was examined in the primary care providers office. Thus, there is no indication for in-home occupational and speech therapy and both therapies can be delivered in a clinic. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a heavy duty 3 or 4 wheeled scooter for treatment of her cerebral palsy. Findings:  The physician reviewer found that the requested equipment is not medically necessary for treatment of the patients medical condition. Auger and colleagues reviewed the outcomes of power mobility devices for middle-aged and older adult users. The authors noted that Most of the research designs were assigned very low evidence grades. Although power mobility can benefit specific individuals, it is not likely to be of benefit in this clinical setting. In this case, the patient has a mild personal mobility deficit and is a functional household ambulatory and she has a caregiver to assist her. She is unable to use a power or manual wheelchair. Additionally her abode cannot accommodate a power device. A transport chair, not a power scooter has been recommended. A power scooter is not medically necessary to safely maximize the patients independence. Accordingly, the request for a heavy duty 3 or 4 wheeled scooter has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services for treatment of an emergency medical condition.  Findings:  The physician reviewer found that The services provided  were necessary for treatment of an emergency medical condition. Evidence-based medical guidelines recommend prompt consultation with hand surgeons for patients presented with possible finger extensor tendon rupture, and support initial radiographs and imaging for a significant change in symptoms and/or findings suggestive of significant pathology. The peer-reviewed literature indicate that EPL tendon ruptures are associated with screw head protrusion after the use of volar locking plates for distal radius fractures and support follow-up with hand surgeons for such events. In this case, the patient sustained severe multiple traumatic injuries in a motor vehicle accident and was status post open reduction and internal fixation of a right distal radius and ulnar styloid fracture. He experienced an acute loss of right thumb function while attending college. He presented to an out-of-state urgent care center for evaluation. Clinical exam documented a loss of tendon function and the patient was referred to an orthopedic surgeon for evaluation. The orthopedic surgeons opinion was that the EPL tendon had ruptured and ordered an MRI for confirmation. Surgical repair of the tendon was performed at a later date. Given the abrupt loss of thumb function and complex surgical history, the services at issue were necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings:  Two 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 radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional (2D) 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: 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: The parent of an enrollee has requested authorization and coverage for an adaptive stroller and pressure vest for treatment of the autism spectrum disorder and gross motor delay. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting the requested equipment as medically necessary for treatment of the patients medical condition. A study examined the effects of the weighted vest during a functional analysis, in which the participant wore a five pound weighted vest or no vest. The researchers reported that The results do not suggest the existence of a functional relationship between the use of a weighted vest and challenging behavior, as the weighted vest had no marked effect on levels of aggression and self-injurious behavior. Similarly, another study found that an inflatable wearable vest known as the Snug Vest failed to reduce any participants stereotypy. Adaptive strollers may be helpful for some autistic children with elopement issues. The stroller can assist with keeping the child contained in a larger stroller when going out in the community. However, in this case, the patient has mild gross motor delay with skills ranking at the 16th percentile per PDMS-2. The records demonstrate that the patient can walk and ambulate within the community. In addition, the records do not show the patient exhibits elopement or dropping to the floor behaviors. Based on the clinical documentation provided for review, the request for an adaptive stroller and pressure vest are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an  enrollee has requested authorization and coverage for 172 hours per month of direct applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and two hours per month of caregiver training. Findings:  The physician reviewer found thatThe Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In addition, a study  evaluated the relationship between ABA treatment intensity and treatment outcomes. The authors found a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made progress in many areas, but continues to demonstrate multiple problematic and dangerous behaviors including elopement, inappropriate touching of strangers, non-compliance and disruptive behaviors. The patient also engages in repetitive gross motor stereotypic behaviors, severity level 3 and obsessive behaviors, severity level 3. The patients ABA provider recommends 40 hours per week of ABA therapy, which is consistent with what is typically recommended for optimal response. For the reasons provided, the request for 172 hours per month of direct ABA therapy, 16 hours per month of supervision and two hours per month of caregiver training are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services at issue 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occupational therapy in an aquatic setting for treatment of the enrollees autism and sensory integration disorder. Findings:  The physician reviewer found that the request for occupational therapy in an aquatic setting has not been established as medically necessary for treatment of the patients medical condition. Mortimer and colleagues examined the effectiveness of hydrotherapy on social interactions and behaviors in the treatment of children with ASD. The review found that Few studies have investigated the effect of hydrotherapy on the social interactions and behaviors of children with ASDs. The authors further state that studies that have been conducted were constrained by small sample size, lack of comparator, crude sampling methods, and the lack of standardized outcome measures. In addition, Getz reviewed 173 articles involving the use of hydrotherapy in children with neuromotor or neuromuscular impairments. The results demonstrated a substantial lack of evidence-based research evaluating the specific effects of aquatic interventions in this population. These findings suggest that the use of hydrotherapy for the treatment of autism has not yet been established as evidenced-based and is therefore not medically necessary. The patient appears to have had delays in several activities of daily living including fastening buttons, snaps and zippers and teeth brushing. The patient would likely benefit from occupational therapy services. Final Result: The reviewers 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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (nuclear magnetic resonance (NMR) lipid panel screening). Findings:  Three physician reviewers found that in this circumstance 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 do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density-lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin-resistance, 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 are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Final Result: Three 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the eight transcranial magnetic stimulation (TMS) sessions provided.  Findings:  The physician reviewer found that TMS is non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30-40 sessions spanning four to six weeks. According to the summary of TMS treatment recommendations authored by Perera and colleagues The standard parameter setprovided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The article did suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. At this time, there are a lack of adequate controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at the time would have improved the patients condition or prevented a more serious episode of illness. Further, there is no evidence in the medical literature to suggest that the patients improvement was more than likely due to the additional TMS sessions. The timing of the remission in this case may have been the natural course of the episode. In sum, based the documentation provided in context of the relevant literature and practice standards, the TMS services in dispute 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 physician 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 authorization and coverage for adapalene gel (Differin) 0.1% and Aczone 5% for treatment of her acne vulgaris. Findings:  The physician reviewer found that the patient reports having tried and failed therapy with generic tretinoin in the past as it was too drying and clindamycin gel 1%, which lost its effectiveness. Treatment with Aczone 5% is reasonable and considered the logical next step in her acne therapy. The use of Aczone gel 5% has been proven to be effective for the treatment of acne, particularly in adult women. As she has failed treatment with clindamycin gel 1% and doxycycline, the requested Aczone gel 5% is medically necessary. Differin 0.1% has recently been moved to over-the-counter status and is readily available for this patient without a prescription. Final Result: The reviewer determined that a portion of the requested medications is 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 dermatology 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 gastric sleeve surgery for treatment of her enrollees obesity. Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested surgery. In this case, the patient is obese and has failed dietary efforts, including supervised weight loss. However, based on standards guidelines by the American Society for Metabolic and Bariatric Surgery, the criteria requires documentation of a behavioral/psychological evaluation as well as a dietary evaluation specific for bariatric surgery. A dietary evaluation and psychological evaluation were not submitted for review. There was also no surgical evaluation provided for review. A multidisciplinary evaluation is considered a standard component to determining if an individual is an appropriate candidate for bariatric surgery. 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 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 her risk of cardiac disease. Findings:  Three physician reviewers found that 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 lipoprotein-associated phospholipase A2 (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 are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. 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: Reviewers 1, 2, and 3 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.