Persius/hicric huggingface dataset:
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 whole body bone scan for evaluation of the enrollees bilateral foot pain.  Findings:  The physician reviewer found that the patients provided records fail to meet the standard criteria for a bone scan.  Prior to ordering a bone scan, the standard practice is that a patient must be suspected of having a stress fracture due to overuse or excessive activity, have localized pain, have symptoms that persist despite rest and have normal x-rays obtained on two separate occasions separated by at least three weeks prior to ordering a bone scan. Typically, a second set of x-rays is obtained after three to four weeks to determine if bone healing is present.  If the second set of x-rays is negative, then a bone scan would be a reasonable test to rule out a stress fracture. However, in this case, the provided records do not support that these criteria have been met by 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 physician 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 digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with extremely or heterogeneously dense tissue, such as the patient under review.  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. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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 morphine 100 mg every six hours for treatment of the enrollees medical condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The use of opiates for fibromyalgia is not supported by the current medical evidence.  Per the medical literature, the use of high-dose morphine may lead to a paradoxical state of increased pain sensitivity, opiate-induced hyperalgesia.  There are alternative, U.S. Food and Drug (FDA) approved medications which have strong statistical evidence backing their use.  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 physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. 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 (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, there are several factors to be considered.  Simply the presence of implants is not, in itself, an indication for tomosynthesis.  However, she had an area of asymmetry involving the left breast one year earlier.  The subsequent diagnostic study apparently did not reveal any areas of significant concern.  Considering that there was an area of asymmetry previously that was felt to be new when compared to the prior mammogram, however, warrants a close re-evaluation of this area.  It is not unreasonable to perform a tomosynthesis for a more thorough screening at this time.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers number one, two, and three are is 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Qsymia for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is support for the requested medication for treatment of this patients medical condition. The medication Qsymia is approved by the U.S. Food and Drug Administration for chronic weight management. Moreover, the medical literature recommends weight loss medication like Qsymia as an adjunct to a reduced-calorie diet and increased physical activity in patients with either an initial BMI greater than 30 kg/m2 or an initial BMI greater or equal to 27 kg/m2 and at least one weight-related comorbid condition. In this patients case, she has a BMI greater than 30 kg/m2. She is also currently participating in a dietary plan and is physically active three to four times per week. Previous treatments have included participation in weight loss programs, physical activity, dietary counseling and the use of Phentermine. However, she has not been able to maintain any weight loss with these programs.  Therefore, given the patients obesity and her failure to loose significant weight on a diet and exercise regimens, Qsymia is medically necessary for treatment of her obesity. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in internal 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 a motorized scooter for treatment of the enrollees medical condition. Findings:  The physician reviewer found that powered mobility can beneficial for well-selected individuals. The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem.  Determining of who will benefit is a matter of clinical judgment more than adherence to criteria defined by the peer-reviewed literature. This patient has been recommended for a motorized scooter due to poor balance, unsteady gait, poor endurance and a history of falls. In this case, the patients medical conditions and mobility deficits are amenable to a motorized scooter. All told, the request for a motorized scooter is medically necessary for treatment of the patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Celebrex 200 mg for treatment of the enrollees medical condition.  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. According to the U.S. Food and Drug Administration (FDA), Health care professionals and patients can be assured that these FDA-approved generic drugs have met our rigorous approval standards. The FDA further states, Generic prescription drugs approved by the FDA have the same high quality and strength as brand-name drugs. Generic drug manufacturing and packaging sites must pass the same quality standards as those of brand-name drugs. Therefore, the FDA approved generic medications are manufactured to be chemically similar to the brand name mediations and the side effects are the same.  As such, the request for name brand Celebrex 200 mg has not been established as 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 rheumatology 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 occipital nerve stimulation for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that although occipital nerve stimulation is not a first-line therapy for chronic headaches, there is adequate clinical trials that demonstrate its use and safety in select populations of patients.  In this particular case, the patient has failed many first-line therapies and has a contraindication to other headache therapies.  The patient has significant limitations secondary to his headaches.  Undertreated headaches are an unnecessary cause of functional impairment.  To this end, a trial of occipital nerve stimulation is a reasonable approach in this particular case.  Thus, the requested occipital nerve stimulation is likely to be more efficacious than other treatment options.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 neurology 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 authorization and coverage for Viagra for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Phosphodiesterase-5 inhibitors are first-line therapies for the treatment of erectile dysfunction.  The current medical literature confirms that patients who have failed one phosphodiesterase-5 inhibitor can respond to another phosphodiesterase-5 inhibitor.  This patient has failed one phosphodiesterase-5 inhibitor, Cialis.  Thus, a trial of another phosphodiesterase-5 inhibitor, Viagra, is medically appropriate prior to considering more invasive therapies. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in urology 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 laser therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that this patient has a history of rosacea.  Her prior treatment has included Oracea, Metrogel, sulfacetamide wash, and Mirvaso topical gel.  The use of intense pulsed light or other pulsed dye laser therapy would be expected to reduce the generalized redness and fixed telangiectasias associated with rosacea.  It is not expected to reduce the inflammatory or acneiform flares which can be seen with rosacea.  The effects on reducing the telangiectatic component of rosacea would be expected to improve the cosmetic appearance of the face, but this is not considered to be medically necessary.  The patients condition is an abnormal structure of the body caused by rosacea, which is a disease.  The requested services are being performed to create a normal appearance, but not improve function.  The requested laser therapy is not likely to offer more than a minimal improvement in the appearance of the patient.  All told, the requested laser therapy is not reconstructive in nature and is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not reconstructive in nature 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 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 special tires (pneumatic rear wheel tires with airless inserts) for management of the enrollees medical condition. Findings: The physician reviewer found that there is a lack of medical support for the requested equipment in this clinical setting. The requested pneumatic rear wheels with airless inserts were recommended for the patient in order to decrease the maintenance needed on the tires. However, the provided records indicated that the patient lives in a residential area in a single family home. No unusual environmental conditions were presented or noted in this patients case. The patient has no communication impairment and would be expected to be able to call for assistance if she required assistance with changing a flat tire. The requested equipment is not clinically supported for the proper mechanical function of the patients wheelchair. Therefore, the requested special tires (pneumatic rear wheel tires with airless inserts) are not medically necessary for treatment of the patient.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was experiencing suicidal thoughts, although without intent or plan.  Her continued suicidal thoughts, especially in the context of a patient with two suicide attempts within the past year, required close monitoring.  She was very depressed, experienced nightmares and tactile hallucinations.  She was felt to be exhibiting posttraumatic stress disorder symptoms, consistent with her history of sexual abuse.  She was started on risperidone and continued to require monitoring for these symptoms.  She no longer was experiencing nightmares or hallucinations.  Therefore, partial hospitalization program services were medically necessary, as she needed monitoring for her symptoms of suicidal thoughts, hallucinations and posttraumatic stress disorder.  She was just started on risperidone and needed to be observed for side effects and effectiveness.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that there is sufficient support for digital breast tomosynthesis in the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue. The studies have shown that there has been an increased survival rate when tomosynthesis has been used as part of screening mammography. 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 diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone. Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been done using two dimensional imaging alone. Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewers number one, tweo, 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one, two, 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.