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

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional (3D) mammogram for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that 3D mammogram is rapidly becoming a standard tool for evaluating patients with dense breast tissue or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. A 3D mammogram is warranted, as a 3D mammogram enhances the ability to separate out the overlapping structures and helps to better delineate an occult mass. Based on the patients breast tissue density, the requested 3D mammogram is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing for polymorphisms for evaluation the enrollees medical condition. Findings:  The 3 physician reviewers found that Genotyping for polymorphisms for pain and pain reliever response is a genetic test that evaluates predispositions for effectiveness of specific pain medicines, risks for resistance and or addiction potential and suggests specific drugs for an individual patient. This relatively new field of study relies on data from other people with similar genetic characteristics who have known responses and outcomes, to make predictions as to the current patients response to a drug. Some studies looking at gene polymorphism associations with pain responses have lacked validity. Genomic pain response determination is considered a subset of translational pain research at this time and is and emerging field. In addition, all of the narcotic pain relievers that the study recommended are commonly used analgesics that would be prescribed for hip pain without any genetic test being performed. Genomic polymorphism analysis as a guide for pain response validation lacks sufficient evidence due to poor replication and inconsistency of valid associations in the literature. In sum, the genotype testing for polymorphisms performed was not 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. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested three (3) physical therapy visits for treatment of the enrollees status post anterior cruciate ligament (ACL) reconstruction of the right knee.  Findings: The physician reviewer found that the medical literature does not provide conclusive evidence of superiority of home based rehabilitation or supervised physical therapy sessions. Van Melick and colleagues conducted a systematic review of physical therapy after ACL reconstruction. The authors found that owing to a lack of high-quality studies and contradictory results, it is unclear whether there is a benefit of supervised rehabilitation compared to home-based rehabilitation or no rehabilitation at all. A minimally supervised rehabilitation programme may result in successful rehabilitation in specific groups of patients that are highly motivated and live far from a physical therapist. In this case, the patient continues to have functional deficits after 14 post-operative physical therapy sessions. In this clinical setting, one additional physical therapy session is indicated to finalize a home exercise program. In sum, one additional physical therapy session is medically necessary for treatment of the patients medical condition.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that TMS treatments are not medically necessary for treatment of the patients medical condition. TMS is a 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. Although there are some positive reports in the literature, at this time there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. In general, for those who respond to TMS, oral medications remain the primary vehicle for maintenance of remission. In this case, the patient achieved remission within typical treatment parameters. Further, there was no mention of psychotherapy or the specifics regarding prior pharmacological interventions while the most recent medication regimen did not include an antidepressant. The medical records indicate that standard therapies had not been exhausted while the medical evidence does not support a reasonable expectation that additional TMS therapy will improve the patients condition or prevent a more serious episode of illness. Thus, TMS services in dispute are not medically necessary for treatment of the 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hip surgery performed for treatment of the enrollees left acetabular labral tear and femoral acetabular impingement. Findings: Three physician reviewers found that based on the clinical documentation provided for review, the patient had multiple hip injuries which would not have been expected to improve without the surgeries performed. Femoracetabular impingement refers to bony prominence around the joint which predisposes a patient to painful injuries such as labral tearing and articular cartilage damage. The bone shapes can only be altered by surgery. At the time of surgery, articular cartilage injury, labral tearing and a piece of bone broken off the acetabulum were identified. Articular cartilage has no healing potential and the unstable fragments were surgically removed. In addition, the hip surgery performed is the standard of care in this clinical setting. All told, the hip surgery performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The three reviewers determined that the procedure at issue was 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 orthopedic surgery and are actively practicing. The reviewer 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 the Prometheus Anser IFX test. Findings:  Two physician reviewer found that based on current guidelines, the recommended dose of Remicade is 5 mg/kg given on week 0, 2 and 6, followed by every eight weeks thereafter. The clinical significance of apparent increased immunogenicity on efficacy and infusion reactions in psoriasis patients as compared to patients with other diseases treated with Remicade over the long-term remains unknown. Thus, as the maximal recommended dose is 5 mg/kg, and the consequence of antibody formation is unknown, there was no role for the Anser IFX testing performed on 1/12/16 as the patient was already being treated with the maximal recommended dose. Final Result: Two 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 medical oncology 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 magnetic resonance imaging (MRI) for evaluation of the enrollees knee pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  MRI is the most optimal means to evaluate an internal derangement.  Plain x-rays are of only limited value.  The reason that plain x-rays are of only limited value is that the menisci and ligaments are not visible on plain x-rays.  One can assess the degree of degenerative disease and whether there are any acute bony structural abnormalities, but this information is only of limited interest in this patient.  There are many people who have absolutely no degenerative disease who have grossly abnormal menisci, and conversely, there are patients who have gross degenerative joint disease, but relatively intact menisci.  The Health Plans requirement that the patient pursue a trial of conservative management prior to obtaining an MRI is medically appropriate, as acute pain will often resolve without more aggressive intervention.  In this patients case, the records document that she has only been seen one year earlier by a chiropractor, who at that time felt that the symptoms would resolve.  The medical evidence supports a trial of intensive anti-inflammatory therapy prior to pursuing an MRI in this case.  This patient has had symptoms for at least one year, has not had any recent trauma, and there is no indication that she has an infection or other condition that requires immediate attention.  Most cases of knee pain, especially in a young individual, will resolve without surgery.  All told, the requested MRI is not medically indicated 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for increased dose of morphine or prescription for Percodan for treatment of the enrollees back, hip and neck pain. Findings:  The physician reviewer found that In the peer-reviewed medical literature, colleagues noted that opioid risk mitigation tools should be part of practice and when patient safety issues are identified such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should be discontinued. Colleagues reported that opioids are not recommended as first-line therapy but when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. In addition, urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse. In addition, current guidelines support use of opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include current pain, the least reported pain since the previous assessment, average pain, and intensity of pain after taking the opioid, how long it takes for pain relief, and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. This patients medical records report chronic pain as well as noncompliance with medication regimen, which suggests the patient is at risk in regard continued use of opioids. All told, the medical records do not support chronic use of either morphine or Percodan in this clinical setting. Thus, the requested increased dose of morphine or prescription for Percodan are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested 15 hours per week of direct applied behavioral analysis (ABA) therapy, six hours per month of oversight and two units per month of family behavioral treatment of the autism. Findings: The physician reviewer found that ABA therapy at the frequency of 15 hours per week of direct ABA therapy, six hours per month of oversight and two units per month of family behavioral treatment were medically necessary for treatment of the patients ASD. The study by Reichow and colleagues shows that ABA therapy started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In this case, the patient has received ABA since his diagnosis which has been effective for teaching him skills including communication and adaptive skills. However he continues to have significant issues with elopement. In this clinical setting, the ABA providers recommendation of 15 hours per week of direct ABA therapy, six hours per month of oversight and two units per month of family behavioral treatment were and are medically necessary for treatment of the patients autism.Final Result: The reviewers determined that the services at issue were and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy, 19.5 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism. Findings: The physician reviewer found that ABA therapy is medically necessary for the treatment of children with autism spectrum disorder. Orinstein and colleagues found that children who started ABA therapy at an earlier age and at a higher level were more likely to have an optimal outcome. Sallow Graupner support a high level of ABA services in the first and second year of ABA therapy. In this case, the patient is in his second year of ABA therapy and requires a high level of ABA therapy due to the patients maladaptive behaviors including aggression, non-compliance and screaming behavior. There is sufficient support for the medical necessity of 172 hours per month of direct ABA therapy, 19.5 hours per month of supervision and four hours per month of parent training in this clinical setting.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 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 residential treatment (RTC) services for treatment of the enrollees behavior health condition.  Findings: The physician reviewer found that although patient presents with a chronic and debilitating formal thought disorder characterized by recurrent psychotic episodes, the documentation does not support the medical necessity for RTC services. The patient improved during the recent three-week acute psychiatric hospitalization. She was treated with the gold-standard medication, clozapine, for refractory psychosis. The psychiatrist indicated that the patient was stable enough for outpatient treatment, while at the time of discharge, the patient did not meet residential level of care criteria. During a follow-up visit the day after discharge at her board and care residence, the patient was not distressed, psychotic or suicidal. An overarching goal in contemporary psychiatric practice is to provide evidence-based treatment in the least restrictive setting. In this case, the treatment team devised a reasonable aftercare plan consistent with good medical practice. There is no subsequent medical documentation detailing a symptom burden that would support the necessity of higher of level of care. As there is no evidence that the current plan of care is unsafe or inadequate, the requested services are not medically necessary for treatment of the patients medical condition.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 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 vaginal hysterectomy for treatment of the enrollees pelvic pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This is a patient with non-cyclic pelvic/abdominal pain that reportedly is brought on with a full bladder or rectum.  She is possibly menopausal, although there is no documentation of laboratory tests to assess her status.  The appeal documentation states that she has had ultrasounds that showed a fibroid and later adenomyosis, but the ultrasound report from the recent study showed neither.  If she actually has adenomyosis or endometriosis as a cause of her pain, this is likely to resolve after menopause.  There is no indication that alternate therapies have been tried and failed.  Her pain may in fact be bowel or bladder related, and no other evaluation has been done.  It is not clear that her symptoms are related to her uterus, which is normal on ultrasound.  It is likely that her pain may persist even after hysterectomy.  In this case, non-gynecologic causes of pain do not seem to have been ruled out, her ultrasound shows a normal uterus, and other therapies for pelvic pain have not been tried.  All told, the requested vaginal hysterectomy is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.