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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 25-30 vision therapy sessions, one hour each week for treatment of the enrollees vision processing disorder, auditory processing disorder, and learning disability. Findings:  Two physician reviewers found that the report by the American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) reports that vision therapy is not effective for treating learning disabilities and dyslexia. Numerous double blind studies have concluded that vision therapy with special glasses, colored lenses or vision exercises do not help with learning, reading or visual accommodation skills. One study found that eye exercises are not effective given the lack of scientific evidence on its efficacy. Another study conducted a research study on treatment approaches for children with reading disabilities and recommended phonics as the most effective approach over vision therapy. All told, the requested 25-30 vision therapy sessions, one hour each week, are 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 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: All three physician reviewers are board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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: The parent of an enrollee has requested authorization and coverage for 26 hours per week of direct applied behavioral analysis (ABA) therapy, 18 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that colleagues indicate that a minimum of two years of intensive ABA therapy is necessary for sustained behavioral and intellectual improvement in an autistic child. In addition, colleagues emphasize early intervention and a minimum of 20 hours of ABA therapy is the most successful program for behavioral improvement in an autistic child. In this case, the patient did not receive early ABA therapy before the age three. Thus, it is medically necessary for this patient to receive ABA therapy. Based on the clinical documentation records submitted for review, ABA therapy at the frequency of 20 hours per week of direct therapy, eight hours per month of supervision and four hours per month of parent training are medically necessary for treatment of the patients autism. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 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, her breast tissue was described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed was likely to have been superior over other methods of evaluating this patient. Final Result: The 3 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule.Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

An enrollee has requested reimbursement and prospective authorization and coverage for Orthofix bone growth stimulator. Findings:  The physician reviewer found that the Orthofix bone growth stimulator has not been established as medically necessary for treatment of the patients medical condition. There is a lack of randomized, controlled clinical trials demonstrating proven clinical efficacy for the device at issue in this clinical setting. Most data indicate a positive effect for use of direct current stimulation, but further studies are necessary to determine its appropriateness as an adjuvant to spinal fusion. Accordingly, the device at issue was not and is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the device at issue was not and 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 neurological 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 the cardiac computed tomography (CT) for calcium scoring.Findings:  Two physician reviewers found that coronary calcium scoring is performed for screening purposes and indicates presence of CAD or coronary atherosclerotic plaque. Guidelines from the American College of Cardiology (ACC) have listed coronary calcium scoring as Class IIb (may be used) rather than a Class I recommendation (should be used) for use in preventive management. This recommendation suggests the testing may be useful if uncertainty remains after standard risk assessment. Overall, the current ACC guidelines recommend use of the pooled risk score to decide upon statin treatment in patients with elevated cholesterol. Also recommended are standard risk factors and standard lipid panels to decide upon preventive management. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high intensity shockwave therapy for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewers found that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is high quality peer-reviewed evidence to support the safety and efficacy of high-intensity ESWT in the treatment of recalcitrant plantar fasciitis. The documentation demonstrates evidence of at least five months of recent reasonable and/or comprehensive non-operative treatment. Therefore, the high intensity shockwave therapy has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the therapy 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:  Physician reviewers number one, two, and three are board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested facial feminization surgeries for treatment of the enrollees gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, the submitted documentation does not support a typical functional deficit in this patients case for each of the requested services. With respect to the patients forehead, hairline and brow treatment, there was insufficient documentation to justify these procedures. A formal examination was not documented. In addition, based on the photographs, the patient has mild forehead prominence and brow ptosis which is consistent with a relatively normal female appearance.  The appearance of the patients forehead and brow is not necessarily gender specific. With respect to the requested lower face/chin and neck procedures, there is a lack of sufficient documentation to support the medical necessity of these services.  A formal examination was not documented - only the procedure request was provided.  In addition, based on the photographs, the patients neck and chin appearance is consistent with a relatively normal appearance and not specifically gender related. With regard to whether the requested services are considered reconstructive in nature, there is a wide spectrum of facial appearance that can be consistent with typical female appearances. In this case, the facial features the patient is seeking to address are consistent with a female appearance and are not considered abnormal. The requested services appear consistent with aesthetic improvement, addressing appearance concerns and not specific sex-related abnormalities.Findings:The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheldCredentials/Qualifications:The reviewer is board certified in plastic 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: The parent of an enrollee has requested reimbursement for genetic testing for treatment of his behavioral health condition. Findings:  Two physician reviewers found that the patient has a primary diagnosis of attention deficit hyperactivity disorder (ADHD).  He is currently treated for this condition with Vyvanse 30 mg which is reported to be effective. The medication is reported to last all day with no observable side effects.  He has been evaluated at school and an Individualized Education Program is in place for him.  On a routine visit, he was noted for the first time to have periods of high energy and impulsive spending, risky behaviors, starts projects and does not complete them, has extreme anger, mood swings and racing thoughts.  He was described as anxious and depressed. Vyvanse continued to be helpful for his focus during school. Abilify, 2 mg was prescribed for his mood instability.  At follow up visit, the note states that the patients parents feel Abilify is helping.  He seems happier, laughing, getting up in the morning easier, has less anger and has an improved mood.  He was less energetic and less hyperverbal.  Genetic testing was ordered.  The results show that all standard ADHD medications can be used.  Abilify showed an increased risk for adverse events or poor response. The Health Plan denied the genetic testing stating it was investigational for evaluation of this patient. According to the progress notes, the patient has done well on a low dose of Vyvanse for many months.  At the most recent visit, he was still able to focus his attention well at school.  He was also started on a low 2 mg dosage of Abilify after stating that he had some changes in his mood.  At a follow up visit, it was reported that this medication was successful and his mood had improved.  The medical record provides no reason for the decision to obtain genetic testing for medication metabolism. There is no indication that the patient was having any difficulty with his current medication regimen, and there was no discussion about trials of other medications that would be used in the future. As such, there was a lack of support for the clinical rationale behind the genetic testing of this patient to assess treatment with psychotropic medications. Therefore, the genetic testing performed was not likely to have been superior to other modes of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 psychiatry 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 and prospective authorization and coverage for 30-day residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient did not have any suicidal or homicidal ideation.  She did not have any agitation, mania, or psychotic symptoms.  The records do not document a history of suicide attempts.  The patient was compliant with treatment, and there were no reports of dangerous or disruptive behaviors.  She was able to perform her activities of daily living. She lives with a supportive family and was medically stable.  Although the patient continued to require treatment, this could have been provided in a less restrictive environment such as an intensive outpatient program level of care.  All told, 30-day residential treatment was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chest computed tomography (CT) scan. Findings:  The physician reviewer found that the American Lung Society and the American Cancer Society have developed guidelines for lung cancer screening CT chest scans.  The patients should be between the ages of 55-74 years old, at least have a 30 pack-year history of smoking (equal to smoking a pack a day for 30 years, or 2 packs a day for 15 years), still smoking or have quit in the past 15 years and no current symptoms.  This patient does not qualify for a chest CT scan based on the guidelines provided by the American Lung Society and the American Cancer Society regarding age or pack-year smoking history. The records do not indicate if the patient is still smoking.  While there may be a desire to screen for lung cancer in this patient, he does not currently meet the recommended guidelines. 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.