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 laparoscopic sleeve gastrectomy bariatric surgery. Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services.  Bariatric surgery is currently indicated for treatment of morbid obesity defined as a body mass index of 40 or 35 with serious obesity comorbid conditions.  In this patients case, the records do not document diabetes, sleep apnea, cardiovascular disease or hypertension at this time.  The medical evidence does not support the requested services in this clinical setting.  All told, the requested laparoscopic sleeve gastrectomy bariatric surgery is not medically indicated for the treatment of this patient. 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: Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that The submitted records support the medical necessity of the services at issue.  In this case, the patients alcohol use was central to her daily routine and contributed to her significant impairment across multiple domains of functionality.  Her drinking was causing problems at work and compromising her judgment.  The enrollee had sleep problems and had misused Ambien for several years.  The enrollee also had co-occurring inattention, anxiety, depression and co-dependent personality traits that fueled recurrent maladaptive relationships. The providers that managed the detoxification recommended residential treatment based on the clinical presentation.  Per the records, the enrollee had not consolidated the treatment gains necessary to succeed in the outpatient setting and was likely to have promptly relapsed in a community-based setting.  The patient had poor concentration and anhedonia.  The enrollee  was anxious and pressured.  According to the records provided, the patient was actively engaged in treatment during the entire admission.  The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services provided at the time were reasonably expected to improve her condition and prevent a more serious episode of illness.  In sum, residential treatment were medically necessary for the treatment of this patient.Final Result: The reviewers 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 two 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 reimbursement for computed tomography (CT) scan. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has had continuing urologic difficulties.  However, per the submitted documentation, the patient had not been seen recently, and the medical records were from approximately one year prior.  Full-body CT scanning became popular several years ago as a patient directed means for preventive medicine.  This modality has been marketed directly to patients as a means for early detection of cancer, cardiac disease, and other abnormalities.  Several studies have been published concerning the possibility that the risks statistically outweighed the rewards.  Per the medical evidence, the increased risk of radiation induced cancers is a definite issue.  The current evidence does not support the services at issue in this clinical setting.  All told, the CT scan performed was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 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 reimbursement for inpatient hospitalization. Findings:  The physician reviewer found that functional impairments due to traumatically acquired brain insults improve with time, i.e., natural recovery processes.  These impairments are also amenable to rehabilitation interventions.  In this case, the patient sustained a mild TBI due to a motorcycle accident and had post-concussive symptoms.  He otherwise did not sustain other significant injuries.  He was originally intubated on account of persistent vomiting, but self-extubated.  He subsequently was eating a regular oral diet, having bowel movements and was stable medically.  There were no surgical needs.  He did have mild mobility issues, ongoing cognitive issues and decreased safety awareness.  He was seen and followed by multiple specialists.  Overall, the records support that the patient was going to need supervision for safety, but he did not otherwise have medical, surgical or other needs requiring acute inpatient hospital level care.  The trauma team was waiting for transfer to a rehabilitation facility during this period, but did not otherwise indicate need for ongoing inpatient level hospital care. The supervision that he needed could have been provided in the community by caregiver(s).  The rehabilitation team had already otherwise demonstrated independence with household level mobility.  He was also otherwise at the supervision to independent level of care for his basic self-care.  His rehabilitation needs could have been provided in the community at the outpatient level.  All told, inpatient hospitalization for the dates of service in question was not medically indicated for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay. Findings:  The physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen level.  This helps guide the most appropriate therapy for patients taking into account their age and comorbidities.  Many patients will not require therapy and may be followed closely instead.  The important features to recognize are Gleason score and prostate-specific antigen, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX Prostate Cancer Assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score.  The genomic prostate score identifies patients with very low risk disease that can be followed rather than referred for surgery. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. The medical evidence supports the services at issue to better stratify such patients with localized disease.  Thus, Oncotype DX Prostate Cancer Assay performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for antigen therapy services and immunotherapy injections. Findings:  The physician reviewer found that there is sufficient support for the medical necessity for the requested services in this clinical setting. Allergy immunotherapy, administered in a medical facility, is medically necessary for the treatment of the following IgE mediated allergies: allergic (extrinsic) asthma, dust mite atopic dermatitis, hymenoptera (bees, hornets, wasps, fire ants) sensitive individuals, mold induced allergic rhinitis, perennial rhinitis, and seasonal allergic rhinitis or conjunctivitis. After reviewing the clinical information, the patients diagnoses include seasonal allergic rhinitis and perennial allergic rhinitis. The progress notes indicate positive skin test results for pollens, dust mites, and mold.  Moreover, the progress notes have indicated that the patient has tried intranasal steroids, oral antihistamines of both first and second generations. Behavioral modifications have not resolved his symptoms. Therefore, the requested antigen therapy services and immunotherapy injections are medically necessary for treatment of this patients medical condition. 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 allergy and immunology 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 the intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that this case incorporates all elements of the biopsychosocial-spiritual model of conceptualization and represents a patient burdened with prominent psychiatric impairment complicated by unresolved, longstanding psychodynamic conflicts. The co-occurrence of major depression and generalized anxiety are of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, that anxiety related mood disorders are difficult to treat. The records document that this patient presented with significant pain, mood symptoms, and anxiety following a suicide attempt one month earlier. The patient reported that she felt very fragile. The provider noted her glumness, depression and anxiety, and increased a medication to address the lingering depression and anxiety. The patient endorsed self-injurious impulses. Thereafter, she continued active treatment that was reasonably expected to consolidate treatment gains, further her clinical improvement and prevent a more serious episode of illness. Additionally, the IOP services facilitated a gradual and seamless transition to the outpatient setting and did not exceed duration consistent with typical community standards. In sum, the IOP services provided during the dates of service in question were appropriate and consistent with good medical practice and thus medically necessary for treatment of the patients behavioral health condition. 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for durable medical equipment utilized between two dates of service. Findings:  Three physician reviewers found that there is a lack of support for the superior efficacy of the equipment at issue in this clinical setting. There is a lack of evidence-based literature to support the use of superficial cold for pain management. Studies found no additional benefit of consistent cryotherapy using the icing device over intermittent ice bags on postoperative pain, passive range of motion, nausea or vomiting, opioid use, blood loss, lower limb function, or length of stay, after knee surgery despite significant differences in patient-reported compliance and satisfaction. According to another study, there does not appear to be a significant benefit using cold compression over standard ice wraps in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Instead, the studies indicate that cold application, in the form of ice packs, is widely accepted as an effective nonpharmacological intervention for pain management.  Ice packs increase the pain threshold, decrease the inflammatory reaction, swelling, and spasm.  Cold is commonly used in the treatment of acute soft tissue injuries and has been shown to reduce pain effectively in the postoperative period after orthopedic surgery procedures.  However, there is very limited data and research on the effects of continuous flow cryotherapy, as used in this patients case.  As such, greater sample sizes are required to fully determine significant differences between the two techniques for these study parameters. Therefore, the literature does not support the superior benefits of continuous flow cryotherapy over the standard cold packs after a spinal fusion. In light of the foregoing, the durable medical equipment utilized between the two dates of services was not likely to have been more beneficial for the treatment of this patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the equipment at issue was 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 orthopedic surgery 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 23 hours per week (100 hours per month) of direct applied behavioral analysis (ABA) therapy and 10.5 hours per month of supervision. Findings:  The physician reviewer found that there is sufficient evidence in the peer-reviewed literature supporting the correlation between treatment outcomes and ABA treatment intensity. In this case, the patient requires a high level of support to complete activities of daily living. She engages in high level non-compliance, which often presents safety concerns. She also demonstrates severe disruptive behaviors and high level stereotypy. The Health Plan has authorized 21.5 hours per week month (86 hours per month) of direct ABA therapy and nine hours per month of supervision, which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. Given the medical necessity of ABA therapy for children with autism, and the patients severe disruptive behaviors and high level of stereotypy, the request for 23 hours per week (100 hours per month) of direct ABA therapy and 10.5 has been established as medically necessary 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs surgery for treatment of the enrollees skin cancer. Findings: The physician reviewer found that there is sufficient support for the requested procedure in this clinical setting. The patient had a biopsy-proven basal cell carcinoma involving the forehead. Mohs micrographic surgery is a technique whereby the best chance of tumor clearance is obtained while minimizing removal of normal tissue.  The Mohs appropriate use criteria is a nationally recognized algorithm, which provides recommendations for the use of Mohs surgery depending on tumor, size and location. In this patients case, the finding of a biopsy-proven basal cell carcinoma on the forehead meets the Mohs appropriate use criteria. Final Result: The reviewer determined that the requested procedure 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 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 magnetic resonance imaging (MRI) of the right ankle for evaluation of the enrollees ankle injury. Findings:  The physician reviewer found that ankle injuries are one of the more frequently injured weight bearing joints in the body.  Considerable research has been performed to best direct diagnostic imaging and eliminate unnecessary studies. Per the medical evidence, it was appropriate for the patient to have had an ankle x-ray, and that x-ray did not detect any bony abnormality or disruption of the ankle mortise (which could necessitate surgery). The diagnosis was that the patient had an ankle sprain.  In general, the only reason to obtain an imaging study is if it will change the course of treatment.  In this patients case, if surgery were a likely immediate option, then there would be support for obtaining an MRI.  Ankle sprains are generally classified as grade 1, 2, or 3.  Depending on the amount of damage or the number of ligaments that are affected, each sprain is classified from mild to severe.  A grade 1 sprain is defined as mild damage to a ligament without instability.  A grade 2 sprain is considered a partial tear to the ligament, and a grade 3 sprain is a complete tear of the ligament. One study published a systemic review and reported balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II, and III lateral ankle ligament ruptures can be managed without surgery. Another study noted stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications.  In this patients case, there is no advantage in obtaining an MRI study at this time. Regardless of any MRI findings, the patient would still need rest, pain medications, and possibly physical therapy. 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.