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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy, 13 hours per week of supervision, four hours per week of group parent training and four hours per week of individual parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA is medically indicated for children with autism spectrum disorders. In this case, the patient has received a high level of ABA services since 2015. However, he has not yet met any of his behavioral goals and continues to have a high level of maladaptive behaviors. There is a lack of evidence provided that shows he has made enough progress to allow for a reduction in ABA hours. In addition, the patients maladaptive behaviors including aggression, non-compliance and vocal protest which require a high level of ABA services. Furthermore, 18 hours per month of supervision is clinically indicated.  Also, four hours per month of group parent training and four hours per month of individual parent training is indicated. Therefore, 40 hours per week of ABA therapy, 18 hours per month of supervision, four hours per month of group parent training and four hours per month of individual parent training are medically necessary in this clinical setting. 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 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 172 hours per month of applied behavioral analysis (ABA) therapy, 16.5 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 the 62 hours per month of direct and supervisory ABA services as authorized by the Health Plan is not appropriate for this patient. Based on the documentation submitted for review, a higher level of ABA services are indicated due to the patients maladaptive behaviors including aggression, agitation, and non-compliance. The patient has made some progress with maladaptive behaviors which have decreased with non-compliance still at a 0.5 per hour level. Given that he has had a decrease in maladaptive behaviors, a reduction in ABA hours is indicted. A significant drop in ABA services is likely to result in a return of maladaptive behaviors. In this clinical setting, 135 hours per month of direct ABA therapy, 16.5 hours per month of supervision and four hours per month of parent training are medically necessary. 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 certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  The physician reviewers found that the patient had a digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population.   The digital breast tomosynthesis was likely to be more beneficial for this patient than other 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 digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: Two of three 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 reviewers number one, two, and three are board certified in diagnostic 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 the enrollees breast cancer screening.  Findings:  Two physician reviewers found that 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. Final Result: Two 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three 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 particular patient, her breasts have been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Three 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: All three physician reviewers are 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review indicate that she was still triggered by the past sexual assault. She also identified family stress as her other main trigger. However, the progress notes indicate that she had a good family session and enjoyed seeing her parents. Subsequent notes indicate that she had gained insight into her triggers and had developed and practiced coping skills successfully. Therefore, the patient could have continued treatment at a lower level of care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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 insertion of an artificial intervertebral disc at C5-6 and C6-7 for treatment of the enrollees spinal stenosis. Findings:  Three physician reviewers found that the evidence based medical peer-reviewed literature supports the use of two-level contiguous cervical artificial disc replacement (ADR) as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease. This patient presents with neck pain radiating into the left arm with weakness and numbness. Functional difficulty was noted in activities of daily living and work ability. Clinical exam findings are consistent with imaging evidence of degenerative disc disease at the C5-6 and C6-7 levels with plausible neural compression. Comprehensive conservative non-operative treatment has been tried and failed to provide sustained improvement. Final Result: 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 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 20 hours per week of direct applied behavioral analysis (ABA) therapy, six hours per month of supervision and one hour per month of parent training for treatment of the enrollees autism spectrum disorder.Findings:  The physician reviewer found that a study found that children with autism who started ABA therapy at an earlier age and had intensive ABA were more likely to have an optimal outcome. The study also found intensive behavioral treatment for children with ASD was effective. Another study found that ABA was effective for disruptive behaviors in children in public school. In this case, 20 hours per week of direct ABA therapy is medically necessary due to the patients maladaptive behaviors that include aggression, non-compliance and vocal protest. In addition, he has trialed multiple medications for treatment of his maladaptive behaviors with only some improvement. 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 armodafinil (Nuvigil) for treatment of the enrollees narcolepsy.  Findings: The physician reviewer found that, in this case, the patient is not documented to have cataplexy, which is why the diagnostic criteria for type 2 narcolepsy are being utilized. The patients multiple sleep latency test was notable for both having a mean sleep latency greater than eight minutes and for an absence of any sleep onset REM periods. In this regard, the current clinical diagnostic criteria are not met. The presence of a possible REM sleep behavior disorder is notable. However, a REM sleep behavior disorder is not a clinical finding commonly associated with narcolepsy and is a separate and distinct sleep disorder (Schenck and Mahowald). As the patients clinical presentation does not establish a diagnosis of narcolepsy, the use of Nuvigil would not be supported. There is insufficient clinical evidence in the current peer-reviewed published literature to support the use of Nuvigil for other causes of generalized daytime sleepiness or for treatment of a REM sleep behavior disorder. Given the clinical information presented for review and the body of literature, the requested Nuvigil is not medically necessary for treatment of this 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 neurology and sleepsmedicine 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient with a reportedly palpable breast lump, it is imperative to specifically evaluate whether or not there is a lesion that warrants a biopsy. While her breasts are not particularly dense, tomosynthesis is better than routine mammography in separating overlapping structures in hopes of demonstrating an otherwise occult tumor. While one could argue that her mammogram has not changed since the last study, it is specifically this type of patient who has an unexplained lump that can benefit most from tomosynthesis. The targeted sonogram was similarly useful. In this patient, the two studies were apparently sufficient in excluding a tumor, and the radiologist deferred to the referring physician for further management. A biopsy was not specifically recommended. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: 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: The parent of an enrollee has requested speech therapy for treatment of the enrollees delayed developmental milestones. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient was referred for a comprehensive evaluation because of speech and language delays and behavioral concerns.  Multifactorial assessments failed to yield a diagnosis of autism spectrum disorder, and his speech and language evaluation placed him at the low normal (expressive) to normal (receptive) level of communication for age.  The current medical evidence does not support the requested services in this clinical setting.  Based on appropriate validated testing and clinical observation, the requested speech therapy is not medically necessary 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 pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocols was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the immune cell functional assay (ImmuKnow) for evaluation of the enrollees Stage V chronic kidney disease secondary to lupus nephritis status post kidney transplant.   Findings:  The physician reviewers found that The ImmuKnow assay is a U.S. Food and Drug Administration (FDA) approved test that has been used as an adjunct for immune monitoring after transplant. The ImmuKnow assay was used by this patients provider as part of the protocol for its labelled indication as described on its FDA label. Combined with other biomarkers can be used to identify kidney transplant patients at high risk of rejection and infection. Further, the Centers for Medicare and Medicaid Services (CMS) support the utility of the ImmuKnow assay for use in this clinical setting. All told, the peer-reviewed medical literature and current guidelines support the immune cell functional assay (ImmuKnow) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of three reviewers determined that the testing 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 reviewers number one, two, and three are board certified in surgery and critical care 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.