Persius/hicric huggingface dataset:
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 107 hours per month of applied behavioral analysis (ABA) therapy (86 hours per month of direct therapy, 17 hours per month of supervision and four hours per month of parent training) for treatment of the autism. Findings:  The physician reviewer found that the request for ABA therapy at the frequency of 107 hours per month (86 hours per month of direct therapy, 17 hours per month of supervision and four hours per month of parent training) has been established as medically necessary for treatment of the patients autism. One study found that ABA was effective to decrease disruptive behaviors in school age children with autism. In this case, the patient requires a higher level of ABA services due to his maladaptive behaviors that include tantrum, elopement and self-biting. Therefore, based on the records submitted for review the requested services are medically necessary for treatment of the patients autism. 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: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for speech therapy for treatment of the enrollees severe mixed receptive and expressive language disorder. Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of speech therapy. The review by colleagues state that It is currently estimated that about 30% of children with autism spectrum disorder remain minimally verbal, even after receiving years of interventions and a range of educational opportunities. Children with autism often have difficulty developing the communicative intent and desire to communicate effectively. A picture exchange communication system (PECS) systems or speech generating devices paired with interactions around desired objects is likely to be more effective in obtaining functional communication than speech therapy. In this case, the KSPT diagnostic test showed that he has a bit more functional oral movement in the percentile than he actually uses in speech sound production, which is in the percentile. This data shows that he has more oral movement skills for speech than he utilizes. Speech therapy for treatment of the patients oral movement is not likely to lead to the functional gains. For the reasons stated, speech therapy provided was not and is not medically necessary in this clinical setting. Final Result: The reviewer determined that the therapy 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 pediatrics with sub-specialty certification in developmental and 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 reimbursement and prospective authorization and coverage for continued partial hospitalization program (PHP) services for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the patients medical records document that, her motivation had increased and she denied suicidal and homicidal ideation. She was medically and psychiatrically stable. She had reduced incidences in binging and purging behaviors and was using coping skills to combat urges. Her parents were supportive and attended therapy. Shr showed the ability to refrain from acting out eating disorder behaviors. She demonstrated no restricting and only mild overeating with one spoon of peanut butter in the evening. According to the American Psychiatric Association (APA) guidelines, PHP services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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 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 Sovaldi and ribavirin for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 2 patients, therapy is recommended with Sovaldi and Daklinza or Epclusa. This is based on the two studies for Sovaldi and Daklinza, and the ASTRAL-2 trial for Epclusa. Sovaldi and ribavirin are no longer recommended. For these reasons, although hepatitis C treatment is needed, the request for Sovaldi and ribavirin is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 internal medicine with sub-specialty certification in gastroenterology 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 admission into an acute brain rehabilitation facility for treatment of the enrollees traumatic brain injury.  Findings: The reviewer found that the Functional impairments due to traumatically acquired brain insults may improve with time via natural recovery processes.  These impairments are also amenable to rehabilitation interventions.  Nevertheless, deficits can remain severe, particularly in the setting of severe injuries.  Functional dependency following intracerebral hemorrhage is high.  In this case, the patient has sustained extensive bi-frontal and bitemporal hemorrhages.  Follow-up imaging has shown chronic encephalomalacic changes, and even early volume loss.  Although there has been some improvement, he has had persistent behavioral issues.  Otherwise, from the physical standpoint, there are no documented significant deficits that indicate a need for ongoing inpatient level care for his rehabilitative needs.  His treating providers have not recommended acute inpatient rehabilitation.  Further rehabilitative services may be considered going forward, but these services can be provided in a community setting, with custodial level services provided for his basic self-care.  There are otherwise no documented ongoing skilled nursing needs (e.g., complex wound care, initiation of self-care related to enteral feeding or ostomy care) requiring ongoing inpatient care.  This patient has a guarded long-term prognosis given the severity of his underlying brain injury condition.  An acute inpatient rehabilitation course at this time would not be reasonably expected to positively modify his health or functional outcomes in a marginally significant manner over less intensive services.  All told, admission into an acute brain rehabilitation facility 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 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 bilateral digital breast tomosynthesis for the evaluation of the enrollee, who presented for an annual breast screening examination. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram and breast tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram exam.  The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. The sonogram noted a few small benign cysts.  Her breasts were described as being extremely dense. The Health Plan has denied reimbursement for bilateral digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 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, however, she has breasts that have been described as being extremely 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. In sum, digital breast tomosynthesis is likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested psychiatric intensive outpatient program services 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. During the dates of service at issue, the patient denied depression and showed no indication of suicidal or self-injurious desires.  He showed improvement and progression in personal functioning.  Although his baseline behavior of avoidance continued, this appeared to be a hardened, ingrained pattern of coping with his emotions that could continue to be dealt with on an outpatient basis.  He had become more open and honest in his communication.  He was motivated and appeared to be working the program.  He was medically and psychiatrically stable.  He had support systems in place.  No new problems had arisen.  Although he continued to struggle with his emotions and required further treatment to help him develop and solidify coping skills, this did not require the structured environment of an intensive outpatient program setting.  All told, psychiatric intensive outpatient program services were 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 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer recurrence. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. The current images were compared to a prior mammogram, and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  The patients breast tissue was described as being extremely dense. Per the Health Plan, the service at issue was denied as investigational for the evaluation of this patient. 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 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 breast tissues have been described as being extremely 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 breast tissue that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis is likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue are 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 enrollee, who was asymptomatic.  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 patients case, her breasts have been described as extremely dense.  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 is likely to have been more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue 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 gene testing of the left breast excision for evaluation of the enrollees recurrent left breast cancer. Findings:  Three physician reviewers found that MammaPrint is a 70 gene signature that has been shown to improve prediction of clinical outcome in women with early stage breast cancer. One research reported a study that demonstrated the validity and usefulness of MammaPrint as compared to a purely clinical evaluation of prognosis. In certain groups of patients, the test appears to be more useful than clinical features, in determining which patients should receive adjuvant chemotherapy. However, thus far MammaPrint has only been validated in early breast cancer, as an aid in making treatment decisions after the initial diagnosis of breast cancer. This is not the situation in this patient, who presents with recurrent breast cancer five years after her initial treatment. There is a paucity of data to indicate that MammaPrint is useful in this clinical situation. Given these findings, the gene testing of the left breast excision performed in this case was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: 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: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue 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.