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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that residential treatment center services were not medically necessary for treatment of the patients medical condition. The patient was not a danger to herself or others, and was able to contract for no self-harm. She was medically and psychiatrically stable. Her body weight was stable. Her eating disorder behavior was somewhat unclear and not witnessed by staff or others. She was engaged in treatment. Although the patient required education and individual, group, and family therapies related to her eating disorder and some degree of supervision to ensure compliance with her meal plan, there is a lack of evidence demonstrating that any of these treatments could not have been safely provided at a lower level of care such as a partial hospitalization program. 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 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense breast tissue.  The advantage relates to the ability to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional technique alone. 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 reviewers are board certified in diagnostic radiology and are actively practicing.  All three 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the due to the advantages it brings radiologists interpreting mammograms especially in cases of extremely or heterogeneously dense tissue such as in this case. Tomosynthesis often allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only.   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 reviewers are board certified in diagnostic radiology and are actively practicing. All three 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 orthopedic inserts for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Per Medicare guidelines, orthotics may be authorized and/or covered if the orthotics are part of a medically necessary shoe attached to a medically necessary leg brace. After review of the clinical notes submitted for review, the patient does not have a medically necessary shoe attached to a medically necessary leg brace. For this reason, orthopedic inserts are not medically necessary for 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 podiatry 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. All told, the services at issue were likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram is due to improved cancer detection rate.  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 reviewers are board certified in diagnostic radiology and are actively practicing.  All three 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 DecisionDx Melanoma Assay testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Uveal melanomas are rare, and up to 50% are at risk for metastases. Among the most important risk factors are chromosomal markers in the tumor identified by use of the Decision DX Melanoma Assay test.  Using samples of primary uveal melanomas obtained by fine needle biopsy, tumors are classified as having low or high metastatic potential, depending on the expression of 15 genes.  DecisionDx Melanoma Assay testing is a standard of care for determining prognosis and need for more aggressive therapy and is superior to other testing available.  Therefore, DecisionDx Melanoma Assay testing was likely to have been of greater benefit than other tools for evaluating this patient.  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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three 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 residential treatment center services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The discharge summary documents that he made slow but steady progress.  The current medical evidence does not support the services in dispute in this patients case.  The medical records do not show that the patient received any specialized type of treatment during the period in question that could not have been provided in a lower level of care.  Therefore, residential treatment center 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested allergy testing for evaluation of her medical condition.  Findings:  The physician reviewer found that the medical records fail to indicate any diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease and the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. As such, IgG food testing is not the standard of care and is not medically necessary for evaluation of the patients medical condition.  However, IgE testing may be helpful in treating this patient. About 50% of children and 35% of adults are sensitive to food or aeroallergens (Schafer). Infants and young children with atopic dermatitis are more commonly sensitized to foods, such as wheat and egg which are the most common (Schafer). Adults and older children are more commonly sensitized to aeroallergens, especially dust mites (Ponyai, et al). In this case, the aeroallergen testing is within guidelines by the American Academy of Allergy, Asthma and Immunology practice parameters for allergy testing and is helpful in atopic dermatitis in adults (Bernstein, et al). As such, the IgE testing for aeroallergens was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a prolotherapy injection for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that there is limited peer-reviewed evidence that prolotherapy is more efficacious compared to standard therapy in treatment of hip pain. The literature provided in support of this appeal includes a case series and a pilot study, which are considered low-level evidence. The pilot study for a different tendinopathy states more research is needed to validate the claims of benefit. Thus, further studies are needed in order to support the use of prolotherapy in alleviating chronic hip pain. There is a lack of medical research showing that prolotherapy for hip tendinopathy has undergone the rigors of scientific research to move it from investigational research to standard of care. In this case, the patient had not yet exhausted all available standard therapy in treatment of her medical condition. Therefore, the requested prolotherapy injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in anesthesiology with sub-specialty certification in pain management and are actively practicing. All three 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 medical condition.  Findings:  The physician reviewer found that according to the referenced literature, articulation disorder treatment involves demonstrating how to produce a sound correctly, practicing sounds in different words, and learning recognize which sounds are correct and incorrect. The clinical documentation submitted for review failed to demonstrate significant speech abnormalities. Given the lack of documentation supporting a speech/language disorder and the need for ongoing therapy, the services at issue were not medically necessary. As such, the requested speech therapy is not medically necessary for treatment of the patients medical condition. 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 pediatric rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient acute rehabilitation services for the treatment of her cerebrovascular accident. Findings: The physician reviewer found that in this clinical setting, inpatient acute rehabilitation services are not medically necessary for treatment of this patients medical condition.  Per standards of care in the practice of rehabilitation medicine, acute inpatient rehabilitation is not necessary if appropriate care meeting a patients clinical and rehabilitation needs can be provided at a less intensive level of care. Functional impairments due to acquired brain insults such as stroke can improve with time, i.e., natural recovery processes; but, are also amenable to rehabilitation interventions. The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature. In the present case, the patient had very profound initial functional deficits following her stroke. She received acute inpatient rehabilitation care and made limited progress. She has now been receiving care at the skilled nursing facility level and has been making functional progress. This functional improvement is due in part to natural recovery processes following stroke, as evidenced by the fact that the patient has continued to make progress more recently despite reduced therapy intensities. Additional recovery and functional improvement are expected. Ongoing rehabilitative management however, does not require an acute inpatient rehabilitation setting of care. In this case, there are no documented ongoing skilled nursing needs: no complex wound care, no initiation of self-care related to enteral feeding or ostomy care. In sum, the requested inpatient acute rehabilitation services are not medically necessary.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested positron emission tomography (PET) scan for evaluation of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patient has been incompletely staged.  It is not known whether she has metastatic disease beyond the axilla or not.  Her breast tumor was enlarging, and so chemotherapy was started urgently before scans could be done. In this clinical setting, the PET scan is medically necessary and appropriate at this juncture in her care.  There is sufficient medical evidence supporting its use during neoadjuvant chemotherapy to evaluate responses. Multiple lines of evidence and standard care dictate that the requested PET scan is medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 magnetic resonance neurography for evaluation of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patients traditional work-up did not offer significant insight into her problems. The requested magnetic resonance neurography is medically appropriate in this case, and the medical records provide a clinical rationale for the requested services.  In sum, the requested magnetic resonance neurography is medically indicated to better elucidate the potential cause of this patients symptoms.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested intensive outpatient program (IOP)services for treatment of the enrollees autism and anxiety disorder. Findings: The physician reviewer found that in this clinical setting, continuation of IOP interventional therapy is not medically necessary. The patients history indicates that the patient was initially referred to the IOP program when he was receiving ABA treatment only 3 days each week. The documentation stated that his behaviors were severe but he improved with the IOP treatment.  Most likely, this is because the treatment time was increased as per Academy of Child and Adolescent Psychiatry (AACAP) guidelines. Per AACAP practice parameters, the guidelines for treatment of ASD state that treatment for young children should be intensive and highly individualized, with up to 40 hours per week of one-to-one direct teaching, initially using discrete trials to teach simple skills and progressing to more complex skills such as initiating verbal behavior. In sum, the standard of care in this setting is intensive ABA services (up to 40 hours per week). This patients records do not indicate that he needs higher level of care through IOP services; rather, the patient is an appropriate candidate for intensive ABA therapy in order to control his symptoms and to prevent further regression. For these reasons, the requested IOP services are not medically necessary for treatment of this patients autism spectrum disorder (ASD) and anxiety.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients behavioral condition. Therefore, the Health Plans denial should be upheld. Qualifications/Credentials: 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.