Persius/hicric huggingface dataset:
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 that was performed for evaluation of the enrollee, who presented for a breast screening examination. Findings:  Two physician reviewers found that the patient presented for a screening mammogram with digital tomosynthesis. The patient reported a family history of breast cancer in her mother. The impression was benign. The patient requested reimbursement for the tomosynthesis portion of the examination. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Therefore, the Health Plan denied the request for reimbursement. The medical literature supports the efficacy of this service at issue. According to one study, 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. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to revise a deformed, contracted scar, mid abdomen, 15 cm vertical by 20 cm horizontal subcutaneous symmetrically distributed fibrous tissue. Findings:  The physician reviewer found that the surgery to revise a deformed, contracted scar, mid abdomen, 15 cm vertical by 20 cm horizontal subcutaneous symmetrically distributed fibrous tissue is medically necessary for treatment of the patients medical condition. The patient underwent a ventral hernia repair and panniculectomy that was complicated by loss of the umbilicus and significant wound healing issues. Although the patient has healed her wounds, her clinical documentation and review of the photographs note that she has a severely abnormal contour of the lower abdomen with loss of the umbilicus. This is not a normal appearance for the abdomen following her medically necessary procedures. The patient has an additional functional deficit associated with painful scarring. Based on these facts, the planned revision is consistent with reconstructive surgery and not cosmetic surgery one study analyzed a series of massive panniculectomies greater than 10 pounds following massive weight loss and to investigate the outcomes achieved. The authors noted Complications included wounds requiring debridement, dressings, vacuum-assisted closure therapy and/or delayed primary closure (20 percent), and seroma requiring drain replacement or dressings (28 percent). In this case, the patient required prolonged healing following umbilical loss and large wounds. The current appearance of the patients abdomen is severely abnormal and she has evidence of painful scarring.  The planned procedure for revision is consistent with reconstructive surgery that is medically necessary. The planned revision is a treatment of a significant complication following her previous surgery. Although the patient has evidence of a functional deficit with painful scarring, the major aspect of this determination is based on the severely abnormal contour of the abdomen.  Final Result: The reviewer determined that the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of four warts (one on each thumb, one on the first left finger and one on the bottom lip) for treatment of the enrollee, who presented for wart removal. Findings:  The physician reviewer found that warts are benign skin lesions that appear when a virus infects the top layer of the skin. The medical literature suggest various methods of treatment for warts. However, in this patients case, the medical necessity criteria for removal of benign lesions have not been established in this clinical setting.  In this patients case, the submitted clinical records do not show that the benign lesions interfere with this patients activities of daily living. Moreover, the providers notes do not say whether the lesions are interfering with this patients daily functions. As such, the requested services are not medically necessary for treatment of this patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stem cell treatment for her multiple sclerosis (MS). Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Hematopoietic stem cell transplantation (HSCT) is well-established in the peer-reviewed literature as the most potent therapy in highly active MS, especially when used early in the course of the disease, with long-term disease free remissions beyond seven years. The study by Researchers found that Among patients with relapsing-remitting MS, nonmyeloablative hematopoietic stem cell transplantation was associated with improvement in neurological disability and other clinical outcomes. In this case, the patient has a diagnosis of MS and her in-Plan provider reports that she is progressing in her disease, at least clinically although not radiologically. Her in-Plan provider noted that HSCT has the potential to stabilize her disease course. Since the patient is progressing despite highly effective therapy, the request for stem cell treatment 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  Three physician reviewers found that she was asymptomatic with respect to her breasts.  She  underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, she had a hand-held whole breast sonography. The current images were compared to prior mammograms. An interval development of indeterminate calcifications and questionable architectural distortion in the mid outer portion of her left breast were noted.  Her breasts were described as average in density. Subsequent to study, it was recommended that the patient return for additional imaging. The patient requested reimbursement for the tomosynthesis portion of the breast examination. The Health Plan has denied reimbursement for 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, the presence of new indeterminate calcifications and a possible area of architectural distortion are both reasonable indications for tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oxygen concentrator, oxygen supplies and portable gaseous oxygen system provided for treatment of the enrollees chronic obstructive pulmonary disease (COPD). Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) coverage requirement for home oxygen and portable oxygen requires an oxygen saturation of room air of 88% or lower. In this case, when the patient is at rest the oxygen saturation and the ABG document that the patient does not meet the criteria for oxygen. However, the records show that once the patient ambulates the oxygen saturation on room air decreases to 83%  and 80%. In this clinical setting, the patient meets criteria for the home oxygen concentrator and the portable oxygen system when she ambulates and/or exerts herself. 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 internal medicine with sub-specialty certification in pulmonary disease 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 a male 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, residential treatment center services provided were medically necessary for treatment of the patients medical condition. In this case, the patient presents with diagnoses of ADHD, anxiety disorder and disruptive behavior disorder. He displayed aggressive and intimidating behavior towards his parents. He was treated with multiple lower level of care interventions including psychotherapists, psychiatrists and home-based therapeutic services. However, despite multiple therapies the patients behavior continued to deteriorate. In this clinical setting the structure of a 24-hour based residential treatment was medically necessary for the patient to develop therapeutic relationships and modeling types of behavior. In addition, the services provided were consistent and beneficial for treatment of the patients medical condition. Based on the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical 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 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 the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings: Three physician reviewers found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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. 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 applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that several concepts must be considered when considering the medical necessity of ABA therapy, such as the impairing nature of symptom and the evidence behind the recommended interventions.  In this case, the records indicate the patients behaviors are impairing, given the multiple and varied behaviors which occur during both speech and occupational therapy sessions on a weekly basis. These behaviors hinder the patients progress towards necessary goals in these areas. ABA is a well-documented behavioral approach for individuals with and without autism spectrum disorder. Children with Down syndrome have been shown to benefit from ABA therapy. ABA provides the tools necessary to address the range (in form and function) of behaviors of children with Down syndrome that have, in the past, precluded them from learning opportunities. In addition, research has shown that access to ABA can increase vocal responses in children with developmental disabilities. For this patient, ABA will likely increase his vocal responses, helping make much needed progress towards speech therapy goals while diminishing behaviors and increasing communication skills. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for kyphoplasty surgery performed on 11/23/16.Findings:  Two physician reviewers found that the current medical evidence supports the use of kyphoplasty for acute vertebral body fractures, less than three months from onset of pain to procedure.  In this case, the patient had chronic thoracolumbar back pain with suspected anterior vertebral collapse at the T12 and L1 levels.  The records documented an apparent acute increase in symptoms prior to presentation for orthopedic evaluation on 10/03/16.  He had severe debilitating pain and interference with activities of daily living and quality of life.  There was reported x-ray and MRI evidence consistent with anterior vertebral collapse at the T12 and L1 levels.  Detailed evidence of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted.  Final Result: Two reviewers determined that the services at issue were 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 reimbursement and prospective authorization and coverage for 36 hours per week of direct applied behavioral analysis (ABA) therapy and 14 hours per month of supervision provided. Findings:  The physician reviewer found that In this case, the medical necessity of ABA services has been established. The correlation between treatment outcomes and treatment intensity is well documented. Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD).  Research studied 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Moreover, several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. In this case, the patient appears to have made progress, but continues to have significantly problematic behaviors. The patient continues to struggle with stereotypic behavior at a high rate, and her outburst behaviors also continues to be problematic. While the patient appears to have made progress, she continues to demonstrate impairment in several areas at a high frequency making it increasingly difficult for her to be successful in more generalized environments. Accordingly, 36 hours per week of direct ABA therapy and 14 hours per month of supervision provided from date of dispute and forward were and are medically necessary in this clinical setting. Final Result: The reviewer determined that services at issue were and 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: The parent of an enrollee has requested authorization and coverage for CPT code 29891  arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia; CPT code 29892  arthroscopy aided repair of large osteochondritis dissecans lesion; and CPT code 28446  open osteochondral allograft, talus (includes obtaining graft(s)) for treatment of her right ankle pain. Findings:  The physician reviewer found that the records provided for review document that this patient has failed two previous arthroscopic procedures for her ankle cartilage injury. She is not a candidate for autograft transfer due to the lesion involving the medial shoulder of the talus. The time expected to fully heal from this procedure is approximately one year, and the patients schooling and activity level will be affected. Given the large lesion that has failed two previous surgeries, the medical literature supports the requested procedures for use 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 orthopedic 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.