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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center (RTC) services for treatment of his medical condition.  Findings:  The physician reviewer found that although chemical dependency specialty services were indicated for this patient, the medical records do not demonstrate the medical necessity of the RTC level of care. Upon his presentation, the patient was not intoxicated and he was not in withdrawal. He was not psychiatrically distressed and his family was supportive of his recovery. The patient was motivated to re-capture sustained sobriety. The documentation from the facility included daily notes without a thorough psychiatric evaluation, mental status examination or treatment plan. There was no evidence in the record that the patient had engaged in chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, community sponsorship, intensive outpatient programming (IOP), or partial hospitalization programming (PHP). This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate at the time. Thus, RTC services were not medically necessary.   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 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 (Helvie). In this particular patient, the presence of breast implants is not, in itself, an indication for tomosynthesis but the dense nature of her breast tissues warranted the use of 3D tomosynthesis.  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. Therefore,  tomosynthesis was likely to be more efficacious than any available standard screening tool for evaluation of the patients medical condition.  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 the her medical condition. Findings: Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her exam been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two 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. However, in this particular patient, there were no problems to be resolved. Specifically, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies over 12 years. Thus, in this clinical setting, the use of the digital breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the diagnostic procedure 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested duloxetine (Cymbalta) for treatment of his medical condition. Findings: The physician reviewer found that peer-reviewed medical literature indicates that chronic alcohol consumption produces painful peripheral neuropathy for which there is no reliable successful therapy, mainly due to lack of understanding of its pathobiology. The mechanism behind alcoholic neuropathy is not well understood, but several explanations have been proposed. These include activation of spinal cord microglia after chronic alcohol consumption, oxidative stress leading to free radical damage to nerves, activation of mGlu5 receptors in the spinal cord and activation of the sympathoadrenal and hypothalamo-pituitary-adrenal (HPA) axis. Nutritional deficiency (especially thiamine deficiency) and/or the direct toxic effect of alcohol or both have also been implicated in alcohol-induced neuropathic pain. Treatment is directed towards halting further damage to the peripheral nerves and restoring their normal functioning. Tricyclic antidepressants (TCAs) are often the first line drugs to alleviate neuropathic pain symptoms. They have central effects on pain transmission and block the active re-uptake of norepinephrine and serotonin. TCAs have been shown to relieve various neuropathic pain conditions in many trials. One recent study has confirmed the efficacy of TCAs in central pain. The serotonin/norepinephrine re-uptake inhibitors (SNRIs), duloxetine (Cymbalta) and venlafaxine, have a well-documented efficacy in painful polyneuropathy. Although duloxetine is indicated for the treatment of diabetic polyneuropathy, it has shown clinical efficacy in treating many different types of polyneuropathy including alcoholic polyneuropathy. Therefore, duloxetine (Cymbalta) has been shown to be an effective therapy in the treatment of patients diagnosed with neuropathy. Moreover, the patient also stated that he has been taking duloxetine (Cymbalta) for the last three months with good results. For all these reasons, the medication at issue was and is medically necessary for treatment of this patients polyneuropathy.  Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Saxenda for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  Saxenda has been approved by the U.S. Food and Drug Administration (FDA) for use in chronic weight management.  The medication is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial BMI of 30 or greater.  The medication may also be appropriate as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.  The medical records indicate that this patient is using the medication in conjunction with diet and exercise.  In sum, Saxenda  injections are medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine 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: The parent of an enrollee has requested gene panel testing for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the patient has optic nerve atrophy. A thorough ophthalmologic and genetic work-up has been performed with no identification of an etiology. There is no reported family history of similar problems. A chromosomal test showed duplication of 11q22.1 of unknown significance and the patients father is unaffected. The pediatric ophthalmologist and geneticist suggested further genetic sequencing studies to provide further insight. However, in the absence of a family history of inherited optic atrophy, additional testing will not provide information that would change the natural history, management, or course of treatment in the patient. Thus, the requested gene panel testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested testing is 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 ophthalmology 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 hip surgery for treatment of her medical condition. Findings: Two reviewers found that review of the medical records indicate that she meets the criteria for surgical treatment given the diagnosis of femoroacetabular impingement syndrome with hip pain that interferes with activities of daily living and has failed conservative treatment. MRI confirmed the presence of femoroacetabular impingement syndrome with evidence of CAM impingement in the form of an osseous ridge at the edge of the femoral neck, as well as a labral tear. In addition to the preoperative clinic diagnosis, the diagnosis was confirmed on direct visualization during the operative procedure. At this patients age, she is not a candidate for alternative procedures such as total hip arthroplasty which will likely require revision with increased risk level of revision for both mechanical complications and increased risk of infection. Treatment of femoroacetabular impingement syndrome is now well established and the technical requirements are well within the experience of an orthopedic surgeon skilled in arthroscopic techniques. In summary, the hip surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the surgery 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. 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 oxycodone for the treatment of his medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, the medical necessity for oxycodone has not been established. The patient presents with low back pain and chronic abdominal pain complicated by previous gastric surgery with notable use of high-dose oxycodone. The pain management note documents that that it would not be in the patients best interest to continue high-dose opioid pain medications. In this clinical setting the recommendation by the Health Plan for treatment in a chemical dependency program is medically reasonable and appropriate. Given the above, the requested oxycodone is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that 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 anesthesiology with sub-certification in pain medicine 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 epidural steroid injections for treatment of her medical condition.  Findings: The physician reviewer found that in this case, the patient has been treated with physical therapy previously. However, there is a lack of documentation of a new course of therapy and home exercise program. The current medical literature indicates that a home exercise program after physical therapy independent of epidural steroid injections can give patient lasting results (Van Zundert, et al). Moreover, the patient does not have any recent physical exam findings supporting a diagnosis of lumbar radiculopathy (Gellhorn, et al). Given these findings, the requested epidural steroid injections 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 anesthesiology with sub-specialty certification in pain medicine 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 behavioral health treatment services for treatment of her behavioral health condition. Findings: The physician reviewer found that the services at issue were not medically necessary for treatment of this patients behavioral health condition.  The patient did not demonstrate any signs of being a danger to herself or others; she was not violent or aggressive; she did not present with self-harm urges. There was no suicidal or homicidal ideation endorsed.   She struggled with taking accountability, was resistant, and remained emotionally reactive. These alternated with showing productivity in groups and being positive. Emotional dysregulation was reported; however, the triggers, type of behavior, duration, and type of containment required were not described. She continued to struggle with feedback and was emotionally reactive; however, she was open and engaged. The records did not indicate acting out behavior. She was cooperative and compliant with her medications.  The records also show that she had insight into her behavior and her difficulties with following through.  All told, the submitted documentation fails to demonstrate the medical necessity for the services at issue.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential substance abuse treatment services for treatment of his medical condition. Findings: The physician reviewer found that upon review of the submitted documentation,  residential substance abuse treatment services were not medically necessary for treatment of the patients condition. During the period at issue, the patient was not at risk for imminent severe withdrawals. He was not experiencing significant post-acute withdrawal symptoms. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive factors to warrant continued residential treatment. The patient was motivated and engaged in the recovery process. He had family support.  All told, the patient no longer required 24 hour supervision at a residential level of care. The patients recovery could have continued at a lower level of care such as in a 12 Step outpatient program. As such, 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 addiction 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in 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.