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 eye movement desensitization and reprocessing (EMDR) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Based on the current peer-reviewed literature, EMDR is a therapeutic technique that is indicated for treating individuals who are diagnosed with PTSD. There is a lack of literature supporting EMDR for the treatment of individuals diagnosed with autism spectrum disorder who do not carry a diagnosis of PTSD. Moreover, the medical literature practice parameter for children with autism strongly recommends behavioral interventions and specifically ABA therapy, which this patient is currently receiving, as being empirically supported by research. In sum, the medical necessity for EMDR in this clinical setting has not been established.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalization for treatment of his medical condition. Findings:  The physician reviewer found that in regards to the treatment of cellulitis, patients with mild cellulitis may be treated with oral antibiotics. It is recommended that patients with signs of systemic toxicity or erythema that has progressed rapidly be treated initially with parenteral antibiotics. Parenteral therapy is also appropriate for patients with persistence or progression of symptoms despite appropriate oral therapy.  In this case the patient is not documented to have an active case of cellulitis or that he has failed outpatient treatment with oral antibiotics. Furthermore for the treatment of chronic venous ulcers, venous ulceration is managed with wound debridement, as needed, barrier creams to protect adjacent skin, and wound dressings tailored to the environment of the wound. In this case the patient has been referred to the appropriate subspecialist. The medical record supports that he has not followed up with either the wound clinic or his primary care physician. There is no documentation to support that he has failed outpatient treatment for either venous stasis ulcers or cellulitis. All told, an inpatient level of care for chronic leg wounds with or without cellulitis is not supported as 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Soma and physical therapy for treatment of her medical condition. Findings:  The physician reviewer found that the request for Soma is not medically necessary for treatment of the patients medical condition. Soma (carisoprodol) is indicated for acute, painful musculoskeletal conditions with noted side effects of drowsiness, dizziness, vertigo and ataxia. In addition, carisoprodol has been linked to dependence and in some states has been classified as schedule IV drug. Researchers performed a review which compared efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions. The authors noted that efficacy was found to be poor for carisoprodol. In musculoskeletal conditions between relaxants, carisoprodol was poor and in comparison to placebo carisoprodol was also poor. Given the increased side effects and lack of support in the peer-reviewed literature, Soma is not medically necessary in this clinical setting. However, the patients request physical therapy is medically necessary. Physical therapy is indicated so the patient can have continued conservative measures for the treatment of her documented pain of the cervical spine and to help the patient better manage her overall pain. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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 Flector (diclofenac epolamine) patches and bilateral knee Supartz injections for treatment of her medical conditions. Findings:  The physician reviewer found that the Flector patch and bilateral knee Supartz injections are not medically necessary for treatment of the patients medical conditions. Flector is a topical non-steroidal anti-inflammatory drug (NSAID). Researchers performed a systematic review to address and summarize the evidence of effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDs. Thus, the Flector patch is not supported as medically necessary in this clinical setting. In regards to bilateral knee Supartz injections, the medical literature supports the use of this injection for osteoarthritis of the knee. However, the medical records submitted for review does not indicate that the patient has osteoarthritis. Therefore, the request for bilateral knee Supartz injections is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a subcutaneous implantable cardioverter defibrillator (S-ICD) for treatment of his medical condition. Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this clinical setting.  In this circumstance of short QT syndrome, syncope, and a family history of sudden cardiac arrest, defibrillator placement is appropriate.  Both traditional endocardial lead systems and subcutaneous systems accurately detect ventricular arrhythmias.  However, placement of a subcutaneous defibrillator has potential long-term advantages in this particular circumstance.  For this patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur, then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Therefore, the requested subcutaneous implantable cardioverter defibrillator is likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested autologous cultured chondrocyte implantation for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the request for autologous cultured chondrocyte implantation of the knee is likely to be more beneficial for treatment of the patients medical condition than available standard modalities. The evidence based peer reviewed literature supports autologous chondrocyte implantation for large patellar lesions in patients who failed operative and non-operative treatment. This patient presents with persistent daily moderate to severe knee pain that significantly limits activities of daily living. There is imaging evidence of a large full thickness osteochondral lesion on the lateral facet of the patella. She has failed long-term comprehensive operative and non-operative treatment. She has exhausted treatment options, short of patellofemoral replacement which is contraindicated due to age. Therefore, the requested services are likely to be more beneficial for the treatment of the patients medical condition that any other standard treatment. Final Result: Two reviewers determined that the requested services are 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 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: 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:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis allows radiologists to differentiate dense glandular tissue from architectural distortion, thereby resulting in decreased callbacks and increased detection of small cancers.  The addition of breast tomosynthesis to two-dimensional screening mammography has gained worldwide popularity among radiologists.  Thus, the addition of digital breast tomosynthesis to the screening mammogram was likely of more benefit to the patient than had the mammogram been done without tomosynthesis.  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 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 epidural steroid injections and radiofrequency ablation of facet joints for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  With regards to the requested epidural steroid injections, the records do not document a home exercise program, which is part of the recommendation of having active exercise with physical therapy.  The literature indicates that a home exercise program independent of an epidural may provide lasting results.  With regards to the requested radiofrequency ablation of facet joints, there should not be radicular pain at the targeted level.  If there is radicular pain, there needs to be documentation of an inadequate relief to epidural injections at that level.  In this case, the records document lower back pain relief from the facet injections.  However, details regarding the resulting relief of the radicular pain were not provided.  The records do not indicate whether the patient was able to avoid any analgesic during the diagnostic part of the injection for her leg pain as well.  This should have been documented in a pain diary for the diagnostic block to be viewed as meeting criteria for use in performing a radiofrequency ablation.  All told, the requested epidural steroid injections and radiofrequency ablation of facet joints are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency neurolysis for treatment of her medical condition.  Findings:  Three physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the requested services.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In this patients case, physical examination was not indicative of facet mediated pain.  The patient reported radiating pain to the bilateral legs and feet, which is indicative of lumbar radicular pain and facet radiofrequency would not be the treatment of choice.  In sum, the requested radiofrequency neurolysis is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are 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 medicine 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 monitored anesthesia care (MAC) for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The MAC services were not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Colonoscopy and endoscopy may be safely and effectively performed with conscious sedation using a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per ASA guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the 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 in anesthesiology 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:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The advantage of tomosynthesis is the ability to often separate dense underlying glandular tissue from mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers. Although there is a lack of long-term studies showing an increased survival rate when tomosynthesis has been added to the usual two-dimensional (2D) views, tomosynthesis was likely of more benefit to the patient than had the exam been done with 2D imaging only. 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 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 total knee replacement for treatment of his medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has had consistent, careful, conservative management. Standing films are stated to show normal alignment. There is no documentation the patient has trialed a medial unloader brace. Also, there is no documentation of the use of walking aides, cane, unilateral crutch, or bilateral crutch. There is no documentation of the possible use of mechanical transportation aides such as a scooter. Moreover, the longevity of ceramic bearing surfaces in the hip and the knee do not extend to beyond clinical studies of two years duration. In this case, the patients age exposes him to long term complications of an increased revision rate. For the reasons provided above, the medical necessity for total knee replacement has not been established. 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 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.
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: Two physician reviewers found that  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) suggests that tomosynthesis be removed from investigational status, due to the advantage the new technique brings to radiologists in the detection of breast cancer. The tomographic nature of this technique often allows the radiologist to separate dense glandular elements from underlying architectural distortion resulting in a decrease in call-backs and increase in detection of small cancers. In sum, the addition of tomosynthesis to two-dimensional (2D) imaging is likely of more benefit to the patient than 2D mammography without tomosynthesis. 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 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.