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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings: Two physician reviewers found that Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine and gross motor skills and processing of sensory and motor information are also common. According to Foxx, ABA therapy is the primary method of treatment for children and adolescents on the autistic spectrum with aberrant behavior. ABA therapy is the standard of care for children with autism spectrum disorder. Studies have shown intensive therapy, 35-40 hours per week, to be most effective, encompassing home, school, and community environments for best generalization. Therefore, the requested hours of direct ABA therapy, hours of supervision, and hours of parent training, are medically necessary and appropriate in this clinical setting.Final Result: Two reviewers 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: All three Physician reviewers are board certified in pediatrics and child neurology 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 Harvoni for treatment of the enrollees 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic patients who have failed PEG-interferon/ribavirin, or treatment-naive (if the patient failed interferon rather than PEG-interferon) genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (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 for 12 weeks 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued skilled nursing services for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Hip fractures are conditions that are known to substantially impact functional performance, and negatively impact both short-term and long-term health-related quality of life.  In this case, the patient also has a history of multiple sclerosis with mild impairments in her mobility and self-care abilities at baseline, further complicating her convalescence.  She underwent a hip replacement and has been undergoing inpatient rehabilitative care.  She has made functional improvements, but has plateaued at requiring stand by assistance for safety for most of her self-care and household level mobility.  She requires assistance for her lower body dressing.  While further gains may be expected going forward, the rate of this progress is not expected to be expedient or predictable, and her rehabilitative needs can be addressed at a less intensive level of care than an inpatient skilled nursing facility, such as a custodial level facility or the home with custodial level assistance and community-based therapy services.  There are no indications that she has been requiring skilled nursing care.  There are no documented impairments that would preclude her from propelling a manual wheelchair for household distances if she fatigues during the course of the day due to deconditioning and her multiple sclerosis.  All told, continued skilled nursing services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested inpatient psychiatric hospitalization services for treatment of the enrollees anxiety, depression, and an eating disorder.  The records indicate that this patient did not meet the criteria for inpatient psychiatric hospitalization services. The patient did not exhibit any suicidal or homicidal ideation, evidence of psychosis, or any symptoms of psychiatric illness severe enough to require inpatient care that could not have been reasonably be provided at a less intrusive, less invasive level of care such as partial hospitalization program (PHP). In a progress note, it was noted that the patient ate 100% of her meals and snacks, had an overall mood of three out of 10, anxiety of five out of 10, and denied urges to self-harm and denied auditory and visual hallucinations. The patient weighed just over 100 pounds. The patient denied side effects on Prozac. The patients body mass index (BMI) was approximately 20. In another note, it was noted her mood improved to six out of 10 and anxiety improved to four out of 10. Prozac was increased. It was noted that she appeared less depressed and anxious and it was noted she was eating much better than she had been at home. It was noted that the patient is planned for transition to PHP. The patient reported feeling different due to psychiatric testing. The patient requested psychological testing be discontinued due to the stress from nature of experience. The provider noted that the patient did not anticipate she would experience suicidal ideation and her mood was six out of 10, anxiety was four out of 10, and the patient denied suicidal ideation and self-injurious behaviors. The patients Prozac was decreased due to increased headaches. Given these findings, the inpatient psychiatric hospitalization services provided were not medically necessary for treatment of this 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 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 testosterone gel for treatment of the enrollees hormone replacement therapy.  Findings: The physician reviewer found that Testosterone replacement therapy can improve the signs and symptoms of low testosterone in men (Miner, et al). However, the data for testosterone replacement therapy remains inconclusive for the female population. For this reason, testosterone replacement therapy has not been approved by the U.S. Food and Drug Administration (FDA) for female patients (Nappi). Moreover, there is a lack of data supporting the off-label use of testosterone gel for patients in this clinical setting. All told, the requested testosterone gel is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the 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 internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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 in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedure at issue 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. 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 digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. 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. Given the support cited above, digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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: 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 in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue 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. 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 Otezla for treatment of his medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  Per the medical records, he has tried and failed therapy with topical steroids and ultraviolet light.  Based upon the medical records, there is no documentation of contraindication to methotrexate, acitretin, or cyclosporine. Previous history of actinic keratosis is not a contraindication to these aforementioned systemic therapies. The Health Plans alternatives are medically appropriate.  All told, the requested medication Otezla is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Orthovisc injections to the knee for treatment of his osteoarthritis.  Findings:  The physician reviewer found that there is a lack of support in evidence based literature for Orthovisc injections for treatment of this patients medical condition. Studies have also shown the possibility of complications such as iatrogenic intraarticular infection and sensitivity reactions to hyaluronan injections. Moreover, the basic science rationale for administering hyaluronan to manage and treat arthritis of the knee has not been confirmed. Long-term tissue reaction to break down products of hyaluronan as well as acute reactions should be considered. Therefore, due to the lack of clinical evidence supporting the use of hyaluronan injections for treatment of osteoarthritis of the knees, the requested Orthovisc injections are not medically necessary for treatment of this patient.   Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a cervical artificial disc for treatment of her medical condition.   Findings:  Two physician reviewers found that the request for cervical artificial disc replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Per the U.S. Food and Drug Administration (FDA), the ProDisc-C total disc replacement is indicated for the treatment of single-level cervical disc disease following discectomy. In this case, the patient presents with neck pain radiating down the left upper extremity. Clinical exam findings have been consistent with imaging evidence of degenerative disc disease at multiple levels. Given that ProDisc-C total disc replacement is FDA approved and supported by the peer-reviewed literature for single-level cervical degenerative disc disease only, the requested cervical total disc replacement is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Final Result: Two 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 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:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with heterogeneously or extremely dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying architectural distortion/mass, resulting in a decrease in biopsies, increase detection of small cancers and decrease in callbacks. Thus, breast tomosynthesis was likely to have been superior over other methods of 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 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 subcutaneous Gammagard for treatment of his common variable immunodeficiency disorder (CVID).  Findings:  Two physician reviewers found that the diagnosis of CVID requires significantly reduced total serum concentrations of immunoglobulin, low immunoglobulin A (IgA) and/or immunoglobulin M (IgM), poor or absent response to immunization and exclusion of other immunodeficiency states or causes. In this case, the patient is reported to have low total IgG, IgM and IgA, but none of the other criteria of CVID (Chapel, and Cunningham-Rundles).  Upon review of the medical records, the patients immune status has not been fully evaluated. Although the provider stated that there have been recurrent infections, there is no supporting documentation (CXR, CT chest, CT Sinus, antibiotic log) to confirm recurrent infections. Moreover, standard therapy for CVID is treatment with prophylactic antibiotic. In this patients case, there is no documentation of a trial of prophylactic antibiotics. Therefore, the submitted documentation does not indicate that the requested services will likely to be more effective for treatment of this patient than any available standard therapy. Final Result: Two reviewers determined that 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 allergy and immunology 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.