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 her medical condition.  Findings:  The physician reviewer found that there is a lack of clinical evidence to suggest that the patient would not respond to treatment at a less intensive level of care.  She no longer required supervision in a highly structured setting to prevent eating disorder behaviors. In addition, no new problems had arisen and there was no evidence to suggest that re-entry into the community would lead to decompensation that would necessitate readmission to a residential setting. Although she continued to struggle with issues of body image, anxiety, depression, and self-esteem, and required ongoing treatment, this treatment did not require the 24-hour supervised setting of residential level of care. Moreover, the records do not support readmission to RTC level of care. Thus, RTC services and resumption of RTC services were not and are not medically necessary for treatment of this patients eating disorder.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in 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:  The parent of an enrollee has requested speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. The article by Myers and colleagues recommends a comprehensive educational program to include speech therapy for children with autism spectrum disorder. In this case, the patient has been treated with speech therapy and has made slow progress with improvements in mean length of utterance, pronoun use and use of correct verb tense. However, in the school and home setting there is not as much generalization. At this point individual speech therapy is not medically necessary. Continued work on her speech goals and social goals can be treated through ABA services, group speech therapy or a social skills group. In sum, individual speech therapy is not medically necessary in this clinical setting.  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 pediatrics with sub-specialty certification in developmental and 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the current peer-reviewed medical literature supports the use of tomosynthesis in the routine screening population. The addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The data suggests the additional of digital breast tomosynthesis reduces recall rates, allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, and has increased cancer detection. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The primary prevention guidelines for the management of cardiac risk and dyslipidemia currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For the reasons provided, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 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.
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: 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 peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, 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. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial 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.  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:   The parent of an enrollee has requested occupational therapy for one hour per week for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that review of the submitted documentation reveals that the patient did not have enough self-regulation to be able to follow the directions of the occupational therapy (OT) testing. As such, it is unlikely that working on adaptive skills will be helpful to him at this time.  Addressing behaviors and compliance is an important first step in this setting and using ABA to work on the adaptive skills, such as dressing, is key. Once the patients behaviors and compliance are improved, he may be an appropriate candidate for OT services. Therefore, occupational therapy, one hour per week, is not medically necessary at this time. 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 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that medical studies support the use of tomosynthesis in this patient. 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 the dense breast. 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. In this particular patient, the presence of breast implants is not, in itself, an indication for tomosynthesis.  More importantly, in patients with implants, it is necessary to obtain additional views to physically exclude or displace the implants so that the native breast tissue can be adequately evaluated. That was done in this patient. However, the presence of an occult breast nodule is an indication to use breast tomosynthesis because breast nodules can often be better characterized by tomosynthesis. All told, breast tomosynthesis was likely to be more beneficial than any standard modality for breast cancer screening. 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.  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 the ReWalk personal exoskeleton system for treatment of his medical condition.  Findings:  Three physician reviewers found that the ReWalk personal exoskeleton system is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Lajeunesse and colleagues conducted a systematic review of lower limb exoskeletons, including ReWalk, for spinal cord injury. The authors concluded The applicability and effectiveness of lower limb exoskeletons as assistive devices in the community have not been demonstrated. More research is needed on walking performance with these exoskeletons compared to other mobility devices and other training contexts in the community. The authors further stated that The level of scientific evidence is low. Other studies are needed to provide more information about performance over the longer term when walking with an exoskeleton, compared to wheelchair mobility, the users usual locomotion, the use of different exoskeletons or the training context in which the exoskeleton is used. There is some medical literature that supports the device as safe in a supervised setting with some health benefits. However, there is a lack of medical literature showing the application of ReWalk outside of supervised settings. In addition, it is unknown if the requested device can be safely and practically be incorporated into an individuals daily routine in their home and community environments. The medical literature does not address the management of a fall when an individual is inside the device away from clinicians familiar with its function. Additionally, the health benefits conferred by standing and aerobic exercise do not require the ReWalk device. All told, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested device is 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 physical medicine and rehabilitation 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 inpatient mental health services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The American Psychiatric Associations clinical practice guideline supports placement in the least restrictive setting. In reviewing the symptom severity, the psychiatric admission history anticipated a five-day hospitalization.  Further, the documentation noted the absence of suicidality and medical comorbidity besides hypertension and obesity.  There was no mention of cognitive impairment, psychosis or posttraumatic stress disorder symptoms in the psychiatry note, while substance use and alcohol consumption were denied.  The physical examination was unremarkable.  She denied hallucinations or thoughts of self-harm.  In terms of support, the patients spouse was involved in her treatment.  The patient had a psychiatrist in the community and was receptive to an intensive aftercare program.  Regarding level of functioning, the patient was attending to activities of daily living and self-ambulatory.  Although distressed, she commanded the cognitive faculties needed to address her discord.   All told, inpatient mental health 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 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 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 therapeutic apheresis treatment for treatment of her medical condition.   Findings:  Two physician reviewers found that neuromyelitis optica (NMO) is a rare demyelinating disease for which there are no Class 1 to 2 studies. However, the available peer-reviewed literature supports the use of plasma exchange for treatment of NMO especially when azathioprine has failed. Kleiter and Gold reported that NMO spectrum disorders are important evolving entities, which have reached much attention in the recent years. NMO spectrum disorders are characterized by inflammatory lesions in the optic nerves, spinal cord, and central parts of the brain, as well as an autoimmune process directed against aquaporin-4. As disability in NMO spectrum disorders accumulate by inflammatory damage from attacks, both the treatment and prevention of attacks are decisive for long-term outcome. NMO spectrum disorders attacks are treated with high-dose intravenous corticosteroids and apheresis therapies, in particular therapeutic plasma exchange. The medical records demonstrate that this patient had good response to treatment with good functional outcome. Given the response effect and the support in the literature, the requested therapeutic apheresis treatment was and is likely to be more beneficial for this patient for the treatment of NMO than any available standard therapy. Final Result: Two reviewers determined that the services at issue were and 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 and neurology 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 a vascular surgery evaluation for treatment of her bilateral lower extremity varicose veins.  Findings:  The physician reviewer found that based on the available documentation, the requested vascular surgery evaluation is medically necessary to manage this patients compression hose, to rule out other causes for pain other than varicose veins, and to interpret diagnostic imaging in the presence of varicose veins. Further, the requested evaluation is consistent with the recommended management and treatment guidelines in the current medical literature. Thus, the requested evaluation with a vascular surgeon is supported as medically necessary for evaluation of this patients painful varicose veins.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in vascular 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.