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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly acupuncture. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has a history of a chronic lumbar condition which flares up.  The patient  reported symptomatic and functional improvement following prior acupuncture care.  The records indicate that the ongoing acupuncture treatment is addressing the patients medical condition, with evidence of objective functional improvement.  Therefore, the continuation of acupuncture treatment is medically necessary. As the symptoms and function were significantly improved with the prior five sessions, an additional five sessions are medically appropriate to help the patient transition to an independent exercise program.  Due to the chronicity of this injury, the use of passive care should be limited, as the benefits obtained with it will be limited as well.  Self-management strategies, such as an independent exercise program, self-imposed restrictions, and proper biomechanics, are supported by the literature to stimulate self-reliance.  All told, a portion of the requested services (five sessions of weekly acupuncture) is medically indicated for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 oriental 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 authorization and coverage for Percocet and morphine pain medications. Findings:  The physician reviewer found that there is a lack of support for the requested medications in this clinical setting.  Per the documentation available for review, not all non-opioid treatment options have been utilized. The records do not indicate that behavior therapy has been documented or performed for this patient despite much research to support its use. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. The medical evidence shows that continuation of pain medications should be under the direct guidance of a mental health professional. In this patients case, there is documentation of a history of getting early refills, not being forthcoming with the opioids she was taking, and misrepresenting what she was doing with the medications. Moreover, a treatment option of non-opioid therapy was offered to this patient, but she declined. The medical literature recommends the consideration of alternatives to opioid medication therapies. It is not unreasonable to wean the patient to a lower dose of opioids or even off opioids. Also, the documentation indicates evidence that this patient has developed a tolerance to her medications since the start of the narcotics. As per medical evidence, dose escalation is not a long term plan but a short term plan for treatment of tolerance. Finally, continuation of opioid prescribing at higher doses without proper treatment for the opioid use, sets the patient up for higher morbidity and mortality. There is sufficient support to offer interventional treatments for this patient's pain. For all these reasons, Percocet and morphine pain medications are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair. Findings:  The physician reviewer found that the requested equipment is not medically necessary for treatment of the patients medical condition. The records submitted for review do not include a detailed functional mobility examination. The providers encounter note indicated that she ambulates slowly but without ataxia. There was no documentation of an antalgic gait or lower limb weakness.  There was no documentation of neuromusculoskeletal impairment precluding the use of a gait implement such as a cane or walker, or a manual wheelchair. An individual does not need to raise the upper extremities above shoulder height to propel a manual wheelchair. Moreover, a manual wheelchairs seat height can be lowered so that the feet can be used to assist propulsion without having to bear much weight at all. The patient does not otherwise have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living. In addition, physical activity and exercise are generally appropriate and recommended for conditions such as back pain and for general musculoskeletal health. A power mobility device has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone . Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis . Given the support above, the digital breast tomosynthesis performed on the date of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that 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: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all 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 reimbursement for residential treatment center services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The progress notes indicate that the patient was cooperative in treatment.  She was noted to be providing and accepting feedback in group therapy.  She was not displaying dangerous behavior during her stay.  There was no notation of severe mood symptoms or psychosis.  She was not noted to be aggressive with peers or staff during her stay.  The records do not indicate that the patient had symptoms that would have necessitated residential care.  It appears that her treatment goals could have been managed in a less restrictive setting.  The records do not indicate that the patient had attempted or exhausted intensive outpatient services prior to her residential treatment center admission.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  There is a lack of support for the services at issue in this clinical setting.  All told, residential treatment center services  were not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer 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.  In this patients case, her breasts were described as very dense.  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. Thus, digital breast tomosynthesis performed on the date of dispute was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all expert sin the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vestibuloplasty and gingival graft to uncover previous implants and six (6) dental implants for treatment of his cherubism with excessive bone formation in the maxilla and mandible.  Findings:  The physician reviewer found that the records demonstrate that this patient has findings consistent with fibro-osseous disease with exuberant bone. In this clinical setting, the approach is to allow natural involution. However, when reduction or osseous contouring is required, re-expansion is a possibility. In this patients case, placement of dental implants was accomplished and is an option for the patient to restore his dentition while other options include fabrication of dentures. Given the lack of support for the requested procedures in this clinical setting, the requested vestibuloplasty and gingival graft to uncover previous implants and six (6) dental implants are not supported as medically necessary for treatment of this patients medical condition. The records demonstrate that this patient has findings consistent with fibro-osseous disease with exuberant bone. In this clinical setting, the approach is to allow natural involution. However, when reduction or osseous contouring is required, re-expansion is a possibility. In this patients case, placement of dental implants was accomplished and is an option for the patient to restore his dentition while other options include fabrication of dentures. Given the lack of support for the requested procedures in this clinical setting, the requested vestibuloplasty and gingival graft to uncover previous implants and six (6) dental implants are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enollee has requested reimbursement for the inpatient continuous positive airway pressure (CPAP) titration study performed. Findings:  The physician reviewer found that Based on the current medical literature and the presented clinical records, the CPAP titration study was medically necessary for evaluation of the patients medical condition. The member's home sleep study for her AHI was 15.6  and the member met the medical necessity criteria for treatment with CPAP. The CPAP titration study was medically necessary to document the optimal setting for treatment with CPAP. The patients optimal setting was CPAP of 8 cm H2O, which normalized the AHI to 1.5 (normal AHI is 0 to 5) and also treated the hypoxia. For the reasons provided, the CPAP titration study performed on the date of dispute was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that in the peer-reviewed medical literature, a study 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, the breast tomosynthesis performed on the date of dispute was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all expert sin 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 reimbursement for the bilateral breast tomosynthesis performed.  Findings:  The physician reviewer found that the patient who is asymptomatic with respect to her breasts. On date of dispute, she underwent a routine screening mammogram consisting of a three-dimensional tomosynthesis study with synthetically reconstructed two-dimensional views. The current images were compared to prior mammograms  and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as average in density. The patient has requested reimbursement for the bilateral breast tomosynthesis performed on date of dispute. The Health Plan has denied this request as investigational. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. 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. In this case, 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 has been no change when compared to prior mammograms. Therefore, the bilateral breast tomosynthesis performed on date of dispute was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers  number 1,2 & 3 are board certified in diagnostic radiology and are  actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis performed.Findings:  The physician reviewer found that the patient is a female who presented on  the date of dipute for a routine screening  mammography which included tomosynthesis. The patient has requested reimbursement for the breast tomosynthesis performed on the date of dispute. The Health Plan has denied this request as investigational. There is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. According to a study, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis . Given the support above, the breast tomosynthesis performed on the date of disput was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all expert sin 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 reimbursement for AmniSure testing for evaluation of her pregnancy. Findings:  The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting.  This patient presented at 38 weeks with discomfort.  She reported passing her mucus plug, which would be a normal event at this stage of pregnancy. She denied ruptured membranes. She was seen and examined, and despite the negative history and examination, including negative ferning of the vaginal swab and normal amniotic fluid on ultrasound, AmniSure test was done to determine whether there was any amniotic fluid leaking.  The diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure testing.  The records do not document that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning.  It does not appear that nitrazine testing was performed. The routine use of AmniSure to diagnose ruptured membranes is not recommended.  Final Result: The 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: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and is 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.