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

A 28-year-old female enrollee has requested ongoing physical therapy 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.  As of the date indicated, the patient was noted to have no pain and no symptoms and was discharged from physical therapy.  While she may intermittently have some ongoing symptoms, she has undergone sufficient physical therapy to be independent with a home exercise and modality program.  Per the medical records, the patient does not have any significant impairment that would preclude her from performing an independent program. There are no documented exercises that she was performing in the formal therapy setting that she cannot perform independently, or substitute with independent exercise.  There is no proven benefit of passive modalities provided in a formal setting on a prolonged basis on health or functional outcomes in this clinical setting.  Palliative modalities such as topical heat can be applied independently by the patient without anticipation of a marginally significant difference in health or functional outcomes compared to modalities provided on a prolonged basis in the formal physical therapy setting.  No marginally significant benefit would be expected from the proposed ongoing formal treatment over an independent program.  All told, ongoing physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Protopic for treatment of her cicatricial alopecia and lichen planus pigmentosus.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. The documentation submitted for review indicates that the patient has been treated with intralesional steroid injections to the scalp, but there is no follow-up documentation as to its effectiveness. The medical records also do not indicate that a trial of topical steroids has been tried and failed. Given that cases of cicatricial alopecia are often refractory to therapy, intralesional, high potency topical steroids or oral immunosuppressive agents are often needed to reduce the inflammation associated (Harries and Messenger; Racz et al). According to Harries and Messenger intralesional steroid injections are the most effective treatment in this patients case. Furthermore, the patient is also being treated for lichen planus pigmentosus of the face and neck and there is no documentation as to having failed a trial of a mild to moderate potency topical steroid. Given that Protopic is not likely to benefit the scalp and that a trial of a mild to moderate topical steroid on the face has not been tried, the request for Protopic ointment is not clinically indicated. Thus, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested chiropractic care for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records do not demonstrate that additional chiropractic care was indicated during a specified time frame.  The submitted office notes do not include documentation indicating how the patient was responding to treatment on each office visit.  Additionally, the records do not show that periodic re-examinations were performed to document the patients progress.  There is a lack of support for the services at issue in this clinical setting.  All told, chiropractic care was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested osteochondral knee allograft procedure for treatment of his right knee osteochondral defect.  Findings:  Two physician reviewers found that based on the peer-reviewed medical literature, the requested procedure is likely to produce a superior health outcome for this patient compared to standard available therapies. Treatment of osteochondral defects with osteochondral allograft have been shown to be beneficial in various clinical studies in well selected patients (Levy, et al). The scientific data supports the use of osteochondral allograft in patients with a body mass index (BMI) of less than 35. The records demonstrate this patient has a BMI below the criteria. In addition, the documentation provides evidence that he has failed multiple conservative measures and has a documented focal lesion of the chondral surface of the patellar without opposing lesion on the trochlea. For these reasons, the requested osteochondral knee allograft procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested physical therapy services for treatment of her knee pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Per the medical records, this patient should have been independent with a self-directed exercise and modality program after an initial exercise instruction session.  There were no significant impairments that would have precluded an independent program, and there were no documented exercises that she was performing in physical therapy that she could not have performed on her own or substituted with independent exercise.  There is no proven benefit of long-term passive modalities such as manual therapy for this condition.  All told, physical therapy services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Orthovisc injections (hyaluronate injections) for treatment of her bilateral knee arthritis. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. There is a lack of adequate randomized, controlled studies demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Finally, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Given the reasons provided, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested skilled level of care services for treatment of her bilateral ankle fracture. Findings:  The physician reviewer found that Medicare and InterQual criteria indicate that for skilled nursing rehabilitation to be medically necessary, the patient should be continuing to make progress in a program of skilled rehabilitation requiring at least one hour per day of such skilled treatment. This patient was non-weightbearing in both lower extremities. The medical records document that the patient continued to work on sliding board transfers, wheelchair activities of daily living, and general conditioning while non-weightbearing in both lower extremities throughout the treatment period. This is consistent with the standard of care and is supported by treatment guidelines. All told, the records support the medical necessity of the skilled level of care services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested Flexitouch Pneumatic Compression System for treatment of her lymphedema of both lower extremities secondary to lipedema surgery.  Findings:  The physician reviewer found that in the medical literature, Todd described the treatment of lipedema as involving external compression and in some cases liposuction. Muluk evaluated various types of external pneumatic compression therapies and noted that the simplest provide non-calibrated, non-gradient static compression to the entire limb. The next category has multiple chambers that provide sequential treatment and may or may not have gradient pressure. The author made a distinction between the latter devices and advanced devices that include new generation technology that provides calibrated, gradient sequential inflation with additional features enabling custom treatment to address individual patient needs. The literature shows that pneumatic compression devices are recognized as standard and effective treatment for this patients condition. The patients medical condition requires the recommended Flexitouch system given the successful trial of the device to establish compatibility and ability to use. All told, the medical records support the medical necessity of the requested Flexitouch system for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 7-year-old male enrollee has requested direct applied behavioral analysis (ABA), supervision and treatment planning for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature supports the utility of ABA therapy for patients with autism. ABA therapy has been documented, in multiple studies, to significantly improve motor, verbal, and social interactive skills in young autistic children. However, there is a lack of peer-reviewed literature studying the appropriate intensity of ABA therapy beyond the early intervention stage. In the case of this patient, he was diagnosed as autistic and began receiving behavioral interventions early in life. Most recently, the submitted clinical documentation reflects that the patient made limited progress with ABA therapy. There is a lack of evidence that the patient has made adequate gains to support an increase in the intensity of ABA services to the level requested. Although continuation of ABA therapy is medically necessary, the frequency of direct ABA therapy and supervision is reasonable and appropriate. Further, the need for treatment planning is not substantiated. All told, the medical necessity of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a cooling vest for treatment of her diagnosis with multiple sclerosis. Findings:  Three physician reviewers found that in this patients case, the requested equipment is not likely to be more effective than other treatment options.  The submitted records do not adequately document the patients reported condition, including treatment alternatives that have failed or are contraindicated.  The records do not mention any heat sensitivity issues, and elevated temperatures have not been documented.  No significant clinical benefit would be reasonably expected with the requested device.  Thus, the requested cooling vest is not likely to be of greater efficacy than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested cell function assay testing (Immune Cell Function Assay) for evaluation of his skin cancer status post heart transplant.  Findings:  Two physician reviewers found that the utility of the Immune Cell Function Assay for assessing the immunosuppressive status of patients who have received a heart transplant has not been accepted as the standard of care. The existing studies do not support a sufficient diagnostic accuracy to identify individuals at risk of rejection or infection. There remains significant heterogeneity across studies such that the International Society of Heart and Lung Transplantation guidelines do not recommend this test for routine clinical use. Therefore, the Immune Cell Function Assay testing is not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Erbitux for treatment of her metastatic anal cancer. Findings:  Two physician reviewers found that in this patients case, the requested medication is not likely to be more effective than other treatment options.  National Comprehensive Cancer Network guidelines recommend a platinum/infusional 5-FU regimen and indicate that following progression on a platinum-based regimen, no other regimen has been shown to be effective.  There is a lack of support for Erbitux in this clinical setting.  All told, Erbitux is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 20-year-old male enrollee has requested 10 hours of applied behavioral analysis (ABA) for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient carries dual diagnoses of autism and moderate intellectual disability. He has previously been treated with at least three years of ABA therapy. According to his school records, the patients behaviors and social skills have failed to significantly improve despite several years of ABA therapy. A study by Remington and colleagues describes the effectiveness of ABA therapy for autistic children. The authors found that after two years of therapy, children had made significant gains in improved behavior and IQ. In assessing the efficacy of ABA therapy for individual patients, there should be evidence of documented gains in behavior, social skills, speech and/or communications skills within a two-year period of the patients participation in ABA therapy in order to find the therapy effective. In this patients case, his vocabulary is limited to 200 words despite three years of prior ABA therapy. Based upon the clinical information provided, ABA therapy has not been effective for the patient. There is a lack of evidence that continuation of ABA therapy is likely to result in meaningful improvement in the patients condition. As such, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested chiropractic services for treatment of his back pain. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support the medical necessity of chiropractic services.  This patient had multiple chiropractic visits in the past. Per the submitted records, the patients symptoms continue to flare up on a regular basis.  The patient is not making additional therapeutic progress with chiropractic treatment.  The office notes do not support continued chiropractic services in this clinical setting.  All told, chiropractic services were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested a vagus nerve stimulator (CPT 64568  incision for implantation of cranial nerve neurostimulator electrode array plus generator, CPT 95971  electronic analysis of implanted neurostimulator pulse generator system, and CPT 95974  complex cranial nerve neurostimulator pulse generator/transmitter) for treatment of his epilepsy.  Findings:  Three physician reviewers found this patient has intractable epilepsy with generalized seizures that have not responded to several seizure medications. In the peer-reviewed medical literature, Terra and colleagues noted that in patients with refractory epilepsy, therapeutic options are limited to ablative brain surgery, trials of experimental antiepileptic drugs, or palliative surgery. In addition the authors reported that, vagal nerve stimulation is an available palliative procedure of which the mechanism of action is not understood, but with established efficacy for medically refractory epilepsy and low incidence of side-effects. As this patient has medically refractory epilepsy, and is not a candidate for resective surgery, vagal nerve stimulation is likely to be more beneficial than other options for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-month-old female enrollee has requested Synagis injection for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical literature does not support the requested services in this clinical setting.  This patient was born at 33 1/7 weeks gestation and does not have a diagnosis of chronic lung disease or significant congenital or acquired heart disease.  The current guidelines do not support the requested Synagis injection in this patients case.  There is a lack of support for the requested services for the treatment of this patient.  All told, the requested Synagis injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment services for treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines for treatment at different levels of care for patients with eating disorders indicate that in general, PHP is appropriate if the patients weight is greater than 80% of her ideal body weight (IBW). For treatment at the PHP level, only partial motivation is required, and the patient can be preoccupied with intrusive, repetitive thoughts more than three hours per day. The PHP level of care is also appropriate for patients that require some structure to gain weight, but do not need supervision at all meals. The records provided for review indicate this patient does not have any significant medical complications that would require hospitalization, and the patient is a candidate for treatment in a less restrictive setting than residential. From the description provided by the treatment team, this patient meets the APA criteria for treatment at the PHP level of care. Most PHP programs will supervise at least two meals daily, and some will supervise all three. All told, the residential treatment center services provided from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a compression unit for the legs for treatment of her edema.  Findings:  The physician reviewer found that in this case, the records indicate that the patient has had stable 1+ pedal edema.  In March 2013, the patients provider recommended elastic hose, and a diuretic was prescribed.  However, there is no documentation that the patient has been treated with elastic hose or other compression garment.  This would be the appropriate first-line intervention for this patients condition, along with leg elevation and an active exercise program.  All told, the requested compression unit for the legs is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his schizophrenia and post-traumatic stress disorder. Findings:  The physician reviewer found that based on review of the available records, the progress notes for the acute inpatient psychiatric services indicate that the patient was still unstable and required treatment at this level of care. The patients mood was changing frequently and his command auditory hallucinations continued. He admits that he was at risk for hurting other people if not in a structured environment. He did continue to develop coping strategies and insight as his thought processes cleared with the medication changes. By the indicated date, he was considered stable enough to be discharged without fear that he would harm someone else. However, the patient was not stable enough for discharge, and his command auditory hallucinations made him a risk to the safety of others. For these reasons, the acute inpatient psychiatric level of care services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a Jazzy select power wheelchair for treatment of his pulmonary fibrosis and chronic pain.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Based upon the documentation provided, the patient is able to ambulate household distances with supplemental oxygen and therefore does not require power mobility for ambulation within the home. The patient can independently perform his ADLs and therefore does not require power mobility for ADLs. In addition, a power chair is indicated for individuals who require a primary means of ambulation and not a means of community ambulation. Given that the patient is able to ambulate household distances and can independently perform his ADLS, the requested equipment is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 14-year-old female enrollee has requested psychiatric residential treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that this patient has struggled with ego fragmentation that has produced a formidable symptom complex. This young patient requires intensive services to achieve the desired end state of identity formation and sustained euthymia in the absence of self defeating behaviors. Applying the American Psychiatric Association (APA) treatment guidelines, the medical records fail to demonstrate the medical necessity for psychiatric residential treatment services. The patient has been showing signs of improvement. She has been active in therapy, including family sessions, and she has been reportedly stable on medication. She has not been disruptive or self-injurious. There is no clinical impression offered by the providers to support the medical necessity for continued residential treatment. All told, the services at issue were not and are not medically necessary for treatment of the patients medical condition.