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

A 62-year-old male enrollee has requested an MRI of the right arm for evaluation of his arm pain and numbness.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient has an injury that could cause neuropathic pain due to nerve trauma. The diagnosis of the site and severity of a nerve injury has implications for prognosis and treatment. Electromyogram (EMG) is considered the first line as part of an evaluation for possible nerve injury and is considered an extension of the neurologic examination. If surgery were to be considered in the future, diagnostic imaging might be warranted. However, at present, there is no clinical information to be gained from an MRI that would help decision-making or facilitate clarification of prognosis. All told, the medical necessity of the requested MRI study has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a power wheelchair for treatment of her degenerative disc disease.  Findings:  The physician reviewer found that the records indicate that the patient has some mobility limitations, but she is able to ambulate within the home with a gait aide. There are no documented impairments that would preclude use of a manual wheelchair for accomplishing her mobility related activities of daily living. She has a history of carpal tunnel syndrome, but has undergone surgical release and has no documented residual impairments causing functionally significant impairment in either upper limb. The records indicate degenerative changes at her spine and shoulder but strength, range of motion and coordination were within functional limits per physical therapy assessment in the patients home. Powered mobility is not medically necessary for the patient to accomplish mobility related activities of daily living and could potentially be less health beneficial than self powered mobility (Hastings, et al; and Valent, et al). In addition, there is no documented face-to-face physician evaluation for mobility related durable medical equipment that has adequately reviewed the patients relevant health and functional history and reported relevant physical examination findings (Johnson and Fitzsimmons). All told, the requested power wheelchair is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested right shoulder arthroscopy, SLAP repair, capsular plication and decompression surgical procedure for treatment of his right shoulder pain.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  This patient is status post motorcycle accident with 25 foot fall, and he was found to have significant SLAP lesion via imaging.  He was appropriately treated conservatively with physical therapy with some improvement in range of motion.  More recently, the patient was found to have ongoing decreased range of motion and decreased strength of the right shoulder as well as positive OBriens test, crank test, and impingement testing.  The medical evidence supports the requested services in this clinical setting.  All told, right shoulder arthroscopy, SLAP repair, capsular plication and decompression surgical procedure are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested an implantable brain stimulator for treatment of his major depressive disorder. Findings:  Three physician reviewers found that the current medical evidence has not established the superior efficacy of the requested device in this setting.  There is a lack of adequately powered, well-designed or statistically meaningful studies in the medical literature to support this intervention in the treatment of major depressive disorder.  Further, deep brain stimulation is not endorsed by the American Psychiatric Associations current practice guideline for treatment of individuals with depression.  Additionally, based on review of the documentation provided, it does not appear that the patient has exhausted standard interventions, such as community programming or augmentative medication management strategies.  All told, the requested implantable brain stimulator is not likely to be superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a follow-up colonoscopy for evaluation of her medical condition.   Findings:  The physician reviewer found that based on currently available recommendations from the American Gastroenterological Association and the American Cancer Society, this patient should be followed with a repeat colonoscopy every 10 years. The patient does not have any documentation of a first degree relative with colorectal cancer, and findings on previous colonoscopy has not increased the patients risk for colorectal cancer such that more frequent testing is indicated. All told, the requested services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested Nuvigil for treatment of her excessive daytime sleepiness due to multiple sclerosis related fatigue.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this clinical setting.  The medical evidence supports Nuvigil for the treatment of this patients condition.  This patient has relapsing-remitting multiple sclerosis, and she has had daytime sleepiness and fatigue.  There is evidence in the medical literature indicating that Provigil may be beneficial for the treatment of fatigue in conditions such as multiple sclerosis.  The alternative treatments, such as amphetamine, have greater side effects and abuse potential.  All told, Nuvigil is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested occupational therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the submitted documentation supports the requested therapy for the treatment of this patient.  Feeding problems are common in childhood, and they can at times be severe enough to result in growth failure and susceptibility to chronic illness.  Up to 25% of all children have some form of feeding problem, and up to 80% of developmentally delayed children experience feeding difficulties.  The medical literature supports the utility and efficacy of a multidisciplinary approach in this clinical setting.  This patient has deficits in fine and gross motor skills, speech and language skills, hearing, and feeding skills.  Occupational therapy is an integral part of any feeding evaluation and intervention.  In addition, with its focus on developing motor planning skills, feeding skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in this patient.  All told, occupational therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested Lyrica for treatment of her migraine. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been diagnosed with migraine, and this has not been responsive to triptans.  Based upon the medical records, she has had a trial of one tricyclic antidepressant.  However, she has not had a trial of standard seizure category preventives, such as Topamax or Depakote, or beta blockers, for which there is strong support.  The medical documentation does not demonstrate that standard, commonly effective preventive medications have been tried in this patients case.  All told, Lyrica is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested hearing aids for treatment of his bilateral hearing loss.  Findings:  The physician reviewer found that the patient has been diagnosed with high frequency sensorineural hearing loss. The patients pure tone average is lower than 35 dB in both ears. The medical literature recommends a pure tone average of 35 dB or greater. Consistent with the patients testing, the requested hearing aids are not supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 22-year-old male enrollee has requested acute inpatient psychiatric care for treatment of his mental condition. Findings:  The physician reviewer found that although well developed clinical guidelines and patient placement criteria provide assistance, determination of the appropriate length of stay for a patient with a severe formal thought disorder complicated by co-occurring anxiety and substance use disorders, poses a significant challenge for inpatient treatment providers. The patients records support the necessity of previous treatment. However, the records do not support continued treatment at the acute level of care. Prior to the date indicated, the patient had demonstrated poor insight. Additionally, he had threatened staff such that care providers had to be notified of specific threats. He was plagued by intrusive thoughts and subsequent repetitive behaviors, yet was resistant to taking medication for obsessive compulsive disorder. On the date indicated, fluoxetine was started for the patients anxiety. On a the subsequent date indicated, he was not suicidal, homicidal or psychotic per the providers note. On the date indicated, the patient posed no danger to himself or others while the discharge plan was adjusted. Based on the documentation provided, and considering the case in its entirety and the relevant peer reviewed literature, the requested continuation for acute inpatient psychiatric treatment level of care services is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Zoll LifeVest for treatment of her congestive heart failure.  Findings:  Two physician reviewers found that in this patients case, the device at issue was likely to have been superior over other available treatment options.  This patient had recent onset non-ischemic cardiomyopathy with a left ventricular ejection fraction estimated at 20-25% of likely viral etiology.  There is a reasonable likelihood of recovery of near normal left ventricular function in this setting over a three to six month period.  A wearable life vest cardioverter-defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period.  There is adequate support for the device at issue in the clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested the Zio Patch for evaluation of his history of intermittent dizziness, pre-syncope and syncope. Findings:  Two physician reviewers found that the device at issue was likely to have been more effective than other modalities for evaluating this patient.  External ambulatory event monitors are used successfully in many clinical circumstances to diagnose, risk stratify and ultimately treat patients with a variety of complaints thought to be secondary to cardiac arrhythmias.  There is adequate support for the device at issue in this clinical setting.  Rosenberg and colleagues compared the Zio Patch to 24-hour Holter monitor in 74 patients with paroxysmal atrial fibrillation.  The authors noted that the Zio Patch allowed for longer continuous monitoring than a Holter monitor, resulting in improved clinical accuracy.  In sum, the Zio Patch was likely to have been of greater benefit than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested maxillary balloon dilation procedure (CPT code 31295, balloon sinus ostial dilation) for treatment of her acute maxillary sinusitis.  Findings:  Two physician reviewers found that balloon sinus ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Although there is support for the efficacy of maxillary balloon dilation in the scientific literature, this patient is not an appropriate candidate for the procedure based upon the documentation provided. This patients CT scan indicates the presence of severe ethmoid disease and moderate maxillary disease with patent ostia.  The goal of maxillary balloon sinuplasty is to create patent ostia to improve sinus drainage with consequent improvement in patient symptoms. The patients severe bilateral ethmoid disease is likely contributing to her symptoms. Thus, it is not possible to conclude that balloon sinus ostial dilation of the maxillary sinuses will be any more effective for this patient than standard available therapy. Therefore, the requested procedure is not likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested transcranial magnetic stimulation (TMS) treatments for his depression.  Findings:  The physician reviewer found that in the absence of documentation in the patients clinical records, there is no support for the presence of a distinct, acute major depressive episode in December 2012. Additionally, the requesting provider has recommended a booster or maintenance TMS. Although the evidence may be promising, the utility of TMS in long-term or maintenance treatment for major depressive disorder has not yet been established by the scientific community. For patients who respond to repetitive TMS, one should attempt to maintain the remission with prophylactic oral medications (George, et al). Given the records provided for review and within the context of the most current practice guidelines and relevant peer-reviewed literature, any application of TMS as maintenance, preventative or long-term therapy for major depressive disorder is not supported as medically necessary. Therefore, the TMS treatments provided during the said timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Armour thyroid medication for treatment of her hypothyroidism.  Findings:  The physician reviewer found that when monitoring and titrating thyroid hormone doses carefully to maintain a normal thyroid stimulating hormone (TSH) level, the result has been rewarding for most patients, and improved their well-being, health, energy, mental function and weight. The American Association of Clinical Endocrinologists and American Thyroid Association have cautioned against the use of T3 containing therapies, such as liothyronine and desiccated thyroid (Armour thyroid), even though these two medications are FDA approved for the treatment of hypothyroidism. However, some patients with hypothyroidism do not feel well on levothyroxine alone despite normal thyroid function tests. In a select patient population, addition of T3 to their therapies in the form of desiccated thyroid, to replace levothyroxine resulted in improvement (Biondi and Wartofsky). While the validity of the study is limited by methodological factors and there is no consensus in what combination of T3 is optimal, the authors concluded that there is a scientific basis that might explain the benefit reported by patients with the combination regimens including T3. On review of this patients medical records, she has responded better to Armour thyroid treatment than with levothyroxine alone. For these reasons, continuation of Armour thyroid treatment in this patient is medically necessary with the proper monitoring.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder.  When feeding difficulties are noted within this population, synthesis of the evidence suggests that various feeding approaches may result in positive outcomes in the areas of feeding performance, feeding interaction, and feeding competence of parents and children (Howe and Wang). This patient is an appropriate candidate for occupational therapy to treat his feeding difficulties noted above. All told, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). This patient has identified fine motor and adaptive skill deficits of 30% or greater. Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder. Furthermore, when feeding difficulties are noted within this population, synthesis of the evidence suggests that various feeding approaches may result in positive outcomes in the areas of feeding performance, feeding interaction, and feeding competence of parents and children (Howe and Wang). This patient is an appropriate candidate for occupational therapy to treat his fine motor deficits, adaptive skills and feeding difficulties noted above. All told, the medical necessity of the requested services has been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested positron emission tomography (PET) scan for evaluation of her Castlemans disease.  Findings:  Two physician reviewers found that there is sufficient medical literature supporting the use of a PET scan in this clinical setting. The study by Szturtz and colleagues stresses the significance of full-body PET/CT scanning during staging and treatment response evaluation. Moreover, Pelosi and colleagues state that based on the results of previous case reports and on those of the present study, Castleman's disease has a high glucose metabolic activity. Thus, the use of a PET scan is considered appropriate in order to stage or restage the disease and to evaluate the response of the disease to treatment. Therefore, based on the peer-reviewed literature and medical evidence submitted the requested service is likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested bilateral mastopexy for treatment of her breast fold infection.  Findings:  The physician reviewer found that  based upon the submitted documentation the patients condition does not meet criteria for reconstructive surgery. The documentation provided does not support the presence of an abnormal structure of the body. The patients current condition of ptotic mildly asymmetric breasts would not be considered abnormal. All told, the requested procedure is not medically necessary or reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested CPT codes 96413, 96415, and 96375 and HCPCS codes J9310 and J1200 for treatment of his multiple sclerosis.  Findings:  Two physician reviewers found that this patient has had relapsing-remitting multiple sclerosis.  Continued treatment on natalizumab is contraindicated due to JCV antibody positivity.  Progressive multifocal leukoencephalopathy has occasionally been reported following rituximab treatment, and other opportunistic infections are also described.  There is a lack of support for the requested services in this clinical setting.  This patient has not been treated with Aubagio or Tecfidera, two FDA approved oral agents for the treatment of relapsing-remitting multiple sclerosis,  both of which are established disease modifying medications for multiple sclerosis, with known safety and efficacy.  In sum, the superior efficacy of the requested services has not been established.  Therefore, CPT codes 96413, 96415, and 96375 and HCPCS codes J9310 and J1200 are not likely to be more effective than other treatment options in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  There is adequate support for the requested services in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association for the treatment of patients with depression.  In this case, the patient is experiencing an acute major depressive episode that is causing significant morbidity and functional impairment.  He has pursued other standard therapies used to combat depression.  Considering the medical records, endorsement from the American Psychiatric Association and the expanding peer-reviewed literature base, TMS is an appropriate treatment.  All told, TMS therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested buprenorphine (Subutex) for treatment of her opioid dependence. Findings:  The physician reviewer found that the medication at issue was not medically necessary in this patients case.  Subutex is an opioid agonist with antagonist effects at higher doses.  Per the medical literature, Subutex serves as an effective bridge to Suboxone as it prevents withdrawal.  However, when used alone for opioid dependence, higher doses must be prescribed to achieve its antagonist effects.  Suboxone is supported in the medical literature as the preferred medication for opioid dependence because it is a combination opioid agonist and antagonist at any dose.  All told, the medication buprenorphine (Subutex) was not medically necessary for the treatment of this patient.