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

A 42-year-old female enrollee has requested diastasis recti repair for treatment of her abdominal pain and lower back pain.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. Based on an evaluation of the submitted medical records this patient is documented to have a ventral hernia. The patient reports abdominal and back pain and the ventral hernia is documented to be contributing to her pain. A ventral hernia can lead to intra-abdominal problems including obstruction and incarceration of the bowel and can also be associated with pain. Moreover, these symptoms are not consistent with diastasis recti, which is a stretching of the abdominal wall and not a true hernia.  Coriddi and colleagues evaluated the functional status of diastasis recti following abdominoplasty and concluded that Rectus plication did not significantly improve functional outcomes. Thus, the proposed diastasis recti repair is not likely to resolve the patients functional issues and therefore is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism and developmental delays.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested occupational therapy. This patient presents with autism and intellectually disability. The school districts evaluation was able to utilize a Vineland Motor Scale to determine that the patient was deficient in both gross and fine motor skills. A child with such severe fine motor deficiency would benefit from interventional OT. Chase-Smith and Arbesman compiled a meta-analysis of the medical literature, documenting the value of OT in the autistic children population. In addition, Myers and Johnson noted that OT is of significant value when the child transitions into a school setting. Finally, the article by Pfeiffer and colleagues compiled an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the unwanted mannerisms associated with autism. All told, the requested occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the requested services in this patients case.  The clinical notes document a body mass index of greater than 45.  However, current guidelines recommend documentation of failed dietary efforts as well as completion of a thorough multidisciplinary evaluation in order to establish that the patient is an appropriate candidate for bariatric surgery.  The documentation submitted for review does not include this information.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a power wheelchair for treatment of his left-sided paralysis.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Although this patient has weakness and joint pathology, based upon the documentation provided the patient can ambulate household distance with a cane and a walker. In addition, the patient is not considered bedbound or chair bound without power mobility. Finally, a power chair is indicated for individuals who require a primary means of ambulation and not a means of community transportation. Given that the patient is not bedbound without power mobility, is able to ambulate household distance with a cane and walker, and has no access to his apartment with a power wheelchair, the requested equipment is not medically necessary in this clinical setting. All told, the medical necessity of the requested equipment has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the records indicate that the patient has idiopathic short stature with normal growth factors. The patients epiphyses are nearly fused, and he is already past the peak of his growth spurt. The addition of exogenous growth hormone therapy will not improve his height potential at this time. Therefore, the requested Genotropin growth hormone therapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old female enrollee has requested occupational therapy two times per week for treatment of the enrollees developmental coordination disorder. Findings:  The physician reviewer found that Smits-Engelsman and colleagues concluded that both occupational and physical therapy interventions produced benefit for motor performance in children with DCD.  Peens and colleagues also noted that intervention programs improved motor proficiency and self-concept for children with DCD and emphasized the potential for emotional dysfunction if DCD was not treated. For the reasons stated above, occupational therapy is a medically appropriate and necessary intervention for this patient with DCD. However, based upon the submitted clinical documentation, once weekly OT is sufficient to address the patients motor coordination/sensory processing deficits. As such, OT one time per week is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested gene testing (GeneSightRx)for treatment of her behavioral health conditions.  Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The efficacy of gene testing to guide psychotropic medication prescribing remains unproven. Although there is some evidence to suggest that such testing may offer promise for the future (Hall-Flavin et al), there is insufficient evidence that gene testing guided psychotropic prescribing is likely to be more beneficial than traditional management of psychotropic medications. Moreover, there is a lack of evidence presented in the form of multicenter long term trials that have been replicated over long periods of time. According to Hall-Flavin and colleagues, more research is needed to fully demonstrate the benefit of these newly developed strategies to guide treatment. As such, gene testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Dilantin (400mg/day) for treatment of her epilepsy.  Findings:  The physician reviewer found that the patient has a history of epilepsy and benefited from Dilantin with no generalized seizures for 3 years. The patient is intolerant to Keppra and had breakthrough seizures on Trileptal resulting in an emergency room (ER) visit. According to Yamada and Welty, there should not be a problem with generic substitution, although some patients are more prone to problems with the generic products. Some evidence suggests that switches between multiple generic antiepileptic drugs (AEDs) products in certain individuals may be problematic. Furthermore, the American Academy of Neurology (AAN) states, The AAN opposes policies that would result in arbitrary switching among anticonvulsants. Therefore, the AAN opposes generic substitution of anticonvulsants for patients with epilepsy at the point of sale (e.g., in the pharmacy), without prior consent of the physician and the patient. Unlike other diseases, a single breakthrough seizure due to change in delivered medication dose can have devastating consequences, including loss of driver's license, injury, and even death. In this patients case, consequences of breakthrough seizures can be substantial and she has done well previously with Dilantin and has tried and failed Keppra and Trileptal. Based on the medical records provided for review and the peer-reviewed literature cited above, the medical necessity of Dilantin (400mg/day) has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 60-year-old male enrollee has requested acute rehabilitation program to include physical, speech and occupational therapy for treatment of the enrollees traumatic brain injury.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The patient sustained a severe brain injury over a year ago, and the benefit of acute rehabilitation accrues in the early stages of acute brain injury (Turner-Stokes et al). Moreover, the benefit of continued therapy after completion of the acute phase has not been established when the injury is severe (Turner-Stokes et al). A well-established concept in neurological rehabilitation is that continued therapy does not improve outcome when there is no neurological recovery. This patient has a severe injury and remains quadriplegic. Although regular exercise may help maintain his current functional status, acute rehabilitation is not likely to improve or change his neurological status. The maintenance of the patients neurological status does not require daily skilled therapy. Based upon the documentation provided, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Humira pen 40mg per week for treatment of the enrollees psoriatic arthritis.  Findings:  The physician reviewer found that Adalimumab (Humira) is FDA approved for the treatment of psoriatic arthritis with or without concomitant methotrexate. Although Humira may be given weekly for active rheumatoid arthritis when methotrexate is contraindicated or not tolerated, this increase in dosing interval is not generally used in the treatment of psoriatic arthritis. In this patients case, the clinical issue is worsening of skin disease rather than worsening of arthritis. Alternative treatments of psoriatic skin involvement exist and include addition of methotrexate, leflunomide, topicals, and light therapy. Thus, the medical necessity for the increased frequency in Humira dosing for this patient is not demonstrated in the records or supported by current literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 5-year-old male enrollee has requested multi-model applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found the medical literature strongly supports applied behavioral analysis (ABA) therapy for the treatment of children with autism. However, around the age of school placement, autistic children tend to be gradually transitioned from individual ABA therapy to a combined school, ABA therapy, and group therapy program (Reichow et al). The 15 hours of ABA therapy is therapeutically adequate for a patient such as this patient who presents with normal/borderline intellect, is attending kindergarten and is also receiving speech and occupational therapies. The medical necessity of the requested 25 hours per week of ABA therapy is not established based upon the submitted clinical documentation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested services for evaluation of a vaginal protrusion and vaginal burning.  Findings:  The physician reviewer found based upon the clinical documentation provided, the patients condition did not require immediate care as her symptoms and exam were identical to those she had at her exam by her in-plan physician in the United States about three weeks earlier. There is no evidence of vaginal bleeding supported by the medical records. The medical records state that the reason for the surgery was the vaginal prolapse, which the patient had already been assessed.  All told, the patients symptoms would not cause a prudent layperson to believe she was experiencing an emergency condition that required immediate attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested repair of ruptured left breast saline implant for treatment of her left breast pain.  Findings:  The physician reviewer found that based on the documentation provided, the original surgery was aesthetic/cosmetic in nature. There was no documentation to suggest a history of congenital deformity, neoplasm or other condition to necessitate medically necessary breast reconstruction. Implant rupture is a well-recognized complication related to augmentation mammaplasty (Jones). The American Society of Plastic Surgeons (ASPS) define cosmetic surgery as surgery that is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem, and reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Reconstructive surgery is generally performed to improve function, but may also be done to approximate a normal appearance. Thus, this patients original surgery is consistent with cosmetic surgery and the patient is experiencing a well-recognized complication related to her cosmetic surgery. Further, the patients complaints are not consistent with the level of documentation provided in the medical record. The patient states that she has severe pain that significantly limits her activity. However, the documentation provided by the provider does not include evidence of these complaints and the examination does not include findings of tenderness with palpation or other reasons for having severe pain. In addition, attempts at conservative pain control are lacking. Overall, the records fail to establish the medical necessity of the requested repair of ruptured left breast saline implant for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a  panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that based on review of the available records, the patient has an abnormal condition of the body given the presence of an enlarged abdominal pannus, which is an abnormal hypertrophy of the soft tissue. The patients condition is caused by the treatment of obesity, which can be considered a disease. Thus, occurrence of this disease and its treatment has lead to the abnormal appearance of the abdomen, an overhanging pannus. The records and photographs indicate the patient has an abnormal appearance given the significant abdominal pannus that would be expected to approximate a more normal appearance with surgical correction. All told, a panniculectomy in this patient would offer more than a minimal improvement. The patient has a large pannus and removal would be expected to make a significant difference. For these reasons, a referral to an independent plastic surgeon is appropriate to fully evaluate the patients abdominal pannus and determine whether the patient is a surgical candidate. Therefore, a consultation with an independent plastic surgeon is supported as medically necessary and reconstructive in nature for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested prescription medication Ambien 10mg tablet for treatment of her insomnia.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to the U.S. Food and Drug Administration (FDA), label changes have been approved specifying new dosing recommendations for zolpidem products because of the known risk of next-morning impairment with these drugs. The recommended initial dose of certain immediate-release zolpidem products (Ambien and Edluar) is 5mg for women. The recommended initial dose of zolpidem extended-release (Ambien CR) is 6.25 mg for women. Although the lowered recommended dose of zolpidem is a recommendation and clinical exceptions can be made, higher doses such as the requested dose of 10mg in women are associated with increased risk of daytime impairment. Furthermore, zolpidem is not intended for chronic use as it can result in dependence. As such, the requested Ambien 10mg tablet is not considered medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested bilateral hernia repair for treatment of his hernia.  Findings:  The physician reviewer found that the records indicate that the providers have not been able to identify hernia on physical examination. However, the patient is symptomatic in the region consistent with findings on CT and ultrasound. Further, the medical literature supports repair for this patient population over watchful waiting as noted by Fitzgibbons and colleagues. Given the records provided for review, the requested bilateral hernia repair surgery is indicated because of the left lower quadrant pain and the documentation of a hernia on two imaging modalities. Since there is evidence of a right sided hernia as well, it is clinically reasonable to repair both hernias at the same time. Thus, the requested surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested emergency services for treatment of her wrist.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the wound recheck and dressing change performed on the date indicated was not emergent in nature. The services provided on the date indicated consisted of a routine follow-up assessment of a laceration repair and could have been performed by the patients primary care physician. A prudent layperson would not have thought this to be an emergency medical condition requiring immediate medical attention in an emergency department. Although it appears the patient was instructed to return to the emergency department for a follow-up evaluation at the time she originally presented for treatment, there is no evidence that the patients symptoms on the date of service in question would have caused a prudent person to believe the follow-up care was emergent in nature. Thus, the patients symptoms on the date indicated did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested a power wheelchair for treatment of his paraplegia.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested power wheelchair. This patient has chronic degenerative disorders, a history of polio with weakness and atrophy of his lower extremities and post-polio syndrome. The patient has chronic low back pain from muscular imbalance and weakness of his lumbar muscles. He has degenerative arthritis of his shoulders and carpal tunnel syndrome from overuse syndrome related to manual wheelchair mobility. These pathologies tend to progress in severity as an individual ages, making mobility more challenging and power mobility medically necessary. The patient ambulates only short distances with crutches or uses the manual wheelchair with discomfort. Additionally, the patients home does support the use of a power wheelchair and there are no medical contraindications. A power wheelchair would allow safe mobility inside and outside of his home without worsening his musculoskeletal pathology. All told, the medical necessity of the requested equipment has been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 71-year-old female enrollee has requested PET/CT scan skull-thigh for evaluation of her biliary cancer.  Findings:  Three physician reviewers found that the records provided for review suggest the requested PET/CT is being requested to stage the patients cancer. PET/CT scans have become widely used in various cancer types as an aid in determining the precise extent and stage of a patients cancer. Further, there is adequate data that PET/CT scanning is useful in biliary duct carcinoma (Delbeke, et al; Anderson, et al). Therefore, the requested PET/CT scan is likely to be more beneficial for evaluation of this patients medical condition than standard alternatives in determining the extent of disease and for radiation planning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested IVIG infusion for treatment of her Raynauds phenomenon.  Findings:  The physician reviewer found the patient has been diagnosed with a presumed undifferentiated connective tissue disease based largely on her symptoms. The patients serologic profile has been largely unremarkable including an ANA titer of 1:40, which is clinically insignificant. As part of the serologic workup, a persistently low level of IgG subclass 2 has been noted in the absence of generalized hypogammaglobulinemia. She has a history of recurrent sinopulmonary and urinary tract infections, but no evidence of inadequate humoral response to immunization to support humoral immune dysfunction. These criteria are needed to support the use of IVIG replacement therapy, as levels of IgG subclasses outside of the reference range can commonly occur in the absence of any actual immune dysfunction (Bonilla, et al; Gelfand et al). As the literature does not support IVIG as the standard therapy for undifferentiated connective tissue disease, scleroderma, or lupus, the only justification for its use in this case would be for documented humoral immunodeficiency. However, there is a lack of documentation of an inadequate antibody response to immunization to support the use of IVIG for treatment of this patients medical condition.