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

A 41-year-old female enrollee has requested coverage for acute inpatient psychiatric treatment for treatment of her bipolar disorder and bulimia.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains; however, placement in more restrictive settings is often clinically appropriate.  In this particular case, acute hospitalization was indicated.  Discharge on the date in question would have more than likely burdened the patient with undue morbidity and an elevated risk for readmission. On that date the patient was described as hopeless and suicidal per nursing, while the physician reported near constant suicidal thoughts and the patients fear that she might act on them. To release a patient from the acute setting under such circumstances would be inconsistent with the standards of good medical practice in this country.  Since that time, the patient has remained symptomatic with acute suicidal ideation and eating disordered behavior.  Per the medical records, the patient has not consolidated the treatment gains necessary to succeed at a lower level of care. Further, three days later, the patient stated she was all good with the exception of other patients triggering her while nursing notes reported no suicidal ideation and positive mood reactivity to visitors. The complexity of the medication regimen has not exceeded a threshold of unsuitability for a less restrictive treatment setting and there is no evidence of an acute medical issue that warrants inpatient medical care. Finally, on a subsequent date at issue, the patient began to explore core conflictual issues in therapy which represents a critically meaningful pursuit, but one that is inappropriate for the acute setting.  Accounting for the patients history, hospital course and documentation provided, and acknowledging the enduring unresolved intrapsychic conflicts, distorted sense of self and chronic suicidality, the patient has reached maximal hospital benefit. Thus, mobilization to a less restrictive setting is indicated. In order for the patient to consolidate her treatment gains, the inpatient services at issue were and are medically necessary for seventeen of the dates at issue. Any inpatient psychiatric services provided from the seventeenth day at issue onward are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested authorization and coverage for gamma knife stereotactic radiation treatment for treatment of the enrollees metastatic renal cell carcinoma to the brain. Findings:  The physician reviewer found that at issue is the use of SRS for multiple brain metastases (>4). In this patients case, the interpretation of the MRI by the radiation oncologist offering SRS is that there are 3 lesions, plus 3 untreated lesions, while other physicians document greater than 12 lesions.  Stereotactic radiosurgery (SRS) implies the use of technologies which improve targeting accuracy, and allow for high dose, single fraction, radiation delivery. Cranial SRS is a radiation planning and delivery technique in which radiation is targeted to discrete lesions to allow for ablative doses of radiation to be delivered. Generally, chemotherapy does not penetrate the blood brain barrier, and therefore radiation is the only viable option for patients with multiple brain metastases.  Whole brain radiation is the standard treatment for patients with greater than 4 brain metastases.  For patients with 1, 2, 3, or 4 brain metastases, multiple cooperative group randomized controlled studies have shown no survival benefit with the addition of whole brain radiation to stereotactic radiosurgery.  Several studies have described SRS for multiple brain metastases.  A study by Liew and colleagues found that a larger number of lesions was associated with poorer survival, but did not impact tumor control and the authors recommend SRS +/- whole brain radiation for individuals with more than eight metastases. Another study indicated that the number of metastases was not significant in a multivariate analysis of survival (Powell, et al.).  A study examining patients with four or more brain metastases concluded that because total treatment volume was the most significant predictor of survival, the total volume of brain metastases, rather than the number of metastases, should be considered in identifying appropriate radiosurgery candidates. They did not evaluate the impact of omitting whole brain radiation (Bhatnager, et al.).  Although several studies have reported on the use of SRS for patients with multiple brain metastases, many of the studies did not study SRS versus treatment with whole brain radiation, but rather in conjunction with or independent of whole brain radiation therapy. SRS is not currently considered a standard therapy and remains investigational, particularly when omitting whole brain radiation. Therefore, the requested gamma knife stereotactic radiation treatment is not medically necessary for treatment of the patients medical condition. The Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested authorization and coverage for a shower bench for treatment of the enrollees lower extremity paraplegia.  Findings:  The physician reviewer found that spinal cord injury can result in significant functional impairments with respect to basic activities of daily living (McKinley, et al). These impairments can require various durable medical equipment devices so that these basic activities of daily living can be accomplished. A shower bench has been requested, but the patient is already reported to have a shower bench per a rehabilitation medicine clinic note. Further, there is no documentation provided to indicate that the current shower bench is dysfunctional or in disrepair. In the absence of medical rationale to support the necessity of a replacement shower bench, the requested equipment is not medically necessary based on the records forwarded for review.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested authorization and coverage for Supartz injections to the bilateral hips for treatment of the enrollees hip osteoarthritis. Findings:  Three physician reviewers found that the patient is has a several year history of hip pain. No radicular symptoms, paresthesias or sensory changes were reported. The patients pain reportedly caused awakening at night and occurs with sitting, walking on stairs and when putting on shoes and socks. The provider recommended treatment with oral medications and Supartz injections. The patient has requested authorization for Supartz injections, which have been denied by the Health Plan. The use of intra-articular injections of viscosupplementation (Supartz) has been demonstrated to be efficacious in the treatment of osteoarthritis in the knee joint and for the treatment of TMJ. However, there is a paucity of data demonstrating the safety and efficacy of treating osteoarthritis in other joints in the body with viscosupplementation. Additionally, the use of viscosupplementation is approved by the Food and Drug Administration (FDA) only for treatment of the knees and TMJ. It has not yet been approved for use in the hip joints. Given the lack of proof regarding the efficacy and safety of Supartz in the treatment of hip pain, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty (UPPP).  Findings:  The physician reviewer found that based on review of the available records, this patient has severe obstructive sleep apnea as demonstrated on polysomnogram. In addition, the patient has failed attempts at treatment with CPAP management. Consistent with the medical literature, the requested UPPP and coblation of the tongue base is clinically indicated (He, et al). As concluded by Woodson and colleagues, multilevel temperature controlled radiofrequency tissue ablation improvements may result from changes in airway volume, apnea index, and respiratory arousal index. Similarly, Steward reported that the procedure was found to improve abnormalities in daytime somnolence, quality of life, and reaction time when compared with baseline. All told, the requested UPPP and tongue base reduction by coblation have been demonstrated to be medically necessary for this patient given their proven effectiveness for the treatment of severe obstructive sleep apnea.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided over a five-week period for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that the patient has major depressive disorder and has requested reimbursement for TMS treatment. She presented with depressed mood, tearfulness, helplessness, anhedonia, cognitive impairment, appetite change, sleep disturbance and isolativeness. She had impaired functioning socially and occupationally. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Prozac, Paxil, Effexor, Elavil, Deplin, Abilify and Topamax which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect.According to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder (MDD). Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for her depression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested a second ablation therapy for treatment of her low back pain.  Findings:  Two physician reviewers found that the patient has chronic low back pain. Seven months ago, lumbar medial branch nerve blocks on the left and right at L4, L5, and S1 were performed.  She reported six hours of complete pain relief following the diagnostic lumbar medial branch nerve blocks.  One month later, radiofrequency lumbar medial branch neurotomy bilaterally at L4, L5, and S1 were performed.  The following month, the patient reported recurrent left buttock pain.  In this clinical setting, the requested services are not likely to be more beneficial than other treatment options.  This patient has chronic low back pain which has failed to respond to multiple modalities of treatments.  However, the submitted documentation does not support the requested services in this patients case.  High volumes of solutions were utilized during the lumbar medial branch nerve blocks, thus compromising the diagnostic specificity.  Diagnostic blocks must be performed utilizing appropriate methodology with low volume injections.  In general, there should be six months of relief prior to a second radiofrequency neurotomy.  In sum, a second ablation therapy is not likely to be more effective than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male has requested coverage for a past MR neurography performed for evaluation and treatment of his shoulder weakness.  Findings:  Two physician reviewers found that the patient presented with complaint of right shoulder weakness following a lymph node biopsy procedure. The provider recommended a nerve graft procedure to address the patients symptoms of pain and atrophy in the brachial plexus region of the right shoulder. The patient underwent MR neurography in preparation for the recommended procedure.  MR neurography is capable of generating high resolution longitudinal and cross sectional images of major peripheral nerves, and has been studied to supplement diagnostic evaluations by electromyography (EMG) and nerve conduction studies in patients with suspected peripheral nerve tumors, traumatic injury, post-irradiation neuritis, chronic compression, and pain syndromes where an anatomic lesion is suspected. Although current evidence supports MR neurography as a promising technique, the outcome data which would determine the efficacy of this technology is limited to studies involving a small number of patients, making it premature to offer conclusions regarding its effectiveness for the general population. Additionally, large-scale, well-conducted, controlled studies with this approach are warranted to determine its efficacy in imaging neurofibromas and distinguishing benign from malignant lesions.MR neurography is not considered a first line technique and should only be used to supplement other diagnostic evaluations. In this patients case, there is no indication in the records provided that he had additional nerve conduction studies, EMGs, or conventional radiological examinations prior to the MR neurography being performed. Given that there is no documentation that other studies had been performed in the work-up of this patient, the diagnostic procedure at issue was not likely to have been more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female has requested a breast MRI  for evaluation of her medical condition.  Findings:  Two physician reviewers found that the patient has a positive family history of breast cancer and of Ashkenazi Jewish descent, placing her at significant increased risk of breast cancer. Genetic testing revealed she is BRCA-1 negative. Her mammograms demonstrate extremely dense breast tissue which markedly limits the utility of mammography in her case. The patient had a MRI of the breasts where a suspicious area of enhancement was seen in the left breast. Targeted ultrasound was equivocal at best. She had a follow-up MRI scan which showed a persistent area of enhancement in the left breast. MRI guided biopsy was suggested. She was scheduled for the planned biopsy but the MRI failed to reveal the abnormal area of contrast enhancement. A six month follow-up MRI was recommended to determine if the suspicious area was no longer present. The Health Plan has denied the request for follow-up MRI in six months stating there is no evidence such a close follow-up is beneficial for the patient.This patient is at increased risk of breast cancer during her lifetime with a 20% risk calculated by the Gail model.  Further complicating the issue is her extremely dense breast tissue on mammography, which limits the usefulness of that technique. Targeted ultrasound has proven to be equivocal. In this patients case, the detection of an abnormality deep within the left breast was only seen with MRI. There were two studies which showed the abnormality and the last study failed to demonstrate the same findings. Since the lesion was previously only seen via MRI, it would be prudent to follow the patient at another six month interval rather than waiting a full year to determine if there is a suspicious abnormality requiring sampling. Since the questioned abnormality has only been seen by MRI, this technique should be used as the follow-up tool. No other technique would be of such value to this patient. Additionally, accepted breast imaging guidelines provide support for short term, six-month follow-up in such cases.  In this case, the requested MRI would not be considered a screening exam. It has been requested as an exam to evaluate suspicious or equivocal findings.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested surgery (thigh excision).   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  The reviewed records do not justify the medical necessity of the removal of these masses.  If the masses were of sufficient size to rub against the opposite leg, they would protrude beyond the normal skin surface contour and would likely be visible in the photographs.  No such mass protrusion is visible in the photographs contained in the reviewed records.  The documentation does not support a functional deficit due to left thigh masses.  All told, the requested surgery (thigh excision) is not medically indicated for the treatment of this patient
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male has requested a gait analysis study for evaluation of his intoeing.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  Intoeing describes a pattern where the feet point inward towards each other rather than parallel to each other.  In severe cases, this negatively impacts a childs ability to ambulate normally.  Long-term sequelae of uncorrected intoeing include patella-femoral pathology, abnormal subtalar joint pronation, hip joint arthrosis, and patella instability.  Multiple different pathologies, structural or postural, may result in this gait pattern, including metatarsus adductus, excessive femoral antetorsion, medial tibial torsion, cerebral palsy, and weak or dominated lateral hip rotators.  As noted by Uden and Kumar, an effective management plan requires the accurate diagnosis of one of these underlying pathologies.  This patient has significant intoeing that is negatively impacting his ability to participate in ambulatory activities.  A comprehensive clinical assessment has not yielded the specific etiology responsible for his intoeing.  Thus, the requested gait analysis study is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female has requested chiropractic services for treatment of her neck pain.  Findings:  The physician reviewer found that based upon the medical records provided, the requested chiropractic care is medically necessary for treatment of the patients neck pain. The patients symptoms, clinical exam findings and physical therapy notes demonstrate that she meets the criteria for chiropractic treatment, in accordance with the Cochrane Library and Mercy Guidelines for chiropractic treatment. The submitted records from the patients providers, document the following: muscle imbalance of the cervical spine and shoulder girdle, decreased functional mobility, and an altered physiological function of the spine. Chiropractors are neuromuscular specialists and have particular expertise in managing these issues. Additionally, it is not indicated by the American Chiropractic Association, Mercy Guidelines, or the Cochrane Medical Library that patients complete a course of physical therapy prior to undergoing chiropractic treatment. The Medicare Guidelines specify the PART criteria for chiropractic treatment. The PART guidelines stated that patient must demonstrate pain, asymmetry of the muscles, range of motion difficulties and temperature change/muscle spasm. The physical therapy evaluation documents that the patient meets all of the PART criteria. Based on the current accepted chiropractic guidelines and the patients medical records, the requested chiropractic services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested total disc arthroplasty with the ProDisc-C for treatment of his myeloradiculopathy and cervical degenerative disc disease at the C5 and C6 levels with foraminal stenosis.  Findings:  Three physician reviewers found that the patient has a history of cervical myeloradiculopathy and cervical degenerative disc disease at C5 and C6 with foraminal stenosis. He has tried physical therapy, acupuncture, various medications, heat/cold therapies, and epidural steroid injections, all without substantial pain relief. On neurological testing, his motor examination is left biceps 4/5, triceps 4/-5, intrinsics 4/5, and grip 4+/5. All other muscle groups are 5/5. A cervical spine magnetic resonance imaging (MRI) revealed facet arthropathy causing moderate right and mild left neural foraminal narrowing at both C3-4 and C4-5, as well as facet arthropathy and a left disc osteophyte causing moderate to severe left neural foraminal narrowing at C5-6. This patients record documents the presence of multi-level cervical disease both radiographically at C3-4, C4-5 and C5-6, and on neurological testing as noted in the biceps, triceps, intrinsics and grip weakness. Additionally, his multi-level disease involves the facet joints. The medical literature and manufacturer do not recommend the use of the ProDisc-C device in patients with more than one vertebral level with facet joint disease or degeneration. All told, arthroplasty is not likely to provide this patient with multi-level facet disease with an improved health outcome when compared with standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested coverage for past anesthesia services provided during a colonoscopy.   Findings:  The physician reviewer found that the patient underwent a routine screening colonoscopy. She has no significant comorbidities. In cases such as this, the standard of care remains to sedate the patient with a combination of an IV benzodiazepine and an IV narcotic which are safe and effective. Given the patient was healthy and had no other contraindications to benzodiazepines or narcotic medications, there was no indication for propofol. In sum, the anesthesia services provided on were not medically necessary.