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

The parent of an 8-year-old female enrollee has requested  testing for central auditory processing disorders (CAPD) for evaluation of the enrollees medical condition. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity for the requested services. The article by Moore notes that CAPD is ill-defined and interventions appear to have limited effectiveness. The author further opines that children who are poor listeners tend to have a range of cognitive difficulties. Fey and colleagues reviewed the peer-reviewed literature on the efficacy of interventions for school-age children with auditory processing disorder. The authors concluded that the evidence base is too small and weak to provide clear guidance for speech pathologists. Further, the article by Moore and colleagues indicates that listening difficulties in children with normal hearing diagnosed with CAPD is the co-concurrence of other learning disorders. Thus, the article suggests that the CAPD diagnosis may be a symptom of more varied neurodevelopmental disorders. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Orthovisc injections for treatment of her right knee osteoarthritis.  Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review of a total of 89 trials involving 12,667 patients with knee osteoarthritis that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Navarro-Sarabia, et al). Several studies evaluating repeated treatment protocols have reported adverse events including inflammatory changes within the knee joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. Overall, there is limited or no benefit demonstrated in well-designed, double-blinded studies, but there is the possibility of acute local reactions. All told, the requested Orthovisc injections are 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 19-month-old female enrollee has requested health services for weekly blood pressure monitoring for evaluation of the enrollees hypertension.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has angiopathy that has resulted in strokes as well as renal artery stenosis, and sequelae include hypertension and hemiparesis. In addition, she has significant gastrointestinal abnormalities. Given the clinical presentation of this patients underlying medical condition, and the potential for additional significant morbidity, it is necessary to continue weekly blood pressure monitoring.  Hypertension in combination with vascular abnormality increases potential for complications, such as further stroke.  In this patients case, it is not medically appropriate to require the family to present to the pediatricians office weekly for blood pressure monitoring given her medical condition.  All told, home health visit services for weekly blood pressure monitoring are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patient continued to report suicidal ideation with plan.  For the duration of her hospitalization, she remained on 15-minute monitoring.  The records do not indicate that progress was made in terms of response to treatment, as she was described daily as having poor insight into appropriate management of emotional regulation with poor judgment and impulse control.  The current medical evidence supports inpatient psychiatric hospitalization in this clinical setting.  All told, inpatient psychiatric hospitalization was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested continued residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found the submitted documentation demonstrates the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting as community interventions optimize treatment gains.  However, patients with anxiety, character pathology, substance use, and mood symptoms may episodically require treatment in a more restrictive setting. This patient is at risk for a poor outcome in the absence of specialized care in a 24-hour setting.  Her family environment remains a prominent stressor for affective dysregulation and cognitive distortions.  Additionally, the patient has required multiple acute admissions and failed less restrictive alternative interventions.  The progress notes document aggressive thoughts aimed towards her family and an inability to self-soothe.  Somatic symptoms were prominent and a new medication, aripiprazole, was added to the regimen for depression, anxiety, mood lability and recurrent interpersonal strife.  Although the patient has made some progress, she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  The services are for active treatment which is reasonably expected to prevent a more serious clinical situation and improve her current condition.  All told, continued residential treatment services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested excision of a hymenal remnant (tag) for treatment of her hymenal tags.  Findings:  The physician reviewer found that vulvar skin disorders, which include hymenal remnants, are common and the symptoms are oftentimes chronic. The American College of Obstetricians and Gynecologists (ACOG) practice bulletin reveals that symptoms associated with vulvar skin disorders can interfere with a patients sexual function and sense of well being. Benign lesions that are symptomatic can typically be managed with simple procedures including cryotherapy, electrosurgery, or excision. Skin tags occur in approximately 25% of adults and the risk increases with age (Banik and Lubach). This patients records indicate that she may have a symptomatic vulvar skin tag due to rubbing by clothing or intercourse. However, the providers notes do not provide evidence of any complaints during physical examination or by history. In the absence of documentation of a symptomatic vulvar skin tag, the requested excision is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested a narrow band UVB home phototherapy unit for treatment of his vitiligo. Findings:  Three physician reviewers found the NBUVB home phototherapy unit was likely to be more effective for this patient than other available options. Treatment for vitiligo is difficult and prolonged and treatment with NBUVB by a home therapy unit provides an established modality for treatment of vitiligo. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist, as not all patients respond to available therapies. The clinical aspects of each individual patients vitiligo should be considered including the treatments tried and failed as well as published results of clinical research trials of NBUVB in vitiligo. In this case, the patient previously had effective treatment with NBUVB therapy with repigmentation of skin lesions. Therefore, the services at issue were likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested positron emission tomography (PET) scan and a single photon emission computed tomography (SPECT) for evaluation of his personality changes, persistent insomnia and mood changes.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature there is a paucity of scientific data supporting the clinical utility of either PET or SPECT imaging in the evaluation of this patient with ADHD and personality issues. There is a lack of evidence that PET or SPECT imaging is within the standard of care over standard available alternatives. All told, the diagnostic procedures at issue were not likely to have yielded additional information helpful in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested magnetic resonance imaging (MRI) (lower extremity) for evaluation of his knee pain.  Findings:  The physician reviewer found that based on review of the available records, it is appropriate for this patient to have an MRI of the left knee with findings on physical examination including knee pain, popping, medial, lateral and anterior pain, and lack of knee extension. The presence of medial compartment or lateral compartment degenerative osteoarthritis also needs to be assessed. Physical examination revealed tenderness, limited range of motion and pain. Given the loss of knee extension and mechanical signs of popping, the differential diagnosis should include degenerative osteoarthritis with osteochondral loose body versus degenerative or traumatic type tear of the medial meniscus or lateral meniscus, as well as ligamentous injuries. Although x-ray and MRI can provide the basis for anatomical imaging, MRI should enable a more precise diagnosis. Thus, the MRI and clinical findings will become the basis for this patients treatment. Consistent with these findings, the requested MRI of the lower extremity is supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a power wheelchair for treatment of his paraplegia. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The patient has adequate strength to use a manual wheelchair as he is noted to have good upper limb strength and therefore does not require power mobility for ambulation within the home. The patient can perform his ADLs at the manual wheelchair level and therefore does not require power mobility for ADLs. Thus, the requested power wheelchair is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested bilateral upper eyelid blepharoplasty for treatment of her dermatochalasis. Findings: The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  In order to support the medical necessity of the procedure, photographs should demonstrate one or more of the following: upper eyelid margin within 2.5 mm of the corneal light reflex, upper eyelid skin rests on the eyelashes, dermatitis of the upper eyelid, or greater than or equal to 12 degrees or 30% loss of upper field of vision with upper lid skin and/or upper margin in repose and elevated by taping to demonstrate potential correction by the proposed procedure.  The submitted photographs do not document the existence of any of these conditions in this patients case.  Additionally, there is no documentation related to the patients complaints of eyelid inflammation in the medical records.  This patients condition does not constitute an abnormal structure of the body, and the requested surgery is not likely to improve function or create a normal appearance from an abnormal one.  The requested service does not qualify as reconstructive surgery.  All told, the requested bilateral upper eyelid blepharoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested monitored anesthesia care (MAC) administered for a screening colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found the submitted documentation of monitored anesthesia care (MAC) during the patients colonoscopy was not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. In addition, Hausman and Reich state that not all procedures are well suited for the office with sedation. The authors note that unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. A colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per American Society of Anesthesiologists (ASA) guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested Victoza and testosterone injections for treatment of his medical conditions. Findings:  The physician reviewer found the requested testosterone injections are medically necessary for treatment of the patients hypogonadism. In this case, the patients testosterone level is low. Diabetes and obesity have been demonstrated to be linked to numerous comorbidities, and low testosterone levels can result from both of these conditions (Prevost, et al). Low testosterone, can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, patients with hypogonadism with a testosterone level less than 350ng/dl should be treated (Nieschlag, et al). The American Urological Association have stated that the decision to treat hypogonadism should be based on the presence of signs and symptoms, and not simply the serum testosterone measurement and stressing that rigid interpretation of T ranges should not dictate clinical decision making (Paduch, et al). In sum, based on the medical records submitted for review, the patients request for testosterone injections is medically necessary. Therefore, the medical necessity of the requested Victoza and testosterone injections has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested UV light home therapy for treatment of her vitiligo. Findings:  Three physician reviewers found that common treatments for vitiligo include topical steroids, topical immunomodulators and phototherapy using UVA or UVB light (Lotti, et al; Eleftheriadou, et al). She has also been treated with ultrapotent topical steroids including Clobetasol cream and topical tacrolimus ointment. The medical records indicate that she has progressive disease and home therapy has been recommended given that treatments are expected to be ongoing. Given that this patient has undergone therapy with both topical steroids and topical immunomodulators and shown improvement with in-office phototherapy, the continued use of home unit is a reasonable next step. All told, the requested home phototherapy unit is likely to provide this patient with greater health benefits for treatment of her medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested cardioverter defibrillator device for treatment of her longed QT syndrome.  Findings:  Three physician reviewers found that this patient had a class II indication for the implanted ICD to prevent sudden cardiac death based on the American College of Cardiology (ACC) guidelines (Rubens, et al). An ICD was indicated for primary prevention of sudden cardiac death in long QT syndrome. The records provided for review document that this patient was found to have the same genetic mutation as family members, which placed her as at risk of sudden cardiac death. All told, the cardioverter defibrillator device was likely to have been 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 59-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) treatment for treatment of his behavioral health condition. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. EMDR is a therapy in which patients generate exposure to trauma via imagery while performing horizontal saccadic eye movements. A skilled therapist assists the patient in decompressing the anxiety burden stemming from the traumatic image or memory. EMDR is not recommended for the treatment of major depressive disorder, but it is a well-accepted treatment for posttraumatic stress disorder (PTSD). The records provided do not substantiate a clinical diagnosis of PTSD. As such, an independent diagnostic PTSD evaluation by a mental health professional specializing in the disorder is recommended.  In addition, if PTSD was diagnosed, EMDR would not be medically necessary unless the patient had a contraindication to, the inability to access, or had failed other evidence based treatments for PTSD, as EMDR has not been shown to have significant advantage over other first-line trauma-focused therapies such as prolonged exposure and cognitive processing therapy, or stress inoculation training. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested Ampyra for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has multiple sclerosis with gait disorder. She showed an improved functional status with Ampyra, in terms of walking speed, balance, and endurance. Further, the records document the patients functional status decreased performance on the 25-foot timed walking test after she discontinued Ampyra for six days. Given the patients progressively worsening status and her improvement with Ampyra, the requested medication is supported as medically necessary for treatment of her medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested urgent care services for evaluation of his mild bilateral sore throat described as aching. Findings:  The physician reviewer found 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 patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he required urgent services. The patient developed a sore throat the day prior to his urgent care visit. He reported back pain that had been present for  weeks. He had no fever, trouble breathing, or swallowing. The patient did not have any signs or symptoms of an acute spinal cord compression such as numbness, or bowel or bladder dysfunction. Thus, the services in dispute were not urgently necessary to prevent serious deterioration of his health, for which treatment cannot be delayed. All told, the patients symptoms did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested uvulopalatopharyngoplasty (UPPP), removal of tonsils, septoplasty and resection of the inferior turbinates for treatment of his medical condition.  Findings:  The physician reviewer found that in this patients case, polysomnography performed on the date indicated showed evidence of obstructive sleep apnea.  Follow-up titration of continuous positive airway pressure was performed and a maximum pressure of 16 cm of water was found to alleviate symptoms of obstruction.  However, the submitted records do not include documentation of a length of trial of CPAP therapy nor of any effectiveness of the CPAP in reducing the symptoms of daytime somnolence.  In order to establish the medical necessity of the UPPP, the medical record must document that the patient has undergone appropriate trial of CPAP therapy prior to surgical intervention.  Uvulopalatopharyngoplasty is a surgical intervention that incorporates removal of the tonsils in addition to sections of the soft palate.  Tonsillectomy is a definitive complement of that intervention which is also not medically necessary. According to the clinical notes, the patient was found to have functional nasal airway obstruction secondary to deviation of nasal septum with some degree of inferior turbinate hypertrophy.  However, the records do not document medical therapeutic attempts with the use of topical nasal medications.  The documentation fails to establish the medical necessity of the requested septoplasty and resection of the inferior turbinates.  Given the lack of documentation of failure of adequate control of the patients symptoms with medical therapy or CPAP, the requested services are not medically necessary.  All told, the requested uvulopalatopharyngoplasty (UPPP), removal of tonsils, septoplasty and resection of the inferior turbinates are not medically indicated for the treatment of this patient.