Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 47-year-old female enrollee requested magnetic resonance imaging (MRI) of the breast (CPT  77058) for medical evaluation of the enrollees left breast swelling.  Findings:  Two physician reviewers found that applying the American College of Radiology (ACR) guidelines, the requested breast MRI is not likely to be more beneficial for evaluation of this patients medical condition than available standard therapies. The records do not indicate the patient is at high or intermediate risk categories. The mammogram report states the breasts are average density and there is no documentation of a family history of breast cancer. Screening breast MRI is recommended in patients at high risk for breast cancer on the basis of family history. All told, the requested breast MRI is not supported as likely to be more beneficial for evaluation of this patients medical condition than any available approach.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee requested mental health residential treatment center (RTC) services for medical treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that applying the American Society for Addiction Medicine (ASAM) criteria, the mental health RTC services provided to this patient were medically necessary for treatment of her medical condition. Based on review of the available records, the patient did not have sufficient coping techniques to avoid a possible relapse if she had been discharged to a lower level of care. The patient had a difficult time on her pass home which also supports the need for continued treatment. In addition, she was opposed to a step-down treatment until only a few days before her discharge. Therefore, the RTC services were medically necessary to help the patient develop appropriate coping strategies and to develop a realistic discharge plan that would prevent a relapse.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. The medical records submitted for review document a slow, but steady, improvement in this patients mood. Upon admission, he wanted to hurt himself. His course was complicated by his long history of migraine headaches and dependence upon pain medications. During the dates in dispute the patient had poor insight, judgment and impulse control with continued impulses to harm himself. On the date indicated the patient did show improvement and was discharged as soon as he was safe to do so. Therefore, based upon the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a power wheelchair for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The records indicate that the patient has normal strength in the upper limbs and poor to trace strength in the lower limbs.  There are no indications that he does not have functional active range of motion in the upper limbs.  Additionally, there are no indications that he has cardiopulmonary or other organ system impairments that would preclude propulsion of a manual wheelchair within the home to perform daily activities.  The records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device.  This patient has multiple chronic health conditions, such as chronic obstructive pulmonary disease and hypertension, which would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease his physical activity levels and would be expected to worsen his health conditions.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested substance abuse residential treatment center (RTC) for treatment of her alcohol dependence.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the time period specified were not medically necessary for treatment of the patients medical condition. Although the admission assessment noted that the patient reported withdrawal symptoms of shakes and sweats, there is no thorough evaluation of this description other than what was briefly mentioned in the admission assessment. Moreover, the documentation submitted for review fails to indicate vital signs, Clinical Institute Withdrawal Assessment (CIWA) scales and a psychiatric evaluation. The patients comorbid biomedical conditions of seizure disorder and psychiatric conditions of depression were controlled on medication and were not of a severity that required 24-hour supervision in a residential setting. She denied suicidal ideation and she was not a danger to herself or others.  She was described as motivated, and was actively engaged in treatment as documented in her counselors notes. While she had the potential for relapse, she demonstrated recognition and insight into her triggers and had formulated a plan of prevention. Although she did not plan to have substantial contact with her family, she was discharged to sober living and planned to attend meetings. Finally, the patient did not show acute psychiatric or medical symptoms that would interfere with her maintaining abstinence and recovery outside of a 24-hour structured setting. She did not show self injurious or dangerous behavior towards self or others. She showed no major functional impairment. Given all of the above, her condition did not meet the medical necessity criteria for residential level of care and could have safely been treated at an outpatient level of care along with community based resources such as 12-step programs. Based on the medical literature cited above and the documentation submitted for review, the RTC level of care provided from the time period specified were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested genetic testing (microarray analysis) for evaluation of her pregnancy.  Findings:  Three physician reviewers found that  the patient underwent chorionic villus sampling (CVS) testing and microarray analysis.  All testing performed was normal.  The genetic testing performed was not likely to be more effective for this patient than any available standard therapies. According to the American College of Obstetricians and Gynecologists (ACOG), Chromosomal microarray analysis is a technique that identifies chromosomal abnormalities, including submicroscopic abnormalities that are too small to be detected by conventional karyotyping. Like conventional fetal karyotyping, prenatal chromosomal microarray analysis requires direct testing of fetal tissue and thus can be offered only with chorionic villus sampling or amniocentesis. Based on the results of a Eunice Kennedy Shriver National Institute of Child Health and Human Development multicenter trial and of prior studies, prenatal chromosomal microarray analysis is most beneficial when ultrasonographic examination identifies fetal structural anomalies.  In this case, there is no documentation identifying fetal abnormalities that would necessitate microarray analysis. In sum, the services at issue were not clinically indicated and not likely be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested direct applied behavioral analysis (ABA) services and 2 hours per week of supervision for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient is an adolescent who was identified as autistic at the age of 2 and has been the recipient of ABA therapy for several years. The patient has also been diagnosed with generalized anxiety disorder. The submitted clinical records do not demonstrate that the patient has shown a significant response to ABA therapy. The patient continues to present with aggression and maladaptive behaviors and has shown regression of previously acquired self-help skills. There is a lack of adequate evidence in the peer-reviewed literature to support the clinical effectiveness of ABA in the adolescent autistic population, particularly where there is marked regression and re-emergence of marked problematic behaviors. Therefore, considering the best available evidence in relation to this patients individual circumstances, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested a comfort carrier transfer sling for medical treatment of her quadriplegia secondary to spinal cord tumor.  Findings:  The physician reviewer found that the patient has profound deficits in mobility and requires a Hoyer Lift for transfers. A comfort carrier device has been requested under the rationale that it is needed for emergency transport. It is a device, not dissimilar to the sling on a patient transfer system such as a Hoyer Lift, that is made of canvas or canvas-like tarp material, which has handles so that multiple caregivers can manually transfer or transport a dependent in situations such as an inaccessible environment or in an emergency situation. However, the requested comfort carrier device is not necessary or appropriate for this patients accomplishment of basic mobility related activities of daily living. Basic mobility related activities of daily living needs are more appropriately met with the Hoyer Lift and its sling. Emergency transport needs can be met with other means. Overall, there is no evidence that use of the proposed comfort carrier device would result in improved outcomes over other alternatives in the event of an emergency. Notably, with respect to dependent level transfers, the comfort carrier requires at least two physically fit persons to use for a transfer, whereas a manual transfer of a person who is totally dependent for transfers can be accomplished by only one physically fit unskilled person with some minimal training. Further, transport of a dependent person in a comfort carrier over an extended distance would also subject the transporters and dependent to risk of injury. For these reasons, the requested comfort carrier transfer sling is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested a panniculectomy (CPT 15830) for medical treatment of her excessive skin.  Findings:  The physician reviewer found that overall, there is inadequate documentation to support that the patient has a functional deficit that would benefit from panniculectomy. The providers notes do not include sufficient detail of the abdominal overhang and the dermatologic treatment that has been attempted. The medication history does not list any topical medications that may be used to treat rashes and/or fungal infections. The photographs depict only a mild overhang and the area underneath the overlap is not provided for evaluation. The examination notes do not include any evidence of intertrigo, increased moisture, malodor and/or chronic changes to support that a functional deficit exists. The patient states that she has problems and this is repeated by the providers, but there is inadequate detail in the documentation to support this. As stated by the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. Manahan and Shermak noted that, the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Without greater detail in the medical documentation, the requested panniculectomy is not medically necessary for treatment of this patients medical condition.In addition, the requested panniculectomy is not reconstructive in nature to treat this patients medical condition. Overlap of abdominal skin after significant weight loss is considered an abnormal occurrence of skin and soft tissue. This patient has been treated for obesity which can be classified as a disease and her condition occurs as a result of this treatment. However, there is insufficient medical documentation or photographic evidence suggesting that the requested panniculectomy is to improve function or that the patient has failed non-operative management. The patients abdominal overhang, as visualized in the photographs, does not indicate that her appearance is more than a mild abnormality. Based on the photographs, panniculectomy would not offer more than a minimal improvement in the patients appearance. All told, the requested panniculectomy has not been demonstrated to be reconstructive in nature or medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee has requested tramadol extended release (ER) 100 mg twice per day for treatment of his ankle pain status post fracture.  Findings:  The physician reviewer found that the requested tramadol 100 mg extended release is medically necessary for treatment of this patients medical condition based on the records provided for review. The clinical documentation submitted for review indicates this patient has been on tramadol ER for over one year with effective pain control with an increased ability to functionally ambulate due to decreased pain. In this circumstance, the peer-reviewed medical literature supports the use of tramadol ER in the management of this patients chronic pain. As the patient has been stable on this medication for an extended duration, continued use is medically indicated. All told, the requested tramadol 100 mg extended release twice per day is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested magnetic resonance imaging (MRI) of the cervical spine and shoulder for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has left upper extremity symptoms which have persisted despite surgery involving both the wrist and left shoulder.  Her pain and tingling may be due to cervical impingement.  Since this patient has already had two procedures on her left upper extremity without relief, there is sufficient support for the requested MRI of the cervical spine to evaluate the cervical spine as a possible cause of the patients symptoms.  However, the medical necessity of the requested shoulder MRI has not been established.  The most recent physical examination does not address the left shoulder, and there is a lack of documentation regarding conservative therapy concerning the right shoulder.  Per the current medical evidence, there is no medical indication to proceed with MRI of the right shoulder prior to conservative management.  All told, a portion of the requested services (MRI of the cervical spine) is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee requested measurement of serum concentration of infliximab and antibodies to infliximab as well as continued measurement of serum concentration of infliximab and antibodies to infliximab for medical evaluation of the enrollees Crohns colitis.  Findings:  Two physician reviewers found that the services at issue were and are likely to be more efficacious than other modalities.  The medical evidence supports the services at issue in this clinical setting.  The services were and are indicated for the evaluation and treatment of this patient.  This patient is currently on Remicade 15mg/kg, which is a high dose.  Thus, measurement of serum concentration of infliximab and antibodies to infliximab and continued measurement of serum concentration of infliximab and antibodies to infliximab were and are likely to be superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested laparoscopic radiofrequency ablation of fibroids (Acessa System of Radiofrequency Ablation for medical treatment of the enrollees uterine fibroids.  Findings:  The physician reviewer found that Radiofrequency ablation is a new alternative, with initial small studies indicating that it may be a reasonable surgical approach for well-selected patients with fibroids.  However, the preferred approach for laparoscopic therapies for fibroids remains laparoscopic myomectomy rather than radiofrequency ablation.  Additionally, appropriate candidates for radiofrequency ablation include women with fewer than four leiomyomas.  This patient was noted to have at least four fibroids and thus is not a suitable candidate for radiofrequency ablation.  In this patients case, there are a number of available standard treatments that have not been tried which are likely to provide relief of her symptoms.  All told, laparoscopic radiofrequency ablation of fibroids (Acessa System of Radiofrequency Ablation) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested Botox injection (OnabotulinumtoxinA injection  HCPCS code J0585 and chemodenervation of muscle; innervated by facial nerve, unilateral  CPT code 64612) for medical treatment of the enrollees hemifacial spasm. Findings:  The physician reviewer found that currently, Botox is considered the standard therapy for treatment of hemifacial spasm and has been proven to be more effective than any other treatment.  Botox weakens or paralyses the muscle it is injected into if the dose is adequate and the placement is correct. The standard of care in the treatment of blepharospasm and hemifacial spasm is to continue treatment approximately every three months and vary the paradigm depending on the last treatment response. All told, the requested Botox injection (onabotulinumtoxinA injection  HCPCS code J0585 and chemodenervation of muscle; innervated by facial nerve, unilateral  CPT code 64612) is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested  E1800 Dynamic adjustable elbow extension/flexion device (Dynasplint) for treatment of his right elbow radial head fracture. Findings:  The physician reviewer found that the patient suffered a right elbow radial head fracture and underwent an open reduction internal fixation on the date indicated. The patient was treated with postoperative physical therapy and a Dynasplint. There was no mention of a postoperative elbow contracture. The patients physical examination on the subsequent date revealed 12 to 150 degree range of motion with full supination and pronation. There was no mention of a contraindication to traditional physical therapy and home exercise as opposed to static progressive stretching. Based on the clinical information received, the medical necessity for the requested Dynasplint device has not been established. All told, the requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Lazanda 100 mcg fentanyl nasal spray for treatment of the enrollees chronic interstitial cystitis. Findings:  The physician reviewer found that Lazanda 100 mcg fentanyl nasal spray is not medically necessary for treatment of this patients interstitial cystitis and chronic pain. Such doses are only indicated for malignant pain. The patient has chronic non-malignant pain. The current standard of care for chronic non-malignant pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, it is in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy to address chronic pain. Consistent with these findings, the requested Lazanda 100 mcg fentanyl nasal spray is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee requested magnetic resonance imaging (MRI) of the breasts for medical evaluation and treatment.  Findings:  Three physician reviewers found that the patient underwent removal of bilateral breast implants and replacement of the implants due to right implant rupture. According to the provider, a breast ultrasound demonstrated rupture of right breast implant and free silicone. Magnetic resonance imaging (MRI) of the breasts revealed evidence of right breast intracapsular rupture and free extracapsular silicone within the left lateral breast and right axillary lymph nodes. Subsequently, the patient underwent surgery to remove the implants and some of the silicone. Bilateral diagnostic mammogram and targeted breast ultrasound showed right axillary silicone containing lymph nodes. The patient was noted to have continued right breast pain and a follow-up MRI was recommended. The patient was evaluated with MRI and determined to have right axillary reactive silicone infiltrated lymph nodes that were also present on MRI earlier. In the peer-reviewed medical literature, Samuels and colleagues noted that mammography supplemented with ultrasonography constitutes the most cost-effective initial study, followed by MRI if these are equivocal. MRI is the most sensitive and specific study to evaluate breast implant rupture. Ahn and colleagues concluded that the most reliable imaging modality for implant rupture detection is MRI, followed by sonogram. Mammogram is the least reliable. Our study supports the clinical indication and diagnostic value of sonogram and MRI in the evaluation of symptomatic breast implant patients. All told, the use of the follow-up breast MRI was indicated to provide information relevant to this patients evaluation and treatment and was likely to have been more beneficial than any available standard modality.