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

A 61-year-old male enrollee has requested skilled nursing facility services for treatment of his post status stroke. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  The current medical evidence supports skilled nursing facility services in this patients case.  This patient had a disabling stroke for which extensive rehabilitation was required for retraining and safety.  Caregiver training and home modifications were needed for safety.  The current medical literature indicates that discharge to an unsafe home environment runs risk of fall or injury.  At the time of home evaluation, further caregiver training was needed, as was durable medical equipment and home modifications for safety.  All told, skilled nursing facility services are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested platelet rich plasma infusion for treatment of his medical condition.  Findings:  Two physician reviewers found that platelet rich plasma infusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of evidence in the medical literature that supports platelet rich plasma for treatment of orthopedic injuries, including tendonitis. The randomized controlled trials that are available have not found superiority of platelet rich plasma injections over standard available treatments such as steroid injections. In addition, the few randomized controlled trials supporting platelet rich plasma injections for tendonitis are short-term follow-ups.  In sum, there is a lack of peer-reviewed studies that provide long-term and randomized data necessary to establish the efficacy platelet rich plasma in this clinical setting. Therefore, the request for platelet rich blood plasma infusion is not likely to be more beneficial for treatment of the patients medical condition than any available modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested acute detoxification services for treatment of her opiate dependence. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The acute detoxification services was not medically necessary for treatment of the patients medical condition. According to the documentation submitted, the patient did not exhibit impaired neurological function, unstable vital signs, coexisting serious injury or illness, a clinical condition that precluded a satisfactory assessment, pathological intoxication or serious antabuse reaction. In sum, the patient did not meet the medical necessity criteria for acute detoxification treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a motorized scooter for treatment of his medical condition.  Findings:  The physician reviewer found the submitted documentation demonstrates this patient is limited in long distance mobility by arthritis in his knees and morbid obesity. However, he can ambulate independently with a four-wheel walker. In addition, he can complete in-home MRADLs independently with a four-wheel walker. Thus, the patient does not meet medical necessity criteria for a power wheelchair, as the patient can function independently with an assistive device.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested hearing aids, Siemens Pure 701 Micon hearing aid with E charger and Mimi Tek remote for treatment of his hearing loss.  Findings:  The physician reviewer found that a hearing aid is a wearable sound-amplifying device that is intended to compensate for impaired hearing. Hearing aids are usually programmed to address an individuals degree of hearing loss across sound frequencies to improve speech intelligibility. Additionally, hearing aids may be coupled acoustically or wirelessly to external electronic products such as televisions, MP3 players, and telephones. A hearing health professional such as an audiologist or a hearing aid dispenser should program and optimize performance of hearing aids with more complex features. Based on the records provided for review, this patient with sensorineural hearing loss, meets the criteria for an assistive device. However, there is a lack of documentation provided in the medical records to support the need of the upgraded hearing aid device for the degree of hearing impairment noted on the hearing tests provided for review.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested heat treatment of varicose veins (endoluminal ablation of varicose veins  CPT code 36478) for treatment of her bilateral lower extremity painful varicose veins.  Findings:  Two physician reviewers found the treatment of perforating veins remains controversial as the recurrence rates are relatively high. The use of perforator directed treatments are generally reserved for patients with ulceration refractory to conservative measures. However, this patients records do not demonstrate that the patient has exhausted conservative treatment for her current complaints or that there is ulceration that has not responded to adequate treatment. Therefore, the medical literature does not support heat treatment of varicose veins with endoluminal ablation as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested fractional laser for treatment of his hypertrophic scar on the lower lip.  Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), actinic keratosis is considered a precancerous lesion that requires treatment. The records indicate that treatment for this patients actinic keratosis caused a hypertrophic scar, which is an abnormal structure of the lip. While a scar is expected after any significant surgical excision, there is not adequate documentation to suggest that this patients scar is creating a functional or significant appearance deficit. The photographs provided do not support that there is significant scar hypertrophy. The treating provider notes that the scar has improved 60-70%. In addition, the patient is not documented to have undergone standard therapy except for one steroid treatment and the success or failure of these treatments is not adequately defined. Overall, there is insufficient documentation to demonstrate that the patient has a significant abnormal appearance to support the requested services as reconstructive in nature. In the absence of a clearly defined functional deficit or a significant abnormal appearance, the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested modafinil (Provigil) for treatment of her shift work sleep disorder (SWSD).   Findings:  The physician reviewer found the submitted clinical documentation demonstrates the patient has a confirmed diagnosis of shift work sleep disorder. Shift work sleep disorder is a recurrent pattern of sleep disruption which results in functional impairment in the form of insomnia or extreme sleepiness. The patient has been symptomatic with persistent insomnia. Provigil is indicated for the treatment of shift work sleep disorder and has established efficacy in this setting. The submitted records indicate the patient has taken Provigil in the past with good response. All told, the requested modafinil (Provigil) is medically reasonable and necessary to treat the patients shift work sleep disorder, as it results in functional impairment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested exposure and response prevention (ERP) therapy, in conjunction with sibling and family mental health therapy for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested therapies. Based on the documentation submitted, the patient has obsessive-compulsive disorder (OCD), generalized anxiety disorder, and mood disorder not otherwise specified. The exposure and response prevention has had a significantly positive impact on reducing not only his overall anxiety level, but also has his obsessive compulsive symptoms. Specifically his obsessional stuckness and perfectionism appears to be breaking down in terms of its rigidity through this treatment. Thus, the requested therapies are specific to stimulus exposure/response prevention, which is medically indicated in this patients case. As such, the medical necessity of the requested exposure and response prevention (ERP) therapy, in conjunction with sibling and family mental health therapy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested magnetic resonance imaging and Norco 10/325 for treatment of her chronic neck pain.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure and medication.  The indications for an MRI of the brain include recent trauma to rule out subdural hematoma or subarachnoid bleed, acute neurologic findings, recent cerebrovascular accident or transient ischemic attack.  These indications are not documented in the submitted records.  The current medical evidence does not support the use of Norco chronically for low back pain or cervicalgia.  Longer acting opiates are thought to be more suitable for chronic administration.  All told, the requested MRI and Norco 10/325 are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested acute inpatient hospitalization admission for treatment of her behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation submitted for review, the patient has been in outpatient treatment for over 5 years and was on Prozac and modafinil, and was noted to be compliant with her medication regimen. She denied suicidal ideation. She was not a danger to self or others, nor did she qualify as having a grave disability. The patient was anergic and amotivational in terms of activities of daily living (ADLs), however these are not conditions for acute inpatient hospitalization. Her medical conditions of morbid obesity and hypertension did not warrant 24-hour medical monitoring in an inpatient setting. The medication adjustments and augmentation, such as the addition of Abilify, could have been made on an outpatient basis. Thus, the patient could safely have been treated at a lower level of care during the services in dispute. In sum, the patient did not meet the medical necessity criteria for acute inpatient hospitalization admission provided during the said timeframe.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Rituxan (rituximab) for treatment of her chronic kidney disease.  Findings:  Two physician reviewers found that Rituximab is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature fails to indicate that rituximab is likely to be superior for the treatment of the patients medical condition than any other modalities. The study by Fernandez-Fresnedo and colleagues demonstrated the efficacy of rituximab in focal segmental glomerulosclerosis; however this study included only three patients who were followed for only 10 to 15 months. Furthermore, there is adequate data in the peer-reviewed literature that supports treatments of agents which have not been used in this patients case, such as sirolimus and plasmapheresis. Based on the reasons provided, Rituxan (rituximab) is not likely to be more beneficial for treatment of the patients medical condition than any available modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her depression and anxiety.  Findings:  The physician reviewer found that the medical records provided for review document that by the date indicated, the patient was no longer suicidal. She was working through feelings of resentment, anger, and grief over the massive disruption in the relationship with her family. The patient was no longer expressing feelings of wishing to engage in self harm. She had already been stabilized on her medication regimen and there were no further significant adjustments. The records indicate the patient could have been safely and adequately treated at a lower level of care. Therefore, the RTC services provided from the time frame specified were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested lipoprotein laboratory testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that in this patients case, the testing at issue was not likely to have been more effective than other methods of evaluation.  At the time of this evaluation, the patient had a documented history of diabetes mellitus, hypertension, and a strong family history of cardiovascular disease.  He was already being appropriately treated with a specific medication, and his fasting lipid profile was within goal parameters.  Therefore, use of the additional lipoprotein analysis would not add any additional clinical information that would change the therapeutic plan.  In sum, lipoprotein laboratory testing is not likely to be of greater benefit than other available diagnostic measures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested ultrasound bone density measurement and interpretation for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The first choice for screening for osteoporosis is a DEXA scan.  This patient previously had a low Vitamin D level.  However, repeat testing  showed a normal Vitamin D level.  He did not have a fracture indicating high risk for osteoporosis.  Per the current medical evidence, although ultrasound has some utility for fracture prediction, DEXA is recommended for screening purposes.  All told, ultrasound bone density measurement and interpretation were not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation submitted, the patient has received more than four years of psychotherapy treatment; the patients notes reflect no treatment goals or symptoms at this time. According to the American Psychiatric Association, when initial treatment is not effective or tolerable after 6 to 8 weeks of therapy, treatment guidelines recommend dose titration, augmentation, or switching (Tierney). All told, the medical literature does not support the services at issue in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested a LINX device surgically implanted around the esophagus for treatment of his gastroesophageal reflux disease, dysphonia and sore throat. Findings:  Two physician reviewers found that LINX is a minimally invasive anti-reflux procedure. The alternative in this setting is a fundoplication procedure. However, a systematic review of more than 6,318 abstracts, 53 cohorts and 10 controlled studies has shown that it remains unclear which patient characteristics influence post-operative success following fundoplication for GERD. (Ip, et al.) LINX has been shown to be as effective as fundoplication and is considered less invasive, with fewer side effects. LINX has the added advantage of being potentially reversible as opposed to permanent anatomic reconstruction which accompanies surgery. All told, the requested LINX procedure is the most minimally invasive option for this patient and has the best chance of a successful outcome. Accordingly, the LINX procedure is likely to be 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 21-year-old female enrollee has requested residential treatment services for her behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation submitted for review, the patient is and has been at her baseline level of functioning for several years. The patient has longstanding chronic symptoms that are unwavering in nature. It is clear that when under stress the patient decompensates and develops suicidal ideation with an increase in anxiety. However, this is not the same as suicidal intent or suicidal attempts. There is no imminent risk to self harm and there is no indication that the psychosocial stressors are temporary and/or given to remit in the near future. In sum, the patient does not meet the medical necessity criteria for residential level of care services provided from the said date forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested duodenal switch bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity for the requested procedure. Bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. This is part of standard guidelines such as the National Institutes of Health (NIH) consensus guidelines for bariatric surgery. Although this patient is an adult that is morbidly obese with a BMI that is greater than 40, the medical necessity for duodenal switch is not determined at this time for failure to document a dietary evaluation and a behavioral evaluation which is part of a standard multidisciplinary evaluation. Thus, the request for duodenal switch bariatric surgery is not clinically indicated at this time. All told, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested residential treatment center services for his alcohol abuse. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. As of the said date the patients vital signs were stable and he was participating in his care and was motivated to remain sober. He had shown improvement. He was not demonstrating any withdrawal symptoms.  He did not have any medical or psychiatric comorbidity.  He did not have any suicidal ideation.  He did not require 24 hour monitoring to insure his safety. Thus, the patient could safely have been treated at a lower level of care during the services in dispute. In sum, the patient did not meet the medical necessity criteria for residential treatment center services provided during the said timeframe.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested a colonoscopy for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. In this case, the patient had a previous colonoscopy that revealed hyperplastic polyps. According to Lieberman and colleagues, There is considerable evidence that patients with only rectal or sigmoid hyperplastic polyps (HPs) appear to represent a low-risk cohort. Although earlier medical literature focused on whether the finding in the distal colon was a marker of risk for advanced neoplasia elsewhere, most studies do not show this relationship (Winawer et al). In fact, most evidence suggests that small lesions, less than 10mm, limited to the rectum and sigmoid are benign (Lieberman et al). Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested colonoscopy has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested an osteochondral knee allograft for treatment of his knee pain. Findings:  Two physician reviewers found that based on the peer-reviewed literature, the requested osteochondral knee allograft is not likely to be more beneficial for treatment for the patients medical condition than any other available treatment.  He has multiple lesions and has failed multiple surgical procedures involving the left knee.  The records do not include an up-to-date clinical evaluation of this patient with radiographs to indicate his current status.  Therefore, the requested osteochondral knee allograft is not likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested lap-band surgery (laparoscopic banding) for treatment of her obesity.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested procedure. Bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. This is part of standard guidelines such as the National Institutes of Health (NIH) consensus guidelines for bariatric surgery. The patient has a BMI above the guidelines and the submitted medical records do not document the presence of serious co-morbid conditions such as diabetes, hypertension, coronary artery disease or sleep apnea. Moreover, there is a lack of documentation showing failed weight loss efforts. Thus the request for lap-band (laparoscopic banding) surgery is not clinically indicated at this time. All told, the medical necessity of the requested procedure has not been established.