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

A 61-year-old male enrollee has requested the removal of his benign skin lesions for treatment of his seborrheic keratoses. Findings:  The physician reviewer found that this case involves a request for liquid nitrogen destruction of seborrheic keratoses.  Destruction of these lesions is considered cosmetic except in instances of inflammation, bleeding, or pain associated with traumatization of the lesions (Brodsky, et al.).  The seborrheic keratoses described in the patients medical records are not documented to be inflamed, bleeding or painful. The additional information provided documents a history of non-melanoma skin cancer, which can place patients at increased risk of developing additional cancerous lesions. This would support annual examinations of the skin by a dermatologist.  However, the presence of seborrheic keratoses does not contribute to an increased risk of skin cancer or potential for malignant conversion. Further, the presence of seborrheic keratoses does not place the patient at risk of infection.  If a lesion were to become inflamed due to trauma, then treatment would be considered medically necessary. However, it is not necessary to prophylactically treat seborrheic keratoses to reduce the risk they will become inflamed or infected, as the vast majority of lesions do not.  As such, the treatment of non-inflamed seborrheic keratoses is not considered to be medically necessary and the Health Plans denial of the patients request for treatment of these lesions should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested acupuncture for treatment of her polymyositis.  Findings:  The physician reviewer found that there is a paucity of evidence supporting the use of acupuncture for the treatment of polymyositis (Firestein, et al). The standard treatment for polymyositis includes corticosteroids and if necessary, steroid-sparing agents such as methotrexate. Specifically, there are no reliable, randomized, clinical trials demonstrating the efficacy of acupuncture in the treatment of this disease. For these reasons, the requested acupuncture treatment is not medically necessary for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a third sacroiliac joint injection for treatment of her pain. Findings:  The physician reviewer found that while there is evidence to support the use of epidural injections in the lumbar spine, randomized, controlled trials have not been identified to support the effectiveness of therapeutic sacroiliac joint injections. Treatment modalities for the sacroiliac joint include medications, therapy, injections, and bracing, but there is a lack of published data regarding the efficacy of these modalities. There is limited evidence for therapeutic intra-articular sacroiliac joint injections.  In this patients case, the diagnosis of sacroiliac joint disease is not documented.  In addition, the use of injections for treatment is not supported in the literature.  All told, the medical necessity of the third sacroiliac joint injection has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female requested an abdominal and pelvic computed tomography (CT) scan.  The physician reviewer found that Uterine leiomyomas (fibroids or myomas) are the most common pelvic tumor in women. They are benign monoclonal tumors arising from the smooth muscle cells of the myometrium. They arise during reproductive age in women and typically present with symptoms of abnormal uterine bleeding or pelvic pain/pressure. Uterine fibroids may also have reproductive effects. The diagnosis of uterine sarcoma is based upon histological examination. Uterine sarcomas are most commonly diagnosed following myomectomy or hysterectomy for presumed leiomyomas. Surgery is the mainstay of therapy for leiomyomas. Hysterectomy is the definitive procedure, while myomectomy by various techniques is the alternative.There are no high quality data regarding the follow-up of fibroids in patients who are asymptomatic or who decline medical or surgical treatment. An initial imaging study, usually an ultrasound, is used to confirm that a pelvic mass is a fibroid and not an ovarian mass. After an initial evaluation, an annual pelvic exam is performed and, in patients with anemia or menorrhagia, a complete blood count. If symptoms or uterine size are increasing, further evaluation is indicated as well as patient counseling regarding treatment options. Preoperative and intraoperative findings are of limited value in estimating the likelihood that a mass is a uterine sarcoma. Additionally, there is no pelvic imaging modality that can reliably differentiate between benign leiomyomas and uterine sarcoma. Leiomyomas and uterine sarcomas appear similar, both are focal masses within the uterus and both often have central necrosis. Computed tomography does not reliably differentiate between leiomyomas and uterine sarcoma and therefore would be of no benefit in the diagnosis or treatment of this patient. The requested diagnostic test is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested TMS therapy for treatment of her major depression, recurrent, severe, with quality of melancholia.  Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive TMS.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  Their conclusions report that although results are suggestive that TMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. Lam and colleagues concluded that for patients with treatment-resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment-resistant depression.  In sum, at this time, the current medical evidence has not established that the requested TMS is likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  The current medical evidence indicates that early intervention can improve speech and language skills.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of his speech and language delay, the requested speech therapy is standard of care. There is sufficient medical evidence supporting the requested services in this clinical scenario.  All told, the requested speech therapy services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested removal of her bilaterally ruptured breast implants for treatment of her ruptured breast implants. Findings:  The physician reviewer found that the patient had these implants placed for cosmetic reasons and her condition has been present for a lengthy period.  Ruptures of breast implants are a known complication and as stated, are generally not considered medically necessary after cosmetic placement. The patient cites concerns such as interference with mammography, capsular contracture, a family history of breast cancer and inability to rule out neoplasm. However, the treating provider has not noted in the medical record that he has any of these concerns. The provider only notes that the patient complains of pain and that the breast envelopes are soft. There is no objective documentation of the severity of the pain. The providers examination and history do not support a severe capsular contracture or that he is concerned about screening or neoplasm. The effect of implants on mammography is well-known and, as a result, special views are needed to adequately visualize the breast tissue (Rohrich & Reece). There is no medical documentation presented that supports that the breast tissue has not been adequately visualized. All told, there is no medically documented information to support that the patient meets medical necessity criteria for removal of her breast implants. Thus, there is not sufficient medical documentation to warrant that removal of the ruptured implants is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Synvisc-One (orthovisc) injections for treatment of her osteoarthritis of the knees bilaterally. Findings:  The physician reviewer found that the peer reviewed medical literature has demonstrated that viscosupplementation is a useful tool for the treatment of patients with mild to moderate osteoarthritis of the knees. This medication is also approved by the Food and Drug Administration for treatment of knee osteoarthritis.  Clinical studies indicate that six-month intervals between injections are optimal.  In the case of this patient, it appears that she has previously responded well to viscosupplementation. The submitted records do not document that viscosupplementation was administered in the six months preceding the injections.  The injections with Synvisc-One in both of the patients knees was medically necessary for treatment of her osteoarthritis in both knees.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Hyalgan (hyaluronic acid) injections for treatment of her osteoarthritis. Findings: The physician reviewer found that review of this patients medical records does not describe a case specific factor which would support the likelihood of a clinical benefit with the requested Hyalgan injections. In addition, the medical literature does not support the efficacy of repeated series of Hyalgan injections. To the contrary, the studies document level II evidence that hyaluronan injections have little to no efficacy in this setting. Well designed double-blinded placebo-controlled studies have not demonstrated a significant positive effect from intra-articular hyaluronan as compared to placebo. In the study conducted by Jorgensen and colleagues, no appreciable improvement was found in patients at 3, 6, 9, and 12 months after injection. In one study it was noted that 80 knees treated with hyaluronic acid and concluded that the therapy should probably be limited to patients with significant surgical risk factors or early osteoarthritic changes failing conservative treatment rather than patients with advanced degenerative osteoarthritis, as is documented in this case (Evanich and colleagues). It should be noted that repeat injections have potential complications including aseptic and septic arthrosis. Overall, there is insufficient evidence in the scientific studies to suggest that further hyaluronan injections are likely to be efficacious for management of this patients osteoarthritis of the knee. As such, it is not medically necessary for this patient to receive an additional Hyalgan injection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar I disorder. Findings:  Three physician reviewers found that peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive TMS.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. They noted that continued trials are required. Lam and colleagues concluded that for patients with treatment-resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment-resistant depression.  Gershon and colleagues also reported positive responses of TMS as an antidepressant treatment, but noted continued need for verification and standardization of best practices and type of patient that would benefit. All told, the superior efficacy of the requested services in this clinical scenario has not been established at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee requested reimbursement for adolescent substance use disorder residential treatment for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found in the submitted documentation that the patient was attending off-site Narcotics Anonymous meetings during the disputed period. The medical records for the date in question noted that the patient was attending all groups. The medical notes indicated that the patient was doing well. The clinical records provided did not reflect emotional or medical instability that required 24-hour supervision under a physicians care during the dates in question. The patient had progressed to the point that he was a candidate for transitioning from residential treatment to a less restrictive level of care. Based upon the American Academy of Child and Adolescent Psychiatry practice parameters, residential treatment was not medically necessary on the date in question.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder and anxiety. Findings:  Three physician reviewers found that although relatively new, TMS is effective treatment as demonstrated in the peer reviewed medical literature. In addition, TMS is becoming more widely used, has been granted a category I CPT code by the American Medical Association and is FDA approved for the treatment of treatment-resistant major depressive disorder. For these reasons, the requested TMS therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested neuropsychological testing for evaluation of the enrollees attention deficit hyperactivity disorder. Findings:  The physician reviewer found that this patients history does not provide evidence of any factors that would necessitate neuropsychological testing. Specifically, he has no medical or neurological impediment to warrant such evaluation. In addition, the patient has no history of low general cognitive ability or low achievement in language or mathematics relative to his intellectual ability. As such, this patient presented without any risk factors supporting the need for neuropsychological evaluation. Further, there was no documentation of a preliminary psychological assessment to rule out common problems before proceeding to the neuropsychological battery of evaluation. All told, the medical necessity of the testing performed on this patient has not been established in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation demonstrates the patient had been experiencing ongoing symptoms for about a week prior to his presentation to the ED. During this period, the patient had sufficient time to undergo an evaluation in a clinic or private office. His pain level upon presentation to the ED was 1 out of 10 and there was no physical evidence of infection. While it is understandable that the patient was concerned about this recent development in a wrist that had previously been badly traumatized and surgically repaired, a reasonable and prudent layperson in theses circumstances would have sought evaluation outside of an emergency room setting. Thus, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to seriously jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested a three piece inflatable penile prosthesis for treatment of his erectile dysfunction. Findings:  The physician reviewer found that treatment of erectile dysfunction is goal directed; appropriate therapy is based on what is successful and acceptable to the individual patient. Although erectile dysfunction is often viewed as only a physical dilemma, the individuals psychological insult and emotional well-being are also affected, as his body is failing in a simple physical function. To regain medical wholeness requires that the patient be given control of his condition in such a way that would allow for the level of activity to which the individual wishes to return. Additionally, the three piece implant is the only device reviewed in the peer reviewed medical literature which approaches that result. Therefore, the requested equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested custom foot orthotics for treatment of the enrollees flexible cavus foot. Findings:  The physician reviewer found that in this patients case, the use of the requested custom foot orthotics is in accordance with the generally accepted standards of medical practice. The current medical evidence supports the use of the requested equipment in this clinical scenario. The submitted documentation has established the medical necessity of the recommended polypropylene custom orthotics. The requested equipment has been used extensively for decades to help control abnormal motion in the foot.  Their efficacy is supported in numerous scientific studies, and their use is standard of care in the medical community.  In this patients case, a pair of custom orthotics will help control the abnormal pronation and alleviate his arch pain.  All told, the requested custom foot orthotics are medically indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested reimbursement for surgical services performed on an urgent basis.  Findings:  The physician reviewer found that this patient had been experiencing ongoing symptoms for several years and her symptoms were worsening. She had been seen by multiple in-plan physicians without improvement in her symptoms. A surgical treatment plan was not in place. As the patients condition progressed and worsened, she consulted a non-plan surgeon who diagnosed her condition and offered her appropriate surgical treatment. A prudent layperson with progressive and worsening symptoms due to a pineal cyst would have believed she was experiencing an urgent medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested lumbar artificial disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that there is a lack of medical literature demonstrating the long-term safety and efficacy of the procedure at issue. In one case series study with longer follow-up, Shim and colleagues followed 24 patients for greater than three years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively), raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease.  Given the overall lack of long-term safety and efficacy data, the procedure at issue was not likely to have been of greater benefit than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested low back fusion surgery for treatment of his low back pain. Findings:  The physician reviewer found that fusion may be indicated for instability of the spine from trauma, tumor, infection, or iatrogenic instability, but rarely for abnormal radiographic results without appropriate clinical findings. There is no strong correlation between MRI changes and low back pain. Improvement can be expected in patients treated with fusion, regardless of technique, when an established indication exists. In most patients with low back pain, symptoms resolve without surgery. For back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, and diffuse low back pain without an explainable functional deficit is not an indication for fusion.  Arthrodesis has a poor success rate when used to treat back pain associated with multiple level disc degeneration seen on MRI images, and multilevel fusions are associated with an increased rate of complications and revisions.  In this case, there is no documentation of conservative care, other than the report of a failure of physical therapy and one epidural steroid injection. There is no documentation of instability of the spine, nor is there any evidence of the presence of a condition, such as trauma, which would elevate the risk of instability. All told, the requested low back fusion surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested Roux-en-Y bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient is obese, but the records provided for review do not document morbid or clinically severe obesity as she has a BMI that is less than 40. Although the patients BMI is greater than 35, there is no evidence of the presence of any serious weight-related co-morbid conditions such as hypertension or diabetes. The patient is on no medications for asthma and reportedly is treated with Pepcid for GERD, and these conditions appear to be medically controlled. Applying the National Institutes of Health (NIH) consensus guidelines, the requested bariatric surgery is not medically necessary for this patient without documented morbid or clinically severe obesity or serious weight-related co-morbid conditions.