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

A 45-year-old male enrollee requested cervical artificial disc surgery for treatment of his cervical degenerative disease, cervical radiculopathy and left-sided C5-6, C6-7 and central C6-7 herniated nucleus pulposus without myelopathy.  Findings:  Two physician reviewers found that Zechmeister and colleagues state, So far, cervical total disc replacement is not recommended for routine use. As many trials are ongoing, re-evaluation at a later date will be required. Future research needs to address the relative effectiveness between cervical total disc replacement and conservative treatment.  As there is a lack of high quality double-blind studies that compare long-term efficacy of cervical artificial disc replacement compared to standard treatment options, the procedure at issue was not likely to be more beneficial for the treatment of the patient's diagnosis than any available standard therapy at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested a continuous passive motion (CPM) for medical treatment of her status right knee arthroplasty.  Findings:  The physician reviewer found that the medical literature does not support the services at issue in this clinical setting. Harvey and colleagues evaluated the effectiveness of continuous passive motion following total knee arthroplasty in people with arthritis. The authors concluded, The effects of continuous passive motion on knee range of motion are too small to justify its use. Furthermore, the documentation submitted for review did not indicate extenuating circumstances or exceptional factors for which the CPM should be considered. The patients diagnoses at the time of surgery were noted as hip pain, hypertension, limb pain, lumbar radiculopathy, and osteoarthritis of the knee.  None of the conditions noted warrant the use of a CPM device. All told, the use of the CPM device was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested a computed tomography (CT) angiogram of the heart for medical evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that the requested diagnostic procedure is not likely to be more effective for this patient than other available options. This patient is asymptomatic and had a negative myocardial perfusion imaging study. The study by Cho and colleagues concluded that CT angiography for risk assessment of individuals without clinically relevant chest pain is not indicated. In this case, the patients negative nuclear stress test results would further reinforce this position. As such, the requested diagnostic procedure is not clinically indicated and is not likely to be more beneficial for evaluation of the patients medical condition than other modalities.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee requested emergency services on an emergent basis for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date of service in question.  Although the patient was afebrile at the time of presentation to the ED, the patients parent reports that the patient had been experiencing a fever up to 103 degrees F as well as other acute symptoms (chills, cough, wheezing). These symptoms were of sufficient severity to cause a prudent layperson to believe the patients health could be in serious risk due to pneumonia, bronchospasm or other serious medical conditions. As such, the patients condition met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested STAR ankle replacement surgery for medical treatment of his left ankle traumatic arthritis. Findings:  The physician reviewer found that based on this patients history including distraction arthroplasty, arthroscopic debridement of the ankle, and a history of osteomyelitis, a total ankle replacement is not medically appropriate. Given the information submitted for review, peer-reviewed literature, and clinical expertise, the medical necessity for a STAR ankle replacement surgery is not established. In the medical literature, Schuh and colleagues concluded that the use of a total ankle replacement versus arthrodesis is not proven to be significantly superior in treating patients with severe ankle arthritis. The documentation submitted for review does not support the patient as a good candidate for a total ankle replacement. Further, as the long-term efficacy of the requested procedure is not established, the medical necessity for a total ankle replacement is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested laser treatment of nasal telangiectasias for the treatment of her medical condition.  Findings:  The physician reviewer found that this patient is status post multiple rhinoplasties and the medical records indicate that further surgery was not recommended by at least one physician.  The patients telangiectasia does not constitute an abnormal structure of the body, as these can develop normally on the face with time.  The requested procedure would not be expected to improve function or more than minimally improve the appearance of the patient.  All told, the requested laser treatment of nasal telangiectasias 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 20-year-old male enrollee has requested a capsule endoscopy for evaluation of his ulcerative colitis and small intestine enteritis.  Findings:  The physician reviewer found that in the medical literature, Goenka and colleagues noted that although capsule endoscopy has also been used for evaluating established Crohns disease, a high capsule retention rate precludes its use ahead of cross-sectional imaging. Niv and colleagues reported that sequential capsule endoscopy studies are feasible and safe in Crohns disease patients. In patients with complete capsule endoscopy studies, they provide reliable information on mucosal changes in Crohns disease and should be considered as an independent and objective follow-up tool in known Crohns disease patients. However, in this patients case, available records support a diagnosis of ulcerative colitis, not Crohns disease. In ulcerative colitis, small bowel involvement is negligible. Thus, a capsule endoscopy in this patient would be expected to yield little useful clinical information. In the event that the provider requires further reassurance about this patients small bowel status pre-operative to colectomy, a small bowel series and a check of inflammatory bowel markers would be appropriate. Therefore, the requested capsule endoscopy is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee requested the LINX procedure for medical treatment of his gastroesophageal reflux disease (GERD).   Findings:  Two physician reviewers found that the patient has documented acid reflux which has been confirmed by endoscopy and pH studies. He has bolus regurgitation. Consistent with the available peer-reviewed medical literature, this patient is an ideal candidate for the LINX procedure. Further, the potential morbidity from a Nissen fundoplication can be avoided. The long-term data is accumulating and in properly selected patients LINX has been shown to be a durable procedure. Therefore, the requested 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

The parent of a six-year-old male enrollee has requested socialization classes for treatment of the enrollees attention deficit/hyperactivity disorder and oppositional defiant disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a lack of support for the requested socialization classes in this clinical setting.  The patient was described by his parent as well-behaved when behavioral therapists are present.  The parent reported that the patient was aware of how he should act around certain people.   Therefore, the records do not indicate a lack of knowledge, but a lack of behavioral control.  Behavioral modification, parent training, and continued work on finding the appropriate medications are the medically appropriate treatments for this patient.  All told, the requested socialization classes are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee requested an insulin pump (E0784), continuous glucose monitoring system (CGMS) transmitter (A9277) and CGMS sensors (A9276) for medical treatment of his type 1 diabetes.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. A continuous glucose monitoring system (CGMS) is a U.S. Food and Drug Administration (FDA) approved device that records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. As this system is likely to benefit the patients health, the requested services are likely to be more beneficial than other available therapies for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a power scooter for treatment of her functional quadriplegia.  Findings:  The physician reviewer found that wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario (Dicianno and Tovey; Johnson and Fitzsimmons). In the current case, the patient was assessed by a physical therapist in the community with respect to her mobility issues. There were no significant neurological deficits or impairments in upper or lower limb strength, coordination, or range of motion. There were no impairments that would preclude the use of an optimally fitted manual wheelchair allowing for bimanual and bipedal propulsion for accomplishing her mobility-related activities of daily living. In addition, the patient has multiple chronic health conditions, such as obesity and chronic pains that would benefit from increased physical activity and exercise (Hagen, et al; Samson and Garber). Regular use of a power mobility device would decrease her physical activity levels and exercise and would be expected to worsen her chronic health conditions in the long-term. A power mobility device is not medically necessary for this patient given that her mobility deficits can be addressed by other means, which are expected to be more beneficial than a power mobility device.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee requested OB/GYN services provided on an emergent basis. Findings:  The physician reviewer found that based upon the documentation provided, there was no documentation of acute symptomatology or deterioration in health (e.g., diabetic coma) that would cause a prudent layperson to seek treatment on an immediate basis. The services were scheduled in advance and took place over a 21-day period. There were not delivered on an imminent or immediate basis to address an acute medical issue. While the services the patient received in Nevada were appropriate and indicated, they were not for treatment of an emergency medical condition.  The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested the MiniMed 530G with Enlite (E0784, A9277, and A9276 for medical treatment of her type 1 diabetes.  Findings:  The physician reviewer found that continuous glucose monitoring systems are U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control. In addition, these devices can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, and show early morning spikes in blood sugar (Cheyne and Kerr). Given this patients history of frequent hypoglycemic episodes, the requested MiniMed 530G pump with Enlite continuous glucose monitoring system is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested laboratory testing for medical evaluation of the enrollees dyslipidemia.  Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more efficacious than other available modalities.  This patient is low risk for cardiovascular disease based on Framingham risk assessment.  The medical record indicated that her lipid disorder is well-managed with medication and lifestyle modification without side effects.  Per the current guidelines, there is a lack of support for the laboratory testing requested.  Thus, laboratory testing was not likely to have been more effective than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee requested gastric bypass surgery for medical treatment of her obesity.  Findings:  The physician reviewer found that the requested gastric bypass surgery is not medically necessary for treatment of the patients medical condition.  The medical documentation provided for review does not demonstrate that she has tried and failed conservative, nonsurgical attempts at weight loss. She has also not been evaluated in a multidisciplinary bariatric surgery clinic. Therefore, in the absence of a bariatric surgery evaluation performed by a bariatric surgical program the request for gastric bypass surgery is not medically indicated at this time. For the reasons provided, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee requested partial hospitalization program (PHP) services for medical 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. This patient meets all seven Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for oppositional defiant disorder.  First-line treatment is therapy and for more severe conduct disorders such as physical aggression, approaches such as multidisciplinary and multimodal treatments are highly recommended, such as those provided in a partial hospitalization program.   During PHP days the patient began to show improvement in the areas of attentiveness, ability to relate to others, and requiring fewer staff prompts. Accordingly, the patient met the medical necessity criteria for continued stay in the partial hospitalization program.  First, his frequent violent physical outbursts represented an imminent risk of harm to others and to property.  Also, he had co-occurring behavioral health problems that could not be managed as manifested by the aforementioned. Finally, assessment and treatment planning required observation and interaction for at least 20 hours per week that included frequent interaction and observation, extended interaction in the program, requiring a structured environment to practice and enhance skills that will help the patient continue in his current living situation or return to school, requires the support of a structured environment to complete treatment goals and develop a plan for post discharge services in a less intensive setting. For the reasons provided, 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 52-year-old female enrollee has requested  abdominoplasty (CPT codes 15830 and 15847) for treatment of her excess skin. Findings:  The physician reviewer found that the requested abdominoplasty is not medically necessary for treatment of the patients medical condition. Abdominoplasty (CPT 15847) is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. This maneuver repairs a diastasis recti which is a widening of the linea alba with separation of the rectus muscles. Unlike a hernia, diastasis is a benign condition with no long term sequelae because the intestines and omentum cannot escape from the intra-abdominal space via the diastasis. It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons. Therefore, the requested abdominoplasty (CPT 15847) is not medically necessary in this clinical setting.In addition, her surgeon recommends a staged belt lipectomy (CPT 15830) via two-stage removal with anterior panniculectomy. The requested CPT 15830 is not medically necessary for treatment of the patients medical condition. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic, interferes with range of motion and blocks a body orifice. However, the mere presence of a pannus and/or its psychological or physical burden on the patient does not make its removal medically necessary. Given the lack of documented treatment or existence of recurrent rashes under the abdominal pannus the request for CPT 15830 is not supported as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested inpatient substance abuse residential treatment for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the patient was stable on gabapentin and fluoxetine, with no change in dosing since admission.  She had chronic issues, but was not psychiatrically distressed.  Her behavior was noted to be impulsive and disruptive, which suggested that the setting may have been suboptimal.  The patient had 10 weeks of sobriety and had achieved the goals listed in the treatment plans.  Finally, the documentation did not include daily progress notes or serial psychiatric assessments, which are needed to evaluate the patients clinical progress, likelihood of failure or success at a less restrictive setting or the appropriateness of the disputed service.  All told, inpatient substance abuse residential treatment services not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 73-year-old male enrollee requested chemotherapy with Erbitux (cetuximab) shots for medical treatment of his lung cancer.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available treatment options. The medical literature supporting cetuximab as a second-line therapy are not convincing as the numbers are small and overall survival benefits are limited. Moreover, Sgambato and colleagues noted that the U.S. Food and Drug Administration (FDA) rejected cetuximab in combination with chemotherapy as a first-line therapy of advanced non-small cell lung cancer (NSCLC). In addition, there are multiple chemotherapy options available to treat lung cancer as a second-line therapy. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested the Acessa procedure that uses radiofrequency ablation for medical treatment of her uterine fibroids.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other treatment options.  A CT scan is not a reliable or preferred method to address the size and location of uterine fibroids.  The current medical evidence supports a laparoscopic or open myomectomy in this clinical setting.  The Acessa procedure has not been recommended in women wishing to retain reproduction capabilities.  Myoma coagulation or myolysis has been associated with adhesion formation and may increase the risk of uterine rupture in pregnancy.  All told, the superior efficacy of the requested Acessa procedure that uses radiofrequency ablation has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested inpatient psychiatric treatment for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Throughout the course of this patients inpatient hospitalization, his medications were adjusted, which he tolerated without difficulty, but his psychotic symptoms remained unchanged.  Olanzapine was discontinued and clozapine was started and was eventually titrated up to 350mg.  The patient was given transcranial magnetic stimulation treatments.   However, his delusions and paranoia remained.  The medical records do not indicate that continuing stay at this level of care would have benefited this patient who presented with a psychotic illness that had proven refractory to multiple modalities of treatment.  Based upon the records submitted for review, his treatment had become custodial in nature.  All told, inpatient psychiatric treatment was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Copaxone 40mg, three times per week for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication dosage.  The patient has been diagnosed with relapsing-remitting multiple sclerosis, and she has requested coverage for Copaxone 40mg, three times per week.  There is sufficient support for the requested medication dosage in this clinical setting.  Copaxone 40mg, three times per week has been shown to have comparable tolerability and effectiveness as Copaxone 20mg daily.  Patient adherence can be impacted by side effects such as pain and injection site reactions.  Overall, three times weekly injections are likely to be less irritating and foster adherence.  All told, Copaxone 40mg, three times per week, is medically indicated for the treatment of this patient.